A nurse has received the morning handoff report for four clients. Using the principles of prioritization, in what order should the nurse assess these clients? Arrange the clients from first to be seen (highest priority) to last to be seen (lowest priority).
- 1A client who has a peanut allergy and is developing new-onset lip swelling and expiratory wheezes.
- 2A client with active gastrointestinal bleeding who is diaphoretic and has a blood pressure of 88/54 mm Hg.
- 3A client with a deep vein thrombosis who requires a routine clinical assessment prior to the next scheduled dose of anticoagulant medication.
- 4A client who is medically stable and asking for assistance with packing belongings for an upcoming transfer to a rehabilitation facility.
Answer
The correct order is to first see the client with lip swelling and wheezes, followed by the client with gastrointestinal bleeding and hypotension, then the client requiring a pre-medication assessment, and finally the client needing assistance with packing.
Prioritization in nursing strictly follows the Airway, Breathing, and Circulation (ABC) framework. Unstable, acute, and life-threatening conditions must be prioritized over stable, chronic, or routine situations. Anaphylaxis (airway) comes first, followed by hypovolemic shock (circulation), then urgent clinical assessments, and finally routine daily tasks.
Step-by-Step Solution
Key Concept
Prioritization using the Airway-Breathing-Circulation (ABC) framework and the unstable versus stable client approach.