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Difficulty: MediumAssignment, Delegation and Supervision

A nurse on an oncology unit has just received shift report for four assigned clients. In which order should the nurse assess these clients? Arrange the clients from highest priority (first to be assessed) to lowest priority (last to be assessed).

  1. 1A client receiving a packed red blood cell transfusion who suddenly reports lower back pain and chills
  2. 2A client with chemotherapy-induced neutropenia who has a new temperature of 100.6°F (38.1°C)
  3. 3A client with bone metastasis requesting a medication refill for an empty patient-controlled analgesia (PCA) pump
  4. 4A client scheduled for a bone marrow biopsy this afternoon who has questions about the informed consent process

Answer

Assess the transfusion reaction first, followed by the neutropenic fever, then the PCA pump refill, and finally the client with consent questions.
Prioritization requires addressing immediate threats to life first (ABCs), followed by systemic physiological threats, localized physiological needs, and finally psychosocial or routine needs. The transfusion reaction is an immediate circulatory threat. The neutropenic fever is a high-risk systemic threat. The empty PCA pump is a localized physiological need. The questions regarding consent represent a routine psychosocial need.

Step-by-Step Solution

1
Identify active, life-threatening physiological emergencies (ABCs).
The client with lower back pain and chills during a blood transfusion is experiencing an acute hemolytic reaction.
This is an immediate airway and circulatory threat requiring the immediate cessation of the blood product.
2
Identify high-risk, time-sensitive conditions.
The neutropenic client with a new fever is placed second.
Neutropenic fever is a medical emergency that can rapidly deteriorate into sepsis, requiring rapid intervention just after stabilizing the actively reacting client.
3
Prioritize acute physiological needs without an immediate threat to life.
The client needing a PCA refill is placed third.
Pain is a high priority for comfort and physiological stability but does not supersede circulatory collapse or sepsis.
4
Address routine, stable, or psychosocial needs.
The client with questions about informed consent is placed fourth.
This is a non-urgent administrative and educational need that can wait until all unstable clients are safely managed.

Key Concept

Prioritization of Care using Maslow's Hierarchy and ABCs (Airway, Breathing, Circulation)
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Topics

Assignment, Delegation and Supervision

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