Report-now: any client with a new airway, breathing, or circulation compromise must be seen and treated immediately.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A client asks the nurse to explain the difference between hospice care and palliative care. Which statement by the nurse is accurate?
Answer: A. Palliative care focuses on relieving symptoms and improving quality of life and can be provided at any stage of a serious illness, alongside curative treatment. Hospice is a form of palliative care for clients near the end of life (commonly a prognosis of 6 months or less) who are no longer pursuing curative treatment.
Question 2 of 5
The charge nurse is assigning clients on an orthopedic unit. Which client is MOST appropriate to assign to a licensed practical/vocational nurse (LPN/LVN)?
Answer: A. A stable client with a healing femur fracture in skeletal traction whose care is routine is appropriate for the LPN/LVN. The other clients are unstable or require initial assessment and complex judgment reserved for the RN: a new dislocation, a new postoperative client requiring the first neurovascular assessment, and a client with suspected fat embolism.
Question 3 of 5
The charge nurse is assigning clients on an oncology unit. Which client is most appropriate to assign to an experienced licensed practical nurse (LPN/LVN)?
Answer: A. An LPN/LVN can care for a stable client with expected, manageable side effects, such as a client with controlled chemotherapy-induced nausea. Clients with neutropenic fever, ongoing blood product reactions, or those requiring complex teaching and initial chemotherapy administration need the assessment and judgment of an RN.
Question 4 of 5
The nurse is assigning rooms and care for four clients. Which client requires placement in a room nearest the nurses' station for closest monitoring?
Answer: B. The least stable client requiring the closest observation is one with frequent dysrhythmias and a borderline blood pressure, who may deteriorate rapidly. The clients awaiting discharge, with controlled pain, and with a healing wound are more stable and do not require the closest monitoring.
Question 5 of 5
The nurse is prioritizing care for four antepartum clients. Which client should the nurse assess first?
Answer: A. A client with painful vaginal bleeding and a rigid uterus has signs of placental abruption, an obstetric emergency that threatens both maternal and fetal life. This client must be assessed first, before clients with stable or nonemergent findings.
Keep the streak going with more questions like these, each with a full rationale.
What is care of multiple clients?
The nurse sees the least stable client with the most urgent ABC threat first and the most stable, predictable client last. Memory aid: unstable and unexpected before stable and expected; ABCs decide who is first.
Key points to remember
- See the client with an airway, breathing, or circulation threat first, then those with other physiological needs.
- Unstable clients and those with new, abnormal, or unexpected findings are seen before stable clients with expected findings.
- Acute problems generally take priority over chronic ones, and actual over potential problems.
- A client with an expected response to a known condition (stable) is lower priority than a client with an unexpected change.
- Delegate appropriate tasks for stable clients to UAP/LPN to focus RN time on the highest-priority clients.
- Reassess and re-prioritize continuously as client conditions and new data emerge.
Nursing priorities
- Quickly screen all assigned clients and rank them by ABC threat and stability.
- Assess and intervene first for the client with the most urgent airway, breathing, or circulation problem.
- Move next to clients with other unmet physiological needs, then to safety and psychosocial needs.
- Delegate stable-client tasks to free time for high-priority clients.
- Reassess priorities after each intervention and when new information arrives.
Red flags: report now
- Report-now: any client with a new airway, breathing, or circulation compromise must be seen and treated immediately.
- Never leave an unstable or deteriorating client to attend a stable client with expected findings.
- Do not assume a quiet client is stable; an absent complaint can mask deterioration, so verify.
References
Clinical references for this topic
