A registered nurse on a medical-surgical unit receives the morning handoff report for four assigned clients. In which order should the nurse assess these clients? Arrange the clients from highest priority (first) to lowest priority (last).
- 1A client with myasthenia gravis who reports new-onset difficulty swallowing and a weakened cough.
- 2A client receiving a continuous heparin infusion for a deep vein thrombosis who develops spontaneous epistaxis.
- 3A client with an exacerbation of heart failure who has bilateral basilar lung crackles and a brain natriuretic peptide (BNP) level of 800 pg/mL.
- 4A client with an acute exacerbation of ulcerative colitis who reports having five bloody, diarrheal stools overnight.
Cevap
The correct sequence prioritizes the airway threat (myasthenia gravis), followed by the acute circulation threat (heparin bleeding), then the expected abnormal systemic finding (heart failure), and finally the expected localized chronic symptom (ulcerative colitis).
The prioritization follows the ABCs and the acute vs. chronic framework. The client with myasthenia gravis has a new, acute threat to their airway (bulbar weakness), making them the highest priority. The client with spontaneous bleeding on a heparin drip represents an acute circulation threat and is the second priority. The client with heart failure has abnormal but expected findings (crackles, elevated BNP) for their condition, placing them third. The client with ulcerative colitis has expected symptoms (bloody stools) without life-threatening systemic compromise, making them the lowest priority.
Adım Adım Çözüm
Anahtar Kavram
Prioritizing client care using the ABCs (Airway, Breathing, Circulation) and Acute vs. Chronic frameworks.
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