After receiving the morning report on a mixed acuity medical unit, the nurse must prioritize the initial assessments for four clients. Order the clients from the highest priority (first to be seen) to the lowest priority (last to be seen).
- 1A client with an acute asthma exacerbation who is suddenly restless and exhibiting audible wheezing
- 2A client with type 1 diabetes mellitus who is reporting a sudden onset of tremors and diaphoresis
- 3A client with bacterial pneumonia who is requesting oral analgesics for mild pleuritic chest pain
- 4A client with lower extremity cellulitis who requires a routine sterile dressing change prior to physical therapy
Cevap
The correct sequence prioritizes the airway emergency first, followed by the metabolic emergency, then pain management, and finally the routine procedural task.
Prioritization in nursing strictly follows the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. The asthma client presents an immediate airway and breathing threat (highest priority). The diabetic client presents a circulation and metabolic threat (second priority). The pneumonia client has an acute but non-life-threatening comfort need (third priority). The cellulitis client requires a routine, stable task (lowest priority).
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Anahtar Kavram
Prioritization using the Airway, Breathing, Circulation (ABC) framework and acute vs. chronic condition analysis.
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