A registered nurse receives the morning handoff report for four clients on a general medical unit. In which order should the nurse assess these clients? Arrange the clients from highest priority (first) to lowest priority (last).
- 1A client who developed auditory stridor five minutes after an intravenous antibiotic infusion was started.
- 2A client with type 1 diabetes mellitus who is diaphoretic, tremulous, and reporting blurred vision.
- 3A client with a documented fractured femur who is crying and requesting prescribed pain medication.
- 4A client waiting for final written instructions prior to a scheduled discharge.
Answer
The correct order of assessment is: 1) the client with stridor (airway threat), 2) the client with symptomatic hypoglycemia (metabolic emergency), 3) the client with acute pain (non-life-threatening urgent), and 4) the client waiting for discharge (stable).
Prioritization in nursing requires addressing life-threatening issues first. Using the ABC framework, the client with stridor (Airway) takes absolute precedence. Following the ABCs, the client with symptomatic hypoglycemia faces a severe, rapid-onset metabolic crisis that requires immediate intervention. Next, applying Maslow's hierarchy of needs, the client experiencing acute pain has an urgent physiological need that supersedes the final stable client, who only requires routine discharge teaching.
Step-by-Step Solution
Key Concept
Prioritization of client care using the ABCs and Maslow's Hierarchy of Needs
Estimated Time:1m 30s