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Question

Difficulty: EasyEstablishing Priorities

A nurse working on a general medical-surgical floor is evaluating client needs following the lunch hour. Which client requires the most immediate assessment by the nurse?

  1. A client with a tracheostomy tube who has a sudden onset of restlessness and an oxygen saturation of 85% on room airAnswer
  2. B
    A client with a casted fractured tibia who reports an aching pain level of 4 on a 0 to 10 scale
  3. C
    A client with viral gastroenteritis who had one episode of loose stool 20 minutes ago
  4. D
    A client with type 2 diabetes mellitus who is waiting for a routine capillary blood glucose check

Answer

The client with a tracheostomy tube who has a sudden onset of restlessness and an oxygen saturation of 85% on room air requires the most immediate assessment.
According to the ABC (Airway, Breathing, Circulation) framework, establishing and maintaining oxygenation is always the highest priority. Sudden restlessness in conjunction with an oxygen saturation of 85% indicates severe, acute hypoxia—likely due to a mucus plug or other airway obstruction in the tracheostomy tube—that requires immediate emergency intervention.

Step-by-Step Solution

1
Identify the clinical status of each client to determine urgency based on the Airway, Breathing, Circulation (ABC) prioritization framework.
The tracheostomy client has an airway/breathing issue, the tibia client has a comfort issue, the gastroenteritis client has a stable/expected symptom, and the diabetic client has a routine need.
Applying the ABC framework helps isolate immediate physiological threats to life.
2
Recognize the clinical significance of restlessness and low oxygen saturation in a client with an artificial airway.
These are classic signs of severe hypoxemia and potential airway obstruction.
Hypoxia can rapidly lead to respiratory arrest and death if not corrected immediately.
3
Compare the severity of the airway issue to the needs of the other three clients.
The airway issue takes absolute priority over expected mild pain, expected loose stool, and a routine scheduled task.
Stable, expected, and routine findings are prioritized lower than acute, unstable, and life-threatening conditions.

Key Concept

Prioritization Framework: Airway, Breathing, Circulation (ABC)
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Establishing Priorities

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