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Question

Difficulty: EasyEstablishing Priorities

The charge nurse on a postoperative unit is determining which client requires immediate evaluation. Which client must be assessed first?

  1. A client who is 2 hours post-thyroidectomy and produces a high-pitched, harsh sound upon inhalationAnswer
  2. B
    A client who is 1 day post-appendectomy and has a temperature of 99.4°F (37.4°C)
  3. C
    A client who underwent a total knee arthroplasty 24 hours ago and is requesting a prescribed analgesic
  4. D
    A client who is scheduled for an inguinal hernia repair tomorrow and is crying uncontrollably due to fear

Answer

The client who is 2 hours post-thyroidectomy and produces a high-pitched, harsh sound upon inhalation.
The client who is post-thyroidectomy and exhibiting a high-pitched, harsh sound on inhalation (stridor) requires immediate assessment. Stridor indicates a narrowing or obstruction of the airway, often caused by edema, hemorrhage, or laryngeal nerve damage following neck surgery. Under the Airway, Breathing, Circulation (ABC) framework, maintaining a patent airway is always the highest clinical priority.

Step-by-Step Solution

1
Analyze the clinical presentation of each assigned client.
The post-thyroidectomy client has stridor; the other clients present with expected postoperative pain, mild fever, or anxiety.
Identifying the severity and acuity of each client's condition is the first step in nursing triage.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The post-thyroidectomy client's symptom indicates an acute airway compromise, making them the highest priority.
Physiological survival needs, specifically maintaining a patent airway, must always be addressed before pain, expected inflammatory responses, or psychological distress.

Key Concept

Prioritization using the ABC (Airway, Breathing, Circulation) framework.
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Topics

Establishing Priorities

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