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Difficulty: MediumEstablishing Priorities

Following the evening shift handoff on a cardiovascular step-down unit, which client should the nurse assess first?

  1. A
    A client with infective endocarditis who has a temperature of 101.2°F (38.4°C) and new splinter hemorrhages.
  2. B
    A client with a known stable thoracic aortic aneurysm who reports a chronic dull, aching pain in the upper back.
  3. A client who underwent a transfemoral cardiac catheterization 3 hours ago and is now restless with mild flank discomfort.Answer
  4. D
    A client with a demand pacemaker implanted 2 days ago who exhibits occasional premature ventricular contractions on the telemetry monitor.

Answer

The client who underwent a transfemoral cardiac catheterization and is now restless with mild flank discomfort.
The client who had a transfemoral cardiac catheterization is exhibiting restlessness and flank discomfort, which are early and subtle clinical indicators of a retroperitoneal hemorrhage. Internal bleeding is a highly acute circulation issue that can rapidly deteriorate into hypovolemic shock. According to prioritization principles, acute and unexpected complications threatening the ABCs take precedence over all other stable or expected findings.

Step-by-Step Solution

1
Analyze the clinical presentation of each client to identify acute versus expected findings.
Three clients have expected manifestations of their chronic or stable conditions, while one has a subtle, unexpected change.
Prioritization requires distinguishing between stable/chronic conditions and acute, life-threatening deteriorations.
2
Evaluate the significance of the symptoms in the client with a recent transfemoral catheterization.
Recognize that new restlessness and mild flank discomfort are early indicators of retroperitoneal bleeding.
Internal bleeding affects circulation and can rapidly progress to hypovolemic shock, requiring immediate intervention.
3
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The client with the suspected retroperitoneal hemorrhage has an acute circulatory compromise and must be assessed first.
Acute and unexpected circulatory complications take precedence over all other stable or expected findings.

Key Concept

Prioritization based on acute vs. chronic and unexpected vs. expected findings
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Topics

Establishing Priorities

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