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Zorluk: OrtaEstablishing Priorities

A clinical leader is evaluating current client statuses on a medical step-down unit following recent assessments. Which of the following client situations represent an unstable condition requiring immediate nursing intervention? Select all that apply.

  1. A client with bacterial pneumonia who suddenly exhibits acute confusion and an oxygen saturation of 86% on room air.Cevap
  2. A client receiving a continuous intravenous heparin infusion who reports spontaneous epistaxis and has an activated partial thromboplastin time (aPTT) of 135 seconds.Cevap
  3. A client with type 1 diabetes mellitus who is noticeably diaphoretic, tachycardic, and reports sudden severe shakiness.Cevap
  4. D
    A client with chronic obstructive pulmonary disease (COPD) who has a resting oxygen saturation of 91% on 2 liters per minute of supplemental oxygen.
  5. E
    A client admitted for acute pyelonephritis who complains of flank pain and has voided 250 mL of cloudy urine.

Cevap

The correct selections are the client with pneumonia experiencing acute confusion, the client on a heparin infusion with spontaneous bleeding, and the client with type 1 diabetes exhibiting signs of acute hypoglycemia.
The correct clinical presentations all involve acute, unstable deteriorations that threaten life or limb if not immediately addressed. Acute confusion with hypoxemia indicates severely impaired gas exchange. Spontaneous bleeding with a supratherapeutic aPTT indicates a severe risk for hemorrhage. Diaphoresis, tachycardia, and shakiness are classic indicators of acute hypoglycemia, which can rapidly progress to unresponsiveness.

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1
Analyze each client's presentation to identify sudden, acute changes versus chronic, expected findings.
Three clients display acute deteriorations (hypoxia, bleeding, hypoglycemia), while two display findings expected for their respective diagnoses (COPD, pyelonephritis).
Prioritization requires addressing sudden physiological instability before assessing stable or expected disease manifestations.
2
Apply the Airway, Breathing, Circulation (ABC) and life-threat prioritization frameworks to the acute findings.
The acute confusion from hypoxia (Breathing), critical bleeding risk (Circulation), and sudden hypoglycemia (Metabolic life-threat) all represent immediate threats to life.
Conditions that compromise the ABCs or represent acute metabolic emergencies demand immediate nursing intervention over stable states.

Anahtar Kavram

Prioritizing client care by distinguishing acute, life-threatening physiological changes from stable, expected manifestations of a disease.
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Establishing Priorities

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