A client is brought to the emergency department with severe acute alcohol intoxication. The client is lethargic and suddenly begins to vomit. Arrange the following nursing actions in the correct order of priority from first to last.
- 1Turn the client into a lateral (side-lying) position.
- 2Assess the client's respiratory rate and oxygen saturation.
- 3Establish peripheral intravenous (IV) access.
- 4Administer prescribed intravenous fluids.
Cevap
The correct sequence prioritizes immediate airway protection (turning the client), followed by respiratory assessment, preparation for circulatory support (IV access), and finally the administration of prescribed treatments.
In any emergency scenario, the ABC (Airway, Breathing, Circulation) framework dictates the order of prioritization. When a lethargic, intoxicated client vomits, the most immediate, life-threatening risk is pulmonary aspiration, which compromises the airway. Therefore, the very first action must be a rapid physical intervention to protect the airway by turning the client to a lateral position. Once the airway is secured, the nurse proceeds to 'B' (Breathing) by assessing the respiratory rate and oxygen saturation. Following this, the nurse addresses 'C' (Circulation) and prepares for intervention by establishing IV access. Finally, the nurse implements the prescribed medical treatment by administering intravenous fluids.
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Anahtar Kavram
Prioritization using the ABC (Airway, Breathing, Circulation) framework during acute substance intoxication emergencies.