Medical Surgical Labs Priority Labs #4

Question

The nurse arrives at work, receives report and lab studies on four clients. Which of the four clients should the nurse assess first?

Answers

  1. The client with a PaCO2 of 39 mmHg and pH of 7.
    • Rationale:

      This answer is not correct because the ABGs are normal in this lab study. PaO2 75-100 mmHG, PaCO2 35-45 mmHG, ph 7.35-7.45 and HcO3 22-26 mEq/L.

  2. The client with a platelet count of 100,000.
    • Rationale:

      This answer is correct because the lab indicates the client is at risk for bleeding. The platelet count is critically low. A normal range for platelets is 150,000 and 450,000. Circulation is the third in the ABCs of triage.

  3. The client with a white blood cell count of 4,500.
    • Rationale:

      This answer is not correct because although this lab indicates the white blood cell count is too low, the client is not in immediate danger with airway, breathing, or circulation. This client is leukopenic.

  4. The client with a white blood cell count of 11,000.
    • Rationale:

      This answer is not correct because although the white blood cell count is too high, the client’s lab does not reveal that the airway, breathing, or circulation are compromised at this time. This lab signifies an infection.

Overview

Lab studies are tools nurses use when prioritizing clients. Remember the ABCs of triage: Airway, breathing, and circulation.

Explanation

Learning Outcomes

The nurse should always consider signs and symptoms during triage. Another useful tool is lab studies. Studies that will indicate an airway and breathing problem will be ABGs, PFTs, CXR, and pulse oximetry. Lab studies that will signify circulation issues will be platelets, PT/INR, PTT, K+, and EKG studies. When assessing for infection, the nurse would look at WBC, CRP, ESR, and blood culture tests. The client with a platelet count of 100,000 is at risk for bleeding and this should be addressed first before the clients with abnormal white counts. White blood cell counts indicate infection.

Test Taking Tip

Remember the ABCs of triage even when reading lab studies: Airway, breathing, and circulation.

Video Rationale