Examkin

Soru

Zorluk: OrtaEstablishing Priorities

A registered nurse begins a shift on a pediatric unit and reviews the current status of assigned clients. Which client requires immediate assessment by the nurse?

  1. A
    An 8-year-old with sickle cell anemia experiencing a vaso-occlusive crisis who reports severe joint pain
  2. A 6-year-old who underwent a tonsillectomy earlier in the day and is observed swallowing frequentlyCevap
  3. C
    A 3-year-old with Kawasaki disease who is highly irritable and has a temperature of 102.6°F (39.2°C)
  4. D
    A 10-year-old with acute poststreptococcal glomerulonephritis who has generalized edema and tea-colored urine

Cevap

The 6-year-old who underwent a tonsillectomy and is swallowing frequently requires the most immediate assessment.
Frequent or continuous swallowing in a client who recently had a tonsillectomy is a subtle but critical sign of active bleeding in the surgical area. This bleeding poses an immediate threat to the client's airway and circulation, making it a medical emergency that requires priority assessment and intervention.

Adım Adım Çözüm

1
Analyze each client's condition using the Airway-Breathing-Circulation (ABC) framework and the concept of expected versus unexpected findings.
The post-tonsillectomy client has a potential airway and circulation compromise, while the other clients present with expected disease manifestations.
Prioritization questions require identifying the client with the most acute, life-threatening, or unstable condition.
2
Evaluate the clinical significance of frequent swallowing in a postoperative tonsillectomy client.
Frequent swallowing indicates blood trickling down the throat, which is a key sign of active postoperative hemorrhage.
Hemorrhage can rapidly lead to airway obstruction or hypovolemic shock, establishing this client as the highest priority.

Anahtar Kavram

Prioritization relies on the ABC (Airway, Breathing, Circulation) framework, addressing unexpected, acute, or life-threatening complications before managing expected disease manifestations or basic comfort needs.
Bu soruyu puanla

Konular

Establishing Priorities

Bu konudan daha fazla soru