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Difficulty: MediumEstablishing Priorities

The registered nurse is prioritizing care for four assigned clients at the start of the shift. Which client requires the nurse's immediate assessment?

  1. A client with an acute asthma exacerbation who has become lethargic and exhibits significantly diminished breath sounds bilaterally.Answer
  2. B
    A client with a suspected gastrointestinal hemorrhage who has a resting heart rate of 110 beats per minute and a blood pressure of 104/72 mmHg.
  3. C
    An older adult client with advanced dementia who is wandering near the unit exit doors and repeatedly asking to go home.
  4. D
    A client who is 24 hours postoperative following an exploratory laparotomy and reports incisional pain rated as 8 on a 0 to 10 scale.

Answer

The client with an acute asthma exacerbation who has become lethargic and exhibits significantly diminished breath sounds bilaterally.
The correct answer identifies a client in impending respiratory failure. In asthma, a shift from wheezing to diminished breath sounds (a 'silent chest') combined with lethargy indicates severe air trapping, hypercapnia, and exhaustion. According to the ABC (Airway, Breathing, Circulation) prioritization framework, a threat to the airway or breathing is always the highest priority because it leads to rapid physiological collapse.

Step-by-Step Solution

1
Analyze each client's clinical presentation to determine if the findings are expected or unexpected for their condition.
The postoperative pain and dementia wandering are expected/chronic. The asthma deterioration and GI bleed tachycardia are unexpected/acute.
Prioritization requires identifying acute, unstable conditions over chronic, stable, or expected conditions.
2
Apply the ABC (Airway, Breathing, Circulation) framework to the remaining acute clients.
The client with asthma is experiencing a breathing/airway crisis (diminished breath sounds and lethargy indicate hypercapnia and respiratory failure). The client with a GI bleed is experiencing a circulation issue (tachycardia indicating early shock).
The ABC framework dictates that airway and breathing emergencies take absolute precedence over circulatory emergencies.
3
Select the client with the highest priority physiological need.
The client with the asthma exacerbation must be assessed first to secure the airway and support breathing.
Without an airway and breathing, the client will rapidly progress to cardiopulmonary arrest.

Key Concept

Establishing Priorities using the ABC (Airway, Breathing, Circulation) Framework
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Topics

Establishing Priorities

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