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Difficulty: MediumEstablishing Priorities

A nurse is reviewing assessment data for a group of clients on a pulmonary care unit. Which of the following clinical cues require immediate intervention? Select all that apply.

  1. A client with a severe asthma exacerbation whose audible wheezing has abruptly stopped.Answer
  2. B
    A client with chronic obstructive pulmonary disease (COPD) displaying a resting oxygen saturation of 89% on room air.
  3. A client being treated for bacterial pneumonia who exhibits sudden, profound restlessness.Answer
  4. D
    A client with a resolving pleural effusion who demonstrates diminished breath sounds at the affected lung base.
  5. A client recovering from a pulmonary embolism who reports a new, sudden onset of hemoptysis and a heart rate of 128 beats/minute.Answer

Answer

The findings requiring immediate intervention include the client with abruptly stopped wheezing, the client with new profound restlessness, and the client with new hemoptysis and tachycardia.
Acute, unexpected changes indicating impending airway loss, hypoxia, or hemodynamic instability must be prioritized immediately. A 'silent chest' in asthma indicates severe bronchospasm and a dangerous lack of airflow. Sudden restlessness in pneumonia is a classic early sign of hypoxia. New hemoptysis with tachycardia in a pulmonary embolism client indicates a potentially life-threatening complication or worsening condition that requires rapid stabilization.

Step-by-Step Solution

1
Evaluate each client's presentation against the Airway-Breathing-Circulation (ABC) framework and expected versus unexpected findings.
Identify clients with acute, unexpected life-threatening changes.
Safe prioritization requires addressing acute, unstable conditions before chronic, stable ones.
2
Analyze the asthma client's lack of wheezing.
Recognized as a 'silent chest,' indicating severe airway obstruction.
Loss of wheezing without clinical improvement signifies an inability to move air, which is a respiratory emergency.
3
Assess the pneumonia client's sudden restlessness.
Identified as an early sign of cerebral hypoxia.
Acute neurological changes in respiratory-compromised clients signal inadequate brain oxygenation.
4
Evaluate the pulmonary embolism client's new hemoptysis and tachycardia.
Indicates potential hemodynamic instability or worsening pulmonary infarction.
New acute bleeding and compensatory tachycardia require rapid medical intervention.

Key Concept

Prioritizing acute, unexpected respiratory deterioration over expected chronic findings.
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Establishing Priorities

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