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Difficulty: MediumEstablishing Priorities

A clinical leader on a medical-surgical telemetry unit is evaluating the electronic health records of several clients during morning rounds. Which of the following client findings warrant immediate clinical intervention by the nurse? (Select all that apply.)

  1. A client with an exacerbation of heart failure who has a new onset of pink, frothy sputum and restlessness.Answer
  2. B
    A client with severe chronic obstructive pulmonary disease (COPD) who has a resting oxygen saturation of 91% on room air.
  3. C
    A client who underwent a laparoscopic cholecystectomy 12 hours ago and is reporting right shoulder pain.
  4. A client admitted for a deep vein thrombosis who suddenly reports sharp chest pain and shortness of breath.Answer
  5. A client receiving a packed red blood cell transfusion who develops a sudden fever, chills, and lower back pain.Answer

Answer

The clients requiring immediate intervention are: the client with heart failure and pink, frothy sputum; the client with a deep vein thrombosis reporting sudden chest pain; and the client receiving a blood transfusion who develops fever and lower back pain.
Prioritization is guided by the Airway, Breathing, Circulation (ABC) framework and the principle of prioritizing acute, unexpected findings over chronic or expected ones. The client with pink frothy sputum (pulmonary edema), the client with sudden chest pain and dyspnea (pulmonary embolism), and the client with fever and lower back pain during a transfusion (hemolytic reaction) are all experiencing acute, unexpected, life-threatening airway, breathing, or systemic crises. These require immediate life-saving interventions.

Step-by-Step Solution

1
Evaluate the client with heart failure and pink, frothy sputum.
Identified as a high-priority acute emergency.
Pink, frothy sputum and restlessness indicate acute pulmonary edema and hypoxia, which is an airway and breathing crisis.
2
Evaluate the client with COPD and an oxygen saturation of 91%.
Identified as stable.
This is an expected, chronic baseline finding for severe COPD and does not indicate an acute decline.
3
Evaluate the post-laparoscopic cholecystectomy client with right shoulder pain.
Identified as stable.
Referred shoulder pain from carbon dioxide used during laparoscopy is an expected, non-life-threatening postoperative finding.
4
Evaluate the client with a deep vein thrombosis presenting with sudden chest pain and shortness of breath.
Identified as a high-priority acute emergency.
These are hallmark signs of a pulmonary embolism, causing an immediate threat to breathing and circulation.
5
Evaluate the client receiving a blood transfusion who develops fever, chills, and lower back pain.
Identified as a high-priority acute emergency.
These symptoms strongly suggest an acute hemolytic transfusion reaction, requiring immediate cessation of the transfusion to prevent further systemic compromise.

Key Concept

Establishing Priorities: Acute vs. Chronic and Unexpected vs. Expected Findings
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Establishing Priorities

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