A registered nurse on a high-acuity cardiac step-down unit is evaluating assessment data for a group of assigned clients. Which of the following client presentations require immediate intervention by the nurse? Select all that apply.
- A client 3 hours post-percutaneous coronary intervention via the right femoral artery who reports a new onset of severe lower back painAnswer
- BA client with severe chronic obstructive pulmonary disease whose arterial blood gas reveals a pH of 7.36 and a PaCO2 of 54 mm Hg
- A client receiving a continuous intravenous furosemide infusion who exhibits new-onset frequent premature ventricular contractionsAnswer
- DA client with a history of atrial fibrillation receiving a diltiazem infusion who has an irregularly irregular apical pulse of 86 beats per minute
- A client recovering from a thoracic aneurysm repair whose pulse pressure has narrowed from 45 mm Hg to 20 mm Hg over the last hourAnswer
Answer
The correct selections are the client with back pain post-PCI, the client with new premature ventricular contractions on furosemide, and the client with a narrowing pulse pressure.
In prioritization triage, acute, unexpected changes that threaten Airway, Breathing, or Circulation take the highest priority. Severe lower back pain following a femoral percutaneous coronary intervention is a cardinal sign of retroperitoneal bleeding, a life-threatening circulatory complication. New-onset premature ventricular contractions in a client receiving a loop diuretic like furosemide strongly suggest hypokalemia, which can rapidly degenerate into lethal ventricular tachycardia or fibrillation. A narrowing pulse pressure is a critical early compensatory mechanism in shock states, reflecting falling cardiac output. All three of these clients require immediate, life-saving nursing and medical interventions.
Step-by-Step Solution
Key Concept
Prioritization of acute circulatory instability and life-threatening dysrhythmias over stable, expected chronic physiological adaptations.