During morning rounds on a medical-surgical floor, the nurse must determine the sequence of client assessments. Which client requires the nurse's immediate attention?
- A client receiving a new intravenous antibiotic infusion who reports a scratchy throat and tightness in the chest.Cevap
- BA client with an exacerbation of heart failure who has a scheduled dose of oral furosemide due in 30 minutes.
- CA client who is 3 days post-operative from a bowel resection and is requesting a PRN medication for abdominal cramping.
- DA client with type 2 diabetes mellitus who is waiting for a breakfast tray and has a fasting blood glucose of 118 mg/dL.
Cevap
The client receiving a new intravenous antibiotic infusion who reports a scratchy throat and tightness in the chest.
The correct answer identifies a client experiencing early symptoms of anaphylaxis (scratchy throat, chest tightness) in response to a new medication. According to the ABC (Airway, Breathing, Circulation) framework, a potential airway obstruction is a life-threatening emergency that must be addressed before any other client needs.
Adım Adım Çözüm
Anahtar Kavram
Prioritizing client care based on the Airway, Breathing, and Circulation (ABC) framework.