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Difficulty: HardEstablishing Priorities

An RN on a busy orthopedic unit is planning initial rounds after completing the change-of-shift report. Among the assigned caseload, which individual requires the nurse's immediate attention?

  1. A
    An older adult who underwent a total hip arthroplasty two days ago whose closed-suction surgical drain has collected 50 mL of serosanguineous fluid over the past 8 hours
  2. B
    A middle-aged adult recovering from a lumbar laminectomy who reports severe back spasms rated as an 8 on a 0 to 10 pain scale and is requesting immediate medication
  3. A young adult recovering from surgical fixation of a fractured tibia who is newly restless, tachypneic, and displays scattered petechiae across the upper chestAnswer
  4. D
    An older adult receiving intravenous antibiotics for chronic osteomyelitis whose morning laboratory results reveal a white blood cell count of 14,500/mm³

Answer

The client recovering from surgical fixation of a fractured tibia who is newly restless, tachypneic, and displays scattered petechiae across the upper chest.
The correct answer identifies a client exhibiting the classic triad of Fat Embolism Syndrome (FES): hypoxemia (evidenced by early restlessness and tachypnea), neurologic compromise, and a petechial rash. FES is a medical emergency most commonly associated with long bone fractures, such as a tibia fracture. This client is experiencing an acute, unexpected breathing and circulatory complication, making them the absolute highest priority for immediate assessment and intervention to prevent respiratory failure.

Step-by-Step Solution

1
Analyze each client's clinical presentation to determine if the findings are expected (stable) or unexpected (unstable).
The hip arthroplasty drain output and the osteomyelitis WBC count are expected findings. The back pain is an expected postoperative finding that requires intervention. The tibia fracture symptoms are highly unexpected and acute.
Prioritization requires distinguishing between stable, expected disease courses and acute, life-threatening changes.
2
Apply the ABCs (Airway, Breathing, Circulation) framework to the unstable or symptomatic clients.
The client with the tibia fracture has respiratory symptoms (restlessness, tachypnea) indicating hypoxia. The laminectomy client has a severe pain issue, which does not threaten the ABCs.
Conditions affecting airway, breathing, or circulation are the absolute highest priority for nursing care and must be addressed first to prevent client mortality.
3
Identify the underlying pathology of the highest priority client.
The triad of restlessness (hypoxia), tachypnea, and an upper chest petechial rash in a client with a long bone fracture strongly indicates Fat Embolism Syndrome (FES).
Recognizing life-threatening complications like FES confirms that this client requires immediate emergency assessment and rapid medical intervention.

Key Concept

Prioritization using the ABCs framework and recognizing life-threatening complications such as Fat Embolism Syndrome.
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Establishing Priorities

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