Nursing Prioritization Delegation Assignment Q 82
Nurse Skye is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?
A. A client scheduled for cardiac ultrasound this morning.
B. A client with syncope being discharged today.
C. A client with chronic bronchitis on nasal oxygen.
D. A client with diabetic foot ulcer that needs a dressing change.
Correct Answer: C. A client with chronic bronchitis on nasal oxygen.
A client with airway problems should be attended first. When the nurse needs to prioritize patients, Maslow’s hierarchy of needs theory is used to decide which patient is to be seen first. A part of Maslow’s hierarchy of needs is airway, breathing, and circulation (ABC),which are physiological elements that are needed for the body to survive and help determine one’s level of health. Observing ABCs is a rapid assessment of life-threatening conditions in order of priority.
Option A: Clinical judgment and prioritization of patient care is built on the nursing process. Nurses learn the steps of the nursing process in their foundational nursing course and utilize it throughout their academic and clinical career to direct patient care and determine priorities. Analysis (interpreting what is going on with the patient through reviewing lab work, diagnostic testing, patient history, complaints and observations) comes after assessment.
Option B: The client who was discharged today is not a priority because he is stable enough to be sent home. Maslow’s Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority.
Option D: The client needing a dressing change for her pressure ulcer belongs to Maslow’s physical and biological needs. Some physical needs include the need for the ABCs of airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene and elimination.