Upon arrival to the progressive care unit, the nurse assumes care for a group of clients. Determine the sequence in which the nurse should assess these clients, arranging them from highest priority (first) to lowest priority (last).
- 1A client with a tracheostomy whose mechanical ventilator is sounding a high-pressure alarm and who exhibits intercostal retractions.
- 2A client with a suspected gastrointestinal hemorrhage who presents with a blood pressure of 88/50 mm Hg and a heart rate of 124 beats/min.
- 3A client with a casted femur fracture who reports severe, unrelenting leg pain and exhibits pale, cool toes on the affected extremity.
- 4A client with acute pancreatitis who describes a constant abdominal pain rated 8 on a 0 to 10 scale and has hypoactive bowel sounds.
Cevap
The correct assessment order is: 1) the client with a tracheostomy and high-pressure alarm, 2) the client with a gastrointestinal hemorrhage and hypotension, 3) the client with a femur fracture and pale, cool toes, and 4) the client with acute pancreatitis and severe abdominal pain.
The priority of care is determined by the ABCs (Airway, Breathing, Circulation) framework, followed by limb-threatening conditions, and finally stable or expected findings. The client with the tracheostomy requires immediate airway intervention. The client with the GI bleed requires urgent circulatory support. The client with the femur fracture requires intervention to save the limb. The client with pancreatitis is stable with expected findings.
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Anahtar Kavram
Prioritization using the ABC (Airway, Breathing, Circulation) framework and the distinction between life-threatening, limb-threatening, and expected clinical findings.