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Zorluk: ZorEstablishing Priorities

A float nurse is covering a busy surgical oncology and endocrine unit. Which clinical presentation among the assigned clients requires the nurse's immediate intervention?

  1. A
    A client 24 hours post-modified radical mastectomy who has accumulated 45 mL of serosanguineous drainage in a closed-suction device over the past 4 hours.
  2. B
    A client recovering from a transsphenoidal hypophysectomy who reports severe thirst and has documented a clear urine output of 350 mL over the last hour.
  3. A client two hours post-total thyroidectomy who exhibits a high-pitched, harsh inspiratory sound and frequent swallowing.Cevap
  4. D
    A client with primary adrenal insufficiency who reports profound generalized fatigue and has a current blood pressure of 98/64 mmHg.

Cevap

The client who is two hours post-total thyroidectomy exhibiting a high-pitched, harsh inspiratory sound (stridor) and frequent swallowing requires immediate intervention.
The client exhibiting a high-pitched, harsh inspiratory sound (stridor) and frequent swallowing immediately following a thyroidectomy is demonstrating signs of acute airway obstruction. Stridor indicates laryngeal edema or laryngospasm, while frequent swallowing suggests active hematoma formation compressing the trachea. According to the Airway-Breathing-Circulation (ABC) framework, maintaining a patent airway is the absolute highest clinical priority, requiring immediate rapid response intervention.

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1
Analyze the assessment of the post-thyroidectomy client.
Stridor and frequent swallowing indicate acute laryngeal edema or hematoma formation compressing the airway.
To identify critical airway threats requiring immediate emergency response.
2
Analyze the clinical presentation of the client recovering from a transsphenoidal hypophysectomy.
Urine output of 350 mL/hr and severe thirst indicate diabetes insipidus, a severe fluid volume issue.
To determine if a life-threatening secondary complication is present.
3
Evaluate the client with primary adrenal insufficiency.
Blood pressure of 98/64 mmHg and fatigue are typical chronic findings for Addison's disease.
To differentiate between expected baseline data and acute deterioration.
4
Assess the finding for the client 24 hours post-mastectomy.
45 mL of serosanguineous drainage over 4 hours is expected and normal.
To eliminate stable clients from the prioritization hierarchy.
5
Apply the Airway-Breathing-Circulation (ABC) prioritization framework.
The thyroidectomy client's airway obstruction takes absolute precedence over the fluid volume deficit (circulation) of the hypophysectomy client.
Airway compromise is the most rapid cause of death and must be addressed first.

Anahtar Kavram

Airway-Breathing-Circulation (ABC) Prioritization Framework
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Konular

Establishing Priorities

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