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Zorluk: OrtaEstablishing Priorities

The nurse is assessing a client with a history of chronic heart failure who has just arrived at the emergency department reporting severe shortness of breath. Which of the following clinical cues require immediate intervention by the nurse? Select all that apply.

  1. Expectoration of pink, frothy sputumCevap
  2. B
    Report of needing three pillows to sleep comfortably at night
  3. New-onset restlessness and confusionCevap
  4. D
    Bilateral 2+ pitting edema in the lower extremities
  5. Respiratory rate of 34 breaths/min with accessory muscle useCevap

Cevap

The clinical cues requiring immediate intervention are the expectoration of pink, frothy sputum; new-onset restlessness and confusion; and a respiratory rate of 34 breaths/min with accessory muscle use.
The correct selections represent acute, life-threatening manifestations of severe heart failure exacerbation, specifically acute pulmonary edema and severe hypoxia. Expectoration of pink, frothy sputum indicates fluid in the alveoli (impaired gas exchange). A respiratory rate of 34 with accessory muscle use indicates impending respiratory failure (breathing compromise). New-onset restlessness and confusion are early signs of cerebral hypoxia (circulation/perfusion compromise). According to the ABCs (Airway, Breathing, Circulation) framework, these acute findings take absolute priority.

Adım Adım Çözüm

1
Analyze the client's baseline diagnosis and current presentation.
The client has a history of chronic heart failure but is presenting with acute severe shortness of breath.
Establishing the baseline helps differentiate between chronic expected findings and acute unexpected deteriorations.
2
Evaluate each finding using the Airway-Breathing-Circulation (ABC) framework and the acute vs. chronic prioritization principle.
Pink, frothy sputum, tachypnea with accessory muscle use, and new-onset confusion indicate acute, severe ABC compromise (pulmonary edema and hypoxia). Orthopnea and pitting edema are chronic, stable findings.
Prioritization requires identifying acute life threats that immediately compromise physiological integrity.
3
Select the cues that represent acute deterioration requiring immediate life-saving action.
The findings indicating pulmonary edema, severe respiratory distress, and cerebral hypoxia are selected.
These findings take highest priority as they will rapidly lead to death if not immediately treated.

Anahtar Kavram

Prioritization: Acute vs. Chronic and ABCs
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Konular

Establishing Priorities

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