A charge nurse on an adult medical-surgical unit is reviewing the clinical status of four assigned clients following the morning safety huddle. In what sequence should the nurse perform the initial client assessments? Arrange the clients from highest priority (first) to lowest priority (last).
- 1A 38-year-old client receiving an initial dose of intravenous vancomycin who suddenly reports a 'thick feeling' in the throat accompanied by audible wheezing.
- 2A 47-year-old client with a recent closed femur fracture who is reporting severe, unrelenting thigh pain that escalates significantly during passive foot dorsiflexion.
- 3A 50-year-old client with hepatic cirrhosis who has developed new-onset disorientation, a flapping hand tremor, and increased lethargy since yesterday.
- 4A 64-year-old client with Parkinson's disease who is demonstrating a continuous 'pill-rolling' resting tremor and marked slowness when attempting to consume breakfast.
Answer
The correct order is: 1) The client with vancomycin-induced wheezing (Airway), 2) The client with a femur fracture and severe pain on passive stretch (Circulation), 3) The client with cirrhosis and new-onset lethargy (Acute Neurological), and 4) The client with Parkinson's disease and a resting tremor (Chronic).
The prioritization of these clients strictly follows the ABCs (Airway, Breathing, Circulation) and the acute versus chronic framework. The client with a compromised airway from anaphylaxis must be seen first. The client with limb-threatening circulatory compromise (compartment syndrome) is second. The client with an acute neurological change is third. Finally, the client with expected, chronic neurological symptoms is the lowest priority.
Step-by-Step Solution
Key Concept
Prioritization using the Airway-Breathing-Circulation (ABC) and Acute vs. Expected/Chronic frameworks