A nurse in the emergency department is caring for a client admitted with a severe asthma exacerbation. The client exhibits audible wheezing, intercostal retractions, and an oxygen saturation of 88% on room air. Arrange the following nursing actions in the correct order of priority from first to last.
- 1Position the client in a high Fowler's position.
- 2Apply supplemental oxygen via a non-rebreather mask.
- 3Administer prescribed nebulized albuterol.
- 4Establish peripheral intravenous (IV) access.
- 5Administer prescribed intravenous methylprednisolone.
Cevap
The correct sequence is to first position the client upright, apply supplemental oxygen, administer nebulized albuterol, establish IV access, and finally administer intravenous methylprednisolone.
The correct sequence adheres to the ABC prioritization framework and the principle of least invasive to most invasive interventions. Positioning immediately addresses airway mechanics (Airway). Oxygen administration directly treats life-threatening hypoxia (Breathing). Nebulized albuterol resolves the acute bronchospasm causing the distress (Breathing). IV access secures a route for circulation-level interventions (Circulation), allowing the administration of systemic corticosteroids, which take hours to act and are therefore the lowest immediate priority.
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Anahtar Kavram
In acute respiratory distress, nursing prioritization follows the ABC (Airway, Breathing, Circulation) framework, initiating the fastest and most direct non-pharmacological interventions before progressing to pharmacological and systemic treatments.