A registered nurse (RN) assumes care for four clients on a medical-surgical telemetry unit after receiving the shift report. In which order should the RN assess these clients? Arrange the clients from highest priority (first to be seen) to lowest priority (last to be seen).
- 1A client with a tracheostomy exhibiting new-onset audible stridor and an oxygen saturation of 88% on room air.
- 2A client with heart failure who is suddenly confused and has a newly prescribed STAT dose of intravenous furosemide.
- 3A client scheduled for a cardiac catheterization in 2 hours who requires completion of the preoperative checklist.
- 4A client with a resolved deep vein thrombosis who is awaiting removal of a peripheral intravenous catheter and final discharge instructions.
Cevap
The RN must first assess the client with tracheostomy stridor (airway), followed by the client with new-onset confusion (circulation/perfusion), then the pre-operative client (time-sensitive), and finally the discharge client (stable).
In nursing prioritization, acute life-threatening conditions involving the airway always take precedence. The client with stridor has a critical airway emergency. Once the airway is secured, circulation and perfusion issues, such as new-onset confusion in a heart failure client, are addressed. Between the two stable clients, time-sensitive needs (preoperative checklist) are prioritized over routine, flexible tasks (discharge).
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Anahtar Kavram
Prioritization using the ABC (Airway, Breathing, Circulation) framework and Maslow's Hierarchy of Needs.