A nurse receives the change-of-shift report for four assigned clients on a medical-surgical unit. In what order should the nurse assess these clients? Arrange the clients from highest priority (first to be seen) to lowest priority (last to be seen).
- 1A client who suddenly reports difficulty breathing and has an oxygen saturation of 89% on room air
- 2A client who just arrived on the unit from the post-anesthesia care unit (PACU) following an appendectomy
- 3A client with pneumonia who is scheduled to receive their next dose of intravenous (IV) antibiotics
- 4A client with chronic kidney disease who is requesting a glass of water and a warm blanket
Answer
The correct order is: the client with difficulty breathing first, followed by the fresh post-operative client, then the client needing scheduled antibiotics, and finally the client requesting comfort measures.
Based on the principles of triage and prioritization in nursing, clients with sudden, unstable airway, breathing, or circulation problems must be seen first. The client with new difficulty breathing (a 'breathing' problem) is the most unstable. Next, a fresh post-operative client returning from the PACU requires an urgent baseline assessment due to the high risk of complications. Third, administering scheduled antibiotics is a priority physiological need but can wait until unstable and high-risk clients are assessed. Finally, attending to the basic comfort needs of a stable client with a chronic condition is the lowest priority.
Step-by-Step Solution
Key Concept
Establishing Priorities Using the ABC Framework and Patient Stability