A registered nurse is planning initial assessments for a group of assigned clients. Arrange the following clients in the correct order for assessment, from highest priority (most urgent) to lowest priority (least urgent).
- 1A client with a deep vein thrombosis who is suddenly reporting shortness of breath and chest pain
- 2A client with acute gastroenteritis who reports feeling dizzy when standing up to use the restroom
- 3A client with type 2 diabetes mellitus who has a fasting capillary blood glucose reading of 145 mg/dL
- 4A client scheduled for an abdominal ultrasound in 3 hours who is asking when they will be allowed to eat breakfast
Answer
The correct sequence for assessment is: 1) the client with sudden shortness of breath and chest pain, 2) the client reporting dizziness when standing, 3) the client with a blood glucose of 145 mg/dL, and 4) the client asking about breakfast.
Prioritization is guided by the Airway, Breathing, Circulation (ABC) framework and the acuity of the clients' conditions. The client experiencing sudden shortness of breath and chest pain with a history of deep vein thrombosis is exhibiting signs of a pulmonary embolism, an immediate threat to breathing and circulation. This client is the highest priority. The client with dizziness when standing has a circulatory issue (orthostatic hypotension) and is a high fall risk, making them the second priority. The client with a fasting glucose of 145 mg/dL is medically stable and requires only routine assessment, placing them third. The client asking a question about a future procedure has an informational need, which is the lowest priority and should be addressed last.
Step-by-Step Solution
Key Concept
Prioritizing Client Care Using the ABC Framework