The nurse is caring for the following assigned clients. The nurse should follow up on which client first? A client who has
The nurse is caring for the following assigned clients. The nurse should follow up on which client first? A client who has
A. mechanical ventilation and the low-pressure alarm sounds.
[69%]
B. a new colostomy and refuses to participate in care.
[2%]
C. acute glomerulonephritis and has periorbital edema.
[9%]
D. atrial fibrillation and an irregular pulse.
[20%]
Statistics
Subject/Lesson
Subject
Leadership & Management
Lesson
Prioritization
Client Need
Test Plan
Management of Care
Related Topic
Establishing Priorities
Item Type
Item Type
Analysis
Explanation
Choice A is correct. A client receiving mechanical ventilation requires multiple assessments. The low-pressure alarm is concerning for ventilator disconnection or low cuff pressure. The high-pressure alarm is concerning for obstruction such as secretions. This client should be assessed first under the priority model of "ABCs" = airway, breathing, circulation.
Choices B, C, and D are incorrect. A client with a new colostomy may be indifferent when caring for themselves as they adjust to the change in body image. Further, a client with acute glomerulonephritis will exhibit periorbital edema and high blood pressure. Finally, an irregular pulse is consistent with atrial fibrillation.
Related Videos
2 Key Topics
ABCs: Airway
15.5 Prioritization Part 1
Additional Info
The client receiving mechanical ventilation should always be assessed over the alarm. The nurse needs to ensure these alarms are functional, but the client's assessment is the priority if the alarm sound goes off. The low pressure alarm may sound for a cuff leak or disconnection. The high pressure alarm may be triggered for obstruction (client biting on the tube, secretions in the airway).
