A registered nurse is receiving shift report for four assigned clients on a medical-surgical unit. In what order should the nurse assess these clients? Arrange the clients from highest priority (to be seen first) to lowest priority (to be seen last).
- 1A client admitted with an asthma exacerbation who is experiencing new-onset expiratory wheezing.
- 2A client with heart failure who reports increased swelling in the lower extremities.
- 3A client who is 1 day postoperative and requesting oral pain medication.
- 4A client preparing for discharge who requires teaching on a new medication prescription.
Answer
The correct order is: the client with asthma exacerbation (highest priority), followed by the client with heart failure, then the postoperative client requesting pain medication, and finally the client preparing for discharge (lowest priority).
Prioritization in nursing follows the Airway-Breathing-Circulation (ABC) framework and the principle of addressing unstable, acute problems before stable, chronic ones. The client with new-onset wheezing has an acute breathing compromise and must be assessed first. The client with heart failure and new swelling has a circulation issue and is assessed second. The postoperative client requesting pain medication has a non-life-threatening physiological need and is assessed third. The stable client requiring discharge teaching is assessed last.
Step-by-Step Solution
Key Concept
Airway-Breathing-Circulation (ABC) framework and acute versus stable prioritization