Question

a nurse coming on shift receives a handoff report from the outgoing nurse on the status of assigned clients. the nurse exercises clinical judgment, prioritizing the need to see which client first?

• client receiving continuous intravenous fluid therapy to treat dehydration
• client who received an antiemetic 4 hours ago for vomiting
• client who had abdominal surgery 2 days ago and requires a dressing change
• client who was started on oxygen therapy for extreme shortness of breath

Explanation:

Analyze client scenarios using prioritization frameworks

Using the Priority Nursing Interventions knowledge point, we apply the Airway-Breathing-Circulation (ABC) framework and Maslow's Hierarchy of Needs to evaluate which client requires the most immediate assessment:

• Client 1 (Dehydration): Receiving continuous IV fluids. This is a circulation-related intervention, but the client is already receiving treatment and is stable.
• Client 2 (Vomiting): Received an antiemetic 4 hours ago. This is a follow-up evaluation, not an acute life-threatening emergency.
• Client 3 (Post-op dressing change): Had surgery 2 days ago. A dressing change is a routine, scheduled task that can be safely delayed.
• Client 4 (Extreme shortness of breath): Started on oxygen therapy. This directly impacts "Breathing" (the "B" in ABCs). A client with extreme shortness of breath is unstable and requires immediate, close monitoring to evaluate the effectiveness of the oxygen therapy and ensure they do not deteriorate.

Identify the highest priority client

Using the Priority Nursing Interventions knowledge point, the nurse must prioritize the client with a compromised respiratory status over stable clients or those with routine care needs. Therefore, the client started on oxygen therapy for extreme shortness of breath must be seen first.

Answer:

• client receiving continuous intravenous fluid therapy to treat dehydration
• client who received an antiemetic 4 hours ago for vomiting
• client who had abdominal surgery 2 days ago and requires a dressing change
• client who was started on oxygen therapy for extreme shortness of breath (Correct answer)