The triage nurse in a busy adult emergency department is concurrently evaluating four walk-in clients. Based on the principles of prioritization and triage, arrange the clients in the order they must be medically evaluated, from highest priority (first) to lowest priority (last).
- 1A 28-year-old client presenting with facial swelling, audible stridor, and drooling after eating a peanut cookie.
- 2A 62-year-old client who reports a sudden onset of large-volume, dark red rectal bleeding and has a heart rate of 118 bpm.
- 3A 35-year-old client experiencing right lower quadrant abdominal pain, nausea, and a temperature of 100.2°F (37.9°C).
- 4A 70-year-old client with a history of heart failure who has 2+ bilateral pedal edema and is requesting a medication refill.
Answer
The correct sequence is to first see the client with stridor and drooling, followed by the client with rectal bleeding and tachycardia, then the client with right lower quadrant pain, and finally the client with chronic pedal edema requesting a refill.
Effective prioritization in nursing requires a systematic approach, typically starting with the ABCs (Airway, Breathing, Circulation), followed by Maslow's Hierarchy of Needs, and distinguishing between acute (unexpected) and chronic (expected) problems. The client with stridor has a closing airway, making them the absolute highest priority. The client with rectal bleeding and tachycardia is experiencing circulatory compromise, making them second. The client with acute abdominal pain is stable but requires timely diagnosis, placing them third. The client with chronic pedal edema has expected findings for their diagnosis and is seeking routine care, making them the lowest priority.
Step-by-Step Solution
Key Concept
Establishing Priorities using the ABCs and Acute vs. Chronic Frameworks