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Zorluk: ZorClient Care Assignments and Collaboration

A licensed practical nurse (LPN) on a medical-surgical unit receives simultaneous requests for assistance regarding four assigned clients. Arrange the clients in the order the LPN should evaluate them and report findings to the supervising registered nurse (RN), from first (highest priority) to last (lowest priority).

  1. 1A client with a history of asthma who is exhibiting intercostal retractions and audible wheezing.
  2. 2A client 6 hours postoperative from a bowel resection whose abdominal dressing is suddenly saturated with bright red blood.
  3. 3A client with type 2 diabetes mellitus who is diaphoretic, tachycardic, and reports feeling jittery.
  4. 4A client with an indwelling urinary catheter who reports bladder spasms and a strong urge to void.

Cevap

The correct priority sequence evaluates airway/breathing first, then circulation, then metabolic needs, and finally comfort needs. The order is: 1) Asthma with retractions, 2) Postoperative client with saturated dressing, 3) Diabetic client with hypoglycemia signs, 4) Client with bladder spasms.
The correct sequence utilizes the ABC (Airway, Breathing, Circulation) prioritization framework and Maslow's Hierarchy of Needs. The client with asthma is experiencing severe respiratory distress (airway/breathing), making them the absolute highest priority. The postoperative client has an active hemorrhage (circulation), which is the second priority. The client with signs of hypoglycemia has an urgent metabolic need, placing them third. Finally, the client with bladder spasms has a comfort/pain issue, which is the lowest priority among this group. The LPN must evaluate them in this order, implement immediate basic interventions, and rapidly collaborate with the RN.

Adım Adım Çözüm

1
Apply the primary ABC (Airway, Breathing, Circulation) framework.
Identify the client with asthma exhibiting retractions and wheezing as having an immediate airway and breathing threat.
Airway and breathing compromise is the most rapid cause of deterioration and death. This client must be evaluated and reported to the RN first.
2
Evaluate the remaining clients for severe circulatory threats.
Identify the postoperative client with a blood-saturated dressing as having active hemorrhage.
Circulatory collapse from severe bleeding is the next most immediate threat to life after airway issues, making this the second priority.
3
Assess the remaining clients for urgent metabolic or systemic needs.
Identify the client with diabetes experiencing diaphoresis and jitteriness as having symptomatic hypoglycemia.
Hypoglycemia is a critical metabolic state that can lead to neurological damage if untreated, but physiological survival (ABCs) must be secured first.
4
Assign the lowest priority to non-life-threatening comfort or routine needs.
Identify the client with bladder spasms as the final priority.
While pain requires management and catheter troubleshooting is necessary, it is a physiologically stable condition compared to the other emergencies.

Anahtar Kavram

Prioritization of Client Care Assignments using the ABC and Maslow's Frameworks
Tahmini Süre:1m 30s
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Konular

Client Care Assignments and Collaboration

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