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Difficulty: MediumEstablishing Priorities

During midday rounds on a general medical-surgical unit, the registered nurse evaluates several assigned clients. Which of the following client presentations demand immediate nursing intervention? (Select all that apply.)

  1. A client 12 hours post-thyroidectomy who reports frequent swallowing and a feeling of tightness around the incisional dressing.Answer
  2. A client with bacterial pneumonia who suddenly becomes restless, confused, and attempts to remove their intravenous catheter.Answer
  3. C
    A client with chronic atrial fibrillation who exhibits an irregularly irregular apical pulse of 86 beats per minute.
  4. D
    A client with a newly applied short-leg cast for a fractured tibia who reports aching pain of 4 on a 0 to 10 scale.
  5. E
    A client with an acute exacerbation of ulcerative colitis who reports mild abdominal cramping and has had two bloody diarrheal stools this morning.

Answer

The clients requiring immediate intervention are the post-thyroidectomy client with frequent swallowing (airway risk) and the pneumonia client with sudden confusion (hypoxia risk).
The correct answers describe acute, life-threatening complications. Frequent swallowing after neck surgery indicates bleeding that can compress the airway. Sudden confusion and restlessness in a respiratory client indicate acute hypoxia. Both require immediate life-saving interventions based on the ABC framework.

Step-by-Step Solution

1
Analyze each client's clinical presentation using the ABC (Airway, Breathing, Circulation) framework.
The post-thyroidectomy client shows signs of airway compression (A), and the pneumonia client shows signs of impaired gas exchange/hypoxia (B).
Airway and breathing emergencies take the highest priority in clinical triage.
2
Evaluate the remaining clients using the acute versus chronic framework to determine if their findings are expected or unexpected.
The clients with atrial fibrillation, a casted fracture, and ulcerative colitis all present with expected findings related to their known chronic or stable conditions.
Clients with expected, non-life-threatening manifestations are a lower priority for immediate intervention compared to those with acute deterioration.

Key Concept

Prioritization using ABCs (Airway, Breathing, Circulation) and identifying acute, unexpected complications over chronic, expected findings.
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Establishing Priorities

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