Examkin

Question

Difficulty: MediumAssignment, Delegation and Supervision

After receiving the shift handoff report on a medical-surgical unit, a registered nurse (RN) is planning the initial assessments for five assigned clients. Arrange the following clients in the order the RN should assess them, prioritizing from the most urgent to the least urgent.

  1. 1A client 1 hour post-thyroidectomy reporting increased neck pressure and demonstrating high-pitched, harsh inspiratory sounds.
  2. 2A client with a closed femur fracture who is newly restless, confused, and has a petechial rash on the upper chest.
  3. 3A client admitted with acute kidney injury whose total urine output was 35 mL over the past 4 hours.
  4. 4A client 1 day post-lumbar laminectomy who is reporting a dull backache (6 on a 0-10 scale) and needs assistance with repositioning.
  5. 5A client with type 2 diabetes mellitus whose morning fasting capillary blood glucose is 138 mg/dL (7.7 mmol/L).

Answer

The correct priority order is based on the ABCs (Airway, Breathing, Circulation) and the severity of instability: 1. Thyroidectomy client (Airway), 2. Femur fracture client (Breathing/Circulation), 3. Acute kidney injury client (Circulation/Renal), 4. Laminectomy client (Pain), 5. Diabetic client (Stable).
Prioritization in nursing follows the ABC framework (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. Unstable, life-threatening conditions (stridor, fat embolism) must be assessed before urgent but non-lethal conditions (oliguria). Expected findings and comfort needs (post-operative pain) follow, while stable, routine findings (slightly elevated fasting glucose in a diabetic client) are the lowest priority.

Step-by-Step Solution

1
Identify the client with an immediate threat to life.
The post-thyroidectomy client with stridor has an imminent airway obstruction.
Airway compromise is the absolute highest priority in any clinical scenario (the 'A' in ABCs).
2
Identify the client with the next most critical physiological instability.
The client with a femur fracture is showing signs of fat embolism syndrome (hypoxia, confusion, petechiae).
Breathing and acute circulatory/oxygenation failures (the 'B' and 'C' in ABCs) take precedence over other systemic issues.
3
Determine which remaining client has a potentially unstable or abnormal finding requiring prompt intervention.
The client with acute kidney injury has significant oliguria (35 mL over 4 hours).
Inadequate urine output indicates compromised perfusion or worsening renal failure, which is a higher priority than routine pain management.
4
Differentiate between expected, stable needs and routine data collection.
The laminectomy client has a comfort need (pain) while the diabetic client has a slightly elevated but stable glucose.
Addressing acute pain (expected post-operative) is prioritized over entirely stable, non-acute chronic condition findings.

Key Concept

Prioritization frameworks: ABCs (Airway, Breathing, Circulation) and Acute vs. Chronic / Unstable vs. Stable.
Estimated Time:1m 30s
Rate this question

Topics

Assignment, Delegation and Supervision

More questions from this topic