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Difficulty: HardEstablishing Priorities

A nurse on an adult medical-surgical unit is reviewing the electronic health records and morning assessment data for a group of assigned clients. Which of the following client findings require immediate follow-up by the nurse? Select all that apply.

  1. A client receiving a continuous heparin infusion for a deep vein thrombosis who develops a sudden onset of a severe headache and sluggish pupillary response.Answer
  2. B
    A client admitted with acute pancreatitis who reports a pain level of 7 on a 0 to 10 scale and has a fasting blood glucose level of 180 mg/dL (10.0 mmol/L).
  3. A client with a tracheostomy who has a sudden decrease in oxygen saturation from 96% to 88% and absent breath sounds on the right side of the chest.Answer
  4. D
    A client with Addison's disease taking prescribed hydrocortisone who has a blood pressure of 110/70 mm Hg and a serum sodium level of 135 mEq/L (135 mmol/L).
  5. A client who underwent a total thyroidectomy 12 hours ago and is reporting a tingling sensation around the mouth and in the fingertips.Answer

Answer

The findings requiring immediate follow-up are the sudden severe headache with sluggish pupils in a client on heparin, the sudden hypoxemia with absent breath sounds in a client with a tracheostomy, and the perioral tingling in a post-thyroidectomy client.
The correct selections represent acute, life-threatening emergencies that require immediate intervention. A sudden, severe headache with sluggish pupils in a client receiving an anticoagulant strongly suggests an intracranial hemorrhage, which is a life-threatening neurological emergency. A sudden drop in oxygen saturation combined with absent unilateral breath sounds in a client with a tracheostomy indicates a severe airway and breathing compromise, such as a pneumothorax or tube displacement. Tingling around the mouth and in the fingertips (paresthesia) in a client recovering from a thyroidectomy is a classic early sign of hypocalcemia (due to inadvertent parathyroid removal or injury), which can rapidly escalate to life-threatening tetany and laryngospasm (airway obstruction).

Step-by-Step Solution

1
Evaluate each client's presentation against the Airway-Breathing-Circulation (ABC) framework and the potential for acute, life-threatening deterioration.
Identify which clients are experiencing unexpected, severe physiological instability versus expected or chronic manifestations.
Prioritization requires identifying the most critical clients who will suffer severe harm or death if interventions are delayed.
2
Analyze the client on a heparin infusion with a sudden headache and sluggish pupils.
This indicates an acute neurological change and potential intracranial bleed, representing a severe circulatory/neurological emergency.
Anticoagulants carry a high risk of bleeding, and acute intracranial changes must be addressed immediately to prevent permanent brain injury or death.
3
Analyze the client with a tracheostomy experiencing sudden oxygen desaturation and unilateral absent breath sounds.
This represents a critical airway and breathing emergency (e.g., pneumothorax, severe mucus plug, or tube displacement).
Airway compromise is the highest priority in emergency triage and requires immediate assessment and intervention to restore oxygenation.
4
Analyze the post-thyroidectomy client reporting perioral and extremity tingling.
These are signs of acute hypocalcemia (tetany), which can rapidly lead to fatal laryngospasm.
Electrolyte imbalances that threaten airway patency are high-priority, life-threatening emergencies.
5
Evaluate the remaining clients (pancreatitis and Addison's disease).
The pancreatitis client has expected disease manifestations (pain, elevated glucose). The Addison's disease client has stable, normal assessment findings.
Clients with stable, expected findings or chronic, controlled conditions are lower priority than those with acute physiological instability.

Key Concept

Prioritization of Care using the ABCs and Acute vs. Chronic Framework
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Establishing Priorities

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