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Question

Difficulty: EasyEstablishing Priorities

After receiving handoff communication at the beginning of the day shift, a registered nurse is planning care for four assigned clients. Which client should the nurse assess first?

  1. A
    A client with chronic heart failure who has bilateral 2+ pitting edema in the lower extremities
  2. A client with an exacerbation of asthma who has new-onset audible wheezing and an oxygen saturation of 88% on room airAnswer
  3. C
    A client with a deep vein thrombosis who is scheduled to receive a routine dose of subcutaneous enoxaparin
  4. D
    A client with a stage 2 pressure injury who requires a scheduled wound dressing change before going to physical therapy

Answer

The client with an exacerbation of asthma who has new-onset audible wheezing and an oxygen saturation of 88% on room air.
The correct answer identifies a client with a new, acute respiratory compromise. Applying the ABC (Airway, Breathing, Circulation) prioritization framework, a client with an airway/breathing issue (wheezing and hypoxia) takes immediate precedence over clients with chronic, stable conditions or routine care needs.

Step-by-Step Solution

1
Analyze each client's condition based on the Airway, Breathing, Circulation (ABCs) framework and the concept of acute versus chronic.
The asthma client has an acute airway/breathing issue. The other clients have chronic or stable routine care needs.
The ABC framework dictates that airway and breathing issues are the highest priority because they pose the most immediate threat to life.

Key Concept

Establishing Priorities using the ABC (Airway, Breathing, Circulation) framework
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Topics

Establishing Priorities

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