Examkin

Question

Difficulty: MediumEstablishing Priorities

While working on a busy pediatric unit, a nurse is determining the order of initial client assessments. Which client should the nurse assess first?

  1. A
    A 4-year-old client with sickle cell anemia who is crying and reporting severe bilateral leg pain
  2. B
    A 9-year-old client with acute poststreptococcal glomerulonephritis who has tea-colored urine and periorbital edema
  3. A 6-year-old client who is 6 hours postoperative following a tonsillectomy and is observed swallowing frequentlyAnswer
  4. D
    A 2-year-old client with viral bronchiolitis who has a respiratory rate of 44 breaths/min and a mild expiratory wheeze

Answer

The 6-year-old client who is 6 hours postoperative following a tonsillectomy and is observed swallowing frequently.
Post-tonsillectomy, frequent or continuous swallowing is a primary indicator of active bleeding in the surgical site, as the client is unconsciously swallowing trickling blood. This presents an immediate threat to both circulation (hypovolemia) and the airway (aspiration or obstruction). This client is experiencing an unexpected, life-threatening emergency and must be assessed first.

Step-by-Step Solution

1
Analyze each client's condition using the Airway, Breathing, and Circulation (ABC) framework.
The post-tonsillectomy client exhibits a sign of potential airway compromise and circulatory volume loss.
Airway and circulation issues are the highest physiological priorities in client care.
2
Differentiate between expected disease manifestations and unexpected acute complications.
The clients with sickle cell anemia, glomerulonephritis, and bronchiolitis are displaying expected signs of their respective conditions. The post-tonsillectomy client is displaying an unexpected complication.
Unexpected findings, especially those indicating physiological deterioration, take priority over expected chronic or acute manifestations.
3
Identify the client requiring the most immediate intervention.
The post-tonsillectomy client must be assessed first to evaluate for hemorrhage and secure the airway.
Hemorrhage is a life-threatening emergency that rapidly compromises the ABCs.

Key Concept

Prioritization using the ABC framework and expected versus unexpected clinical findings
Rate this question

Topics

Establishing Priorities

More questions from this topic