A nurse has received change-of-shift report on four clients.
Which of the following clients should the nurse plan to see first?
A.
A client who is short of breath.
B.
A client who received pain medication 30 min ago.
C.
A client who is to be discharged at 11:00.
D.
A client who is ambulatory and going for an x-ray at 10:00.
The Correct answer and Explanation is:
Correct Answer: A. A client who is short of breath.
Explanation:
In the context of prioritizing client care, the nurse should plan to see the client who is experiencing shortness of breath first. This decision is based on the application of critical thinking principles, including the ABCs (Airway, Breathing, Circulation), Maslow’s hierarchy of needs, and the urgency of the client’s condition.
1. ABCs (Airway, Breathing, Circulation): The ABC framework is a fundamental tool used in nursing to prioritize patient care. Airway and breathing take precedence because a compromised airway or respiratory distress can quickly lead to life-threatening situations. Shortness of breath indicates that the client might be experiencing respiratory distress, which could rapidly progress to hypoxia or respiratory failure if not promptly addressed. The nurse needs to assess the client’s respiratory status immediately, including checking for signs of cyanosis, measuring oxygen saturation, and listening to lung sounds. Interventions may include administering oxygen, positioning the client for optimal breathing, or notifying the healthcare provider for further evaluation.
2. Maslow’s Hierarchy of Needs: Maslow’s hierarchy of needs is another prioritization tool in nursing. According to Maslow, physiological needs (such as breathing) are the most basic and must be met before attending to other needs, such as pain relief, discharge planning, or mobility. A client with compromised breathing is at risk of not meeting this fundamental physiological need, which makes this situation a high priority.
3. Urgency and Potential Complications: Shortness of breath can be a symptom of various conditions, such as pulmonary embolism, heart failure, or severe asthma exacerbation. These conditions can deteriorate rapidly, leading to life-threatening complications if not promptly managed. Therefore, the nurse should prioritize this client to prevent potential complications.
4. Comparison with Other Clients:
- Client B: While pain management is important, the client has already received pain medication, and the effectiveness of the intervention will need to be reassessed later, usually within an hour. This client is not in immediate danger.
- Client C: Discharge planning is a necessary part of care, but it is not an urgent matter compared to a client who is short of breath.
- Client D: The client who is ambulatory and scheduled for an x-ray is stable and does not have an immediate need compared to the client with respiratory distress.
In conclusion, prioritizing the client with shortness of breath aligns with nursing principles aimed at ensuring the safety and well-being of clients by addressing the most critical and life-threatening conditions first.