The nurse has received the shift report for four assigned clients. In what order should the nurse assess these clients? Arrange the clients from highest priority (first to be assessed) to lowest priority (last to be assessed).
- 1A client 4 hours post-thyroidectomy who reports a new onset of difficulty swallowing and a feeling of tightness in the neck
- 2A client with heart failure who has developed new-onset atrial fibrillation with a ventricular rate of 128 beats/min
- 3A client admitted with acute cholecystitis who is requesting intravenous pain medication for severe abdominal pain
- 4A client scheduled for discharge later today who requires instructions on how to use a newly prescribed metered-dose inhaler
Cevap
The correct sequence of assessment is: the post-thyroidectomy client first, followed by the client with new-onset atrial fibrillation, then the client with acute cholecystitis, and finally the client requiring discharge teaching.
Based on the ABC prioritization framework, airway emergencies take absolute precedence. The post-thyroidectomy client's symptoms suggest a developing airway obstruction. Next is circulation; the client with rapid atrial fibrillation is at risk for compromised cardiac output. Third is the client with acute pain, which requires prompt but not life-saving intervention. Finally, routine tasks such as discharge teaching are the lowest priority and should be addressed last.
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Anahtar Kavram
Prioritization utilizing the ABC (Airway, Breathing, Circulation) framework and the Acute vs. Routine care principles.