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Difficulty: MediumEstablishing Priorities

The nurse receives the shift report for four clients on a medical-surgical unit. Which client should the nurse assess first?

  1. A client with an acute asthma exacerbation who reports severe shortness of breath and has diminished breath sounds with absent wheezing.Answer
  2. B
    A client with heart failure who reports a 3-lb (1.4 kg) weight gain over 2 days and has 2+ pitting edema of the lower extremities.
  3. C
    A client who is 12 hours postoperative following an open cholecystectomy and reports incisional pain rated 8 on a 0 to 10 scale.
  4. D
    A client with a pulmonary embolism on a continuous heparin infusion who has an activated partial thromboplastin time (aPTT) of 75 seconds.

Answer

The client with an acute asthma exacerbation who reports severe shortness of breath and has diminished breath sounds with absent wheezing.
The correct answer identifies a client experiencing a 'silent chest.' In acute asthma, the sudden disappearance of wheezing without clinical improvement indicates that airways are so tightly constricted that not enough air is moving to produce sound. This is a medical emergency requiring immediate intervention to prevent respiratory arrest.

Step-by-Step Solution

1
Analyze the clinical status of each client based on the Airway, Breathing, Circulation (ABC) framework and expected versus unexpected findings.
Identify that the client with asthma is experiencing a critical airway/breathing issue.
The ABCs provide the primary framework for prioritizing acute patient care.
2
Evaluate the asthma client's symptoms (absent wheezing with diminished breath sounds).
Determine that this represents a 'silent chest,' indicating severe airway obstruction.
When a patient with asthma stops wheezing and breath sounds diminish, it means airflow is severely restricted, leading to respiratory failure.
3
Compare the severity of the asthma client's condition with the other clients.
Conclude that the asthma client is the most unstable.
The other clients present with expected findings for their conditions (chronic fluid retention, post-operative pain, and therapeutic anticoagulation).

Key Concept

Prioritizing care using the Airway, Breathing, Circulation (ABC) framework and distinguishing acute, life-threatening complications from expected or chronic findings.
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Establishing Priorities

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