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Difficulty: HardEstablishing Priorities

The nurse on a medical-surgical unit receives the morning handoff report for four clients. Which client should the nurse evaluate first?

  1. A
    A client receiving a continuous heparin infusion for a pulmonary embolism whose partial thromboplastin time (aPTT) is 90 seconds
  2. A client 24 hours post-open reduction internal fixation of a fractured femur who has become increasingly restless with a respiratory rate of 28/minAnswer
  3. C
    A client with acute pancreatitis experiencing severe epigastric pain radiating to the back with a capillary blood glucose of 218 mg/dL
  4. D
    A client with cirrhosis and significant ascites who exhibits shallow respirations and an oxygen saturation of 92% on room air

Answer

The client who is 24 hours post-femur fracture repair and exhibiting new-onset restlessness with tachypnea.
The correct answer describes a client exhibiting new-onset restlessness and tachypnea after a long bone fracture. Restlessness is frequently the earliest physiological sign of hypoxia. In this specific postoperative context, these symptoms highly suggest a developing fat embolism syndrome, which is a life-threatening acute respiratory emergency. According to the ABC (Airway, Breathing, Circulation) prioritization framework, this acute and unexpected change requires immediate nursing assessment and rapid intervention to prevent respiratory failure.

Step-by-Step Solution

1
Analyze the clinical status and expected findings for each client in the vignette.
Three clients present with abnormal but expected findings for their specific disease processes or treatments. One client presents with an acute, unexpected change.
Identifying expected versus unexpected clinical manifestations is the first step in nursing triage.
2
Apply the Airway-Breathing-Circulation (ABC) framework to determine the highest risk of immediate mortality.
The post-operative femur fracture client demonstrates early signs of hypoxia (restlessness, tachypnea), which threatens breathing and circulation (potential fat embolism).
Airway and breathing emergencies always take precedence over pain management, chronic adaptations, or stable therapeutic ranges.
3
Select the client requiring immediate life-saving assessment.
The client with the fractured femur is identified as the highest priority.
Early recognition of fat embolism syndrome is critical to prevent respiratory failure and death.

Key Concept

Prioritization using the ABC framework and the principle of acute/unexpected versus chronic/expected clinical findings.
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Establishing Priorities

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