At the start of the morning shift, a nurse on a medical unit reviews the client census to determine the sequence of rounds. Arrange the following clients in the order the nurse should assess them, from most urgent to least urgent.
- 1A client admitted with an acute asthma exacerbation who is exhibiting new-onset audible wheezing and a respiratory rate of 32 breaths per minute.
- 2A client who is preoperative for an appendectomy and reports a sudden increase in abdominal pain to an 8 on a 0 to 10 scale.
- 3A client with diabetes mellitus who requires a routine morning blood glucose check and administration of scheduled subcutaneous insulin.
- 4A client who is medically stable and awaiting a final review of printed discharge instructions before leaving the hospital.
Cevap
The correct assessment sequence is: first, the client with asthma and wheezing; second, the preoperative client with severe abdominal pain; third, the diabetic client needing routine insulin; and finally, the stable client awaiting discharge instructions.
In nursing prioritization, clients experiencing acute changes in airway, breathing, or circulation are always seen first. Therefore, the client with wheezing and tachypnea takes precedence. The next priority is acute pain or potential physiological deterioration, such as the preoperative appendicitis client reporting a sudden increase in pain. Routine, scheduled care for stable clients, like insulin administration, follows acute issues. Finally, stable clients awaiting discharge are the lowest priority for immediate assessment.
Adım Adım Çözüm
Anahtar Kavram
Prioritization using the ABC (Airway, Breathing, Circulation) framework and Maslow's Hierarchy of Needs.
Tahmini Süre:1m 0s