Following the morning handoff report on a maternity postpartum unit, a registered nurse must prioritize client assessments. In what order should the nurse assess the following clients? Arrange the clients from highest priority to lowest priority.
- 1A client 12 hours post-cesarean birth who is reporting a sudden onset of dyspnea and sharp chest pain.
- 2A client 3 hours post-vaginal delivery who has a boggy fundus and is experiencing heavy lochia rubra.
- 3A client 24 hours postpartum who is requesting prescribed ibuprofen for uterine cramping.
- 4A client preparing for discharge who requires a demonstration of newborn umbilical cord care.
Cevap
The correct sequence for assessing the clients is based on the ABC (Airway, Breathing, Circulation) framework and physiological stability. The highest priority is the client with dyspnea and chest pain (Airway/Breathing), followed by the client with a boggy fundus (Circulation), then the client with uterine cramping (Pain), and finally the client needing discharge education (Routine Teaching).
Based on the nursing process and prioritization frameworks, the nurse must always address Airway and Breathing first, followed by Circulation. Therefore, the client with a suspected pulmonary embolism is seen first, followed by the client at risk for hemorrhage. Pain management follows physiological survival needs, and routine teaching is always the lowest priority.
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Anahtar Kavram
Client Prioritization using ABCs and Maslow's Hierarchy of Needs