Upon completing initial safety rounds on an acute care unit, a charge nurse must determine the assessment sequence for four newly admitted or transferring clients. Arrange the clients in the priority order they must be evaluated, from first (highest priority) to last (lowest priority).
- 1A client with a newly placed tracheostomy who is restless, tachypneic, and has a pulse oximetry reading dropping to 87% on room air.
- 2A client admitted with gastrointestinal bleeding who has a current blood pressure of 86/50 mm Hg, a heart rate of 122 beats/min, and pale skin.
- 3A client who is 12 hours postoperative following a total knee arthroplasty and is requesting an intravenous analgesic for severe surgical site pain.
- 4A client with resolved acute pancreatitis who is medically cleared and waiting for the nurse to review the final dietary discharge instructions.
Answer
The nurse should first assess the client with the tracheostomy and hypoxia (Airway/Breathing), followed by the client with the GI bleed and signs of shock (Circulation). The third assessment should be the client experiencing severe postoperative pain (Comfort), and the final assessment should be the stable client waiting for discharge instructions.
Prioritization in nursing follows the ABCs (Airway, Breathing, Circulation) framework and Maslow's Hierarchy of Needs. The client with a tracheostomy and an oxygen saturation of 87% has an immediate airway/breathing threat and is the highest priority. The client with a GI bleed and signs of hypovolemic shock (hypotension, tachycardia) has a critical circulatory issue and is the second priority. The client with severe postoperative pain requires urgent comfort measures and is the third priority. The client awaiting discharge instructions is physiologically stable and is the lowest priority.
Step-by-Step Solution
Key Concept
Prioritization of Care using ABCs and Maslow's Hierarchy