Respiratory Question #13

Question

The nurse is caring for several clients on the hospital respiratory unit and all require initial assessment following off-going shift report. In what numerical order will the nurse prioritize her assessments based on the following clients:

1. Elderly client with bacterial pneumonia, shortness of breath, and 102° temp.
2. 35-year-old client with tuberculosis and a cough.
3. 50-year-old client following lobectomy with chest tube asking for pain medicine.
4. 48-year-old client with emphysema needing scheduled medications who is not distressed.

Answers

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

Overview

Explanation

The most acutely ill client with highest priority is the elderly client with pneumonia, elevated temperature, and shortness of breath. The client may experience 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 need, not on nurse convenience, and priority requires critical thinking and decision-making skills.

Learning Outcomes

Test Taking Tip

Video Rationale