Medical Surgical Assessment & Lung sounds #5

Question

The nurse is caring for several clients on the hospital respiratory unit and all require initial assessment following the off-going shift report. In what numerical order will the nurse prioritize assessments based on the following clients?
1. Elderly client with bacterial pneumonia, shortness of breath, and 102°F/ 38.9°C temp.
2. 35-year-old client with tuberculosis and a productive cough.
3. 50-year-old client following lobectomy with chest tube requesting pain medicine.
4. 48-year-old client with emphysema needing scheduled medications in no distress.

Answers

  1. 1, 3, 2, 4
    • Rationale:

      The most acutely ill client with highest priority is the elderly client with pneumonia, elevated temperature, and shortness of breath. The client may experience a decline in oxygenation as a result. The next priority will be the client with a chest tube asking for pain medication. Pain control is important and part of the assessment and intervention, but is not as important as maintaining airway of an already compromised client (pneumonia with symptoms). The third client to be assessed is the one with tuberculosis and a cough, since full assessment of the cough, mucous, teaching, and secretion hygiene is important, but not as critical as the first two. The last person to prioritize is the emphysema client who is receiving routine scheduled medications. Prioritization should be based on client needs, not on nurse convenience, and priority requires critical thinking and decision-making skills.

  2. 2, 3, 4, 1
    • Rationale:
  3. 3, 1, 4, 2
    • Rationale:
  4. 4, 1, 3, 2
    • Rationale:

Overview

The focus of this question is the use of critical thinking to prioritize the assessment of a group of 4 clients. The nurse must decide which client, based on the hand-off report, is the most critically ill client, requiring immediate attention and assessment. A client with emphysema with no signs of distress is the most stable and may be assessed last by the nurse.

Explanation

Learning Outcomes

An elderly client with bacterial pneumonia is at high risk for complications of the disease process including acute respiratory failure and should therefore be assessed first. This client is displaying signs of acute distress which needs to be immediately addressed by the nurse. The next client to be assessed should be the client requesting pain medication. The final two clients are not displaying any unexpected signs/symptoms or making any requests and are therefore the nurse’s lowest priorities.

Test Taking Tip

A-B-C. Also, counting risk factors will assist in answering this question correctly. The client in option #1 has the most risk factors for rapid deterioration including age, an acute respiratory illness, fever, and shortness of breath.

Video Rationale