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Question

Difficulty: EasyEstablishing Priorities

While covering for a colleague on a general medical unit, a nurse receives requests to evaluate four different clients. Which client must the nurse attend to first?

  1. A client with a right leg deep vein thrombosis who suddenly reports shortness of breath and pleuritic chest painAnswer
  2. B
    A client with chronic obstructive pulmonary disease who is resting in bed with an oxygen saturation of 91%
  3. C
    A client with a history of heart failure who has 2+ bilateral pitting edema in the lower extremities
  4. D
    A client who is one day post-appendectomy requesting oral medication for surgical site pain rated 4 on a 0 to 10 scale

Answer

The client with a deep vein thrombosis reporting sudden shortness of breath and pleuritic chest pain.
This client is exhibiting classic signs of a pulmonary embolism, a life-threatening acute complication of a deep vein thrombosis. Sudden shortness of breath and chest pain indicate an immediate threat to airway, breathing, and circulation, making this the highest clinical priority.

Step-by-Step Solution

1
Analyze each client's presentation using the Airway, Breathing, Circulation (ABC) prioritization framework.
The client with the deep vein thrombosis is presenting with new-onset respiratory and circulatory symptoms.
The ABC framework is the primary tool for establishing clinical priorities and identifying life-threatening emergencies.
2
Distinguish between expected chronic findings and unexpected acute changes among the remaining clients.
The chronic obstructive pulmonary disease saturation, heart failure edema, and mild post-operative pain are all expected, stable findings.
Unexpected, acute conditions must be prioritized over chronic, stable, or expected manifestations of a disease.

Key Concept

Prioritization: ABCs and Acute vs. Chronic
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Topics

Establishing Priorities

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