Examkin

Soru

Zorluk: KolayEstablishing Priorities

A nurse at a pediatric clinic is reviewing telephone messages from caregivers. Which client should the nurse contact first?

  1. A 4-year-old client with asthma who has intercostal retractions and nasal flaringCevap
  2. B
    A 6-month-old client who is fussy and frequently pulling at the right ear
  3. C
    A 7-year-old client with a temperature of 100.2°F (37.9°C) and a mild cough
  4. D
    A 2-month-old client who spit up a small amount of formula after the last two feedings

Cevap

The client with asthma who has intercostal retractions and nasal flaring.
According to the Airway, Breathing, Circulation (ABC) prioritization framework, intercostal retractions and nasal flaring are severe signs of acute respiratory distress and hypoxia in a pediatric client. This child requires immediate medical intervention to maintain a patent airway and ensure adequate oxygenation.

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1
Review the clinical presentation of each client to determine stability.
Three clients have stable, expected, or non-life-threatening conditions, while one client has signs of acute compromise.
Prioritization requires differentiating between expected findings and acute physiological deterioration.
2
Apply the Airway, Breathing, and Circulation (ABC) prioritization framework.
The client with intercostal retractions and nasal flaring has a 'Breathing' issue, taking the highest priority.
Conditions that threaten the airway or breathing must be addressed before pain, low-grade infections, or expected physiological findings.

Anahtar Kavram

Prioritization using the ABC framework (Airway, Breathing, Circulation)
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Konular

Establishing Priorities

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