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Difficulty: HardAssignment, Delegation and Supervision

After receiving the shift report on an adult oncology unit, a registered nurse must determine the sequence of client assessments. Arrange the clients in the order they should be assessed, from highest priority (most urgent) to lowest priority (least urgent).

  1. 1A client with a cervical lymph node malignancy who has developed inspiratory stridor and difficulty swallowing.
  2. 2A client receiving an intravenous vesicant chemotherapy agent who reports burning and swelling at the infusion site.
  3. 3A client with multiple myeloma who reports increasing lethargy and has a serum calcium level of 12.0 mg/dL (3.0 mmol/L).
  4. 4A client scheduled for surgical resection of a breast tumor who is crying and expressing fear about the procedure.

Answer

The correct assessment sequence is: 1) the client with stridor, 2) the client with a potential vesicant extravasation, 3) the client with symptomatic hypercalcemia, and 4) the client with anxiety.
The correct sequence follows the ABC framework and Maslow's hierarchy of needs. Airway compromise (stridor) is the highest priority, followed by an acute, actively occurring tissue injury (extravasation). Systemic metabolic issues (hypercalcemia) follow acute emergencies, and psychosocial needs (anxiety) are addressed after all physiological needs are stabilized.

Step-by-Step Solution

1
Identify the client with the most critical, immediately life-threatening condition using the ABC framework.
The client with the cervical malignancy has inspiratory stridor, indicating impending airway obstruction.
Airway issues take absolute precedence over all other physiological emergencies.
2
Determine the second priority among the remaining clients with acute needs.
The client receiving the vesicant chemotherapy agent has signs of extravasation (burning, swelling).
Extravasation is an actively occurring injury that will result in severe, irreversible tissue necrosis if the infusion is not stopped instantly, placing it immediately after airway management.
3
Evaluate the remaining clients based on physiological versus psychosocial stability.
The client with multiple myeloma has symptomatic hypercalcemia (lethargy, elevated calcium).
Systemic metabolic imbalances represent a physiological threat that must be addressed before psychological needs.
4
Assign the lowest priority to the most physiologically stable client.
The client crying about an upcoming mastectomy is assigned the last assessment priority.
According to Maslow's hierarchy of needs, emotional and psychosocial support are provided after acute physiological needs are stabilized.

Key Concept

Prioritization of Care using the ABCs and Maslow's Hierarchy of Needs
Estimated Time:1m 30s
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Topics

Assignment, Delegation and Supervision

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