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Zorluk: ZorEstablishing Priorities

A nurse on a medical-surgical unit is reviewing the electronic health records of six assigned clients following the morning shift report. Which of the following client findings require immediate follow-up by the nurse? Select all that apply.

  1. A client who is 1 day postoperative following a right total knee arthroplasty and reports sudden-onset dyspnea and pleuritic chest pain.Cevap
  2. B
    A client with end-stage renal disease scheduled for hemodialysis today who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L).
  3. A client receiving a continuous intravenous heparin infusion whose platelet count drops from 210,000/mm3 to 95,000/mm3.Cevap
  4. D
    A client admitted with acute pancreatitis who reports a mid-epigastric pain level of 7 on a 0 to 10 scale and has a serum lipase level of 850 U/L.
  5. A client with bacterial pneumonia who develops new-onset restlessness, confusion, and a respiratory rate of 28 breaths per minute.Cevap
  6. F
    A client with chronic heart failure who has 2+ bilateral pitting edema, fatigue, and a brain natriuretic peptide (BNP) level of 750 pg/mL.

Cevap

The clients requiring immediate follow-up are the postoperative client with sudden dyspnea and chest pain, the client on heparin with a significant drop in platelets, and the client with pneumonia experiencing new-onset restlessness and tachypnea.
In establishing priorities, the nurse must identify clients experiencing acute, life-threatening, or unexpected complications that require immediate intervention based on the Airway, Breathing, and Circulation (ABC) prioritization framework. A sudden onset of dyspnea and pleuritic chest pain in a postoperative client strongly suggests a pulmonary embolism (an airway/breathing emergency). A significant drop in platelet count (greater than 50% from baseline or below 150,000/mm3) in a client receiving heparin indicates heparin-induced thrombocytopenia (HIT), a life-threatening paradoxical clotting condition requiring immediate cessation of the infusion. New-onset restlessness and confusion accompanied by tachypnea in a client with pneumonia are critical early signs of hypoxemia and respiratory decline, necessitating immediate airway and breathing support.

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1
Analyze each client's clinical presentation using the Airway, Breathing, Circulation (ABC) framework and the concept of expected versus unexpected findings.
Identified that three clients have acute, unexpected, or life-threatening conditions, while the other three have expected manifestations of their chronic or admitting diagnoses.
Prioritization requires the nurse to first address clients with acute physiological deterioration or compromised ABCs.
2
Evaluate the clients with expected or chronic findings.
The clients with end-stage renal disease (potassium 5.2 mEq/L), acute pancreatitis (pain and elevated lipase), and chronic heart failure (edema and elevated BNP) all exhibit findings that are anticipated for their disease processes.
Clients with expected abnormalities are considered stable relative to those with sudden, uncompensated changes.
3
Select the clients requiring immediate intervention.
The postoperative client has signs of a pulmonary embolism. The client on heparin has signs of heparin-induced thrombocytopenia. The client with pneumonia has early signs of hypoxemia.
These three clients are experiencing unexpected, acute complications that threaten airway, breathing, or circulation and could lead to rapid clinical decline if not immediately addressed.

Anahtar Kavram

Clinical Prioritization: Acute vs. Chronic and Unexpected vs. Expected Findings
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Establishing Priorities

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