The registered nurse (RN) is the leader of a team on a unit that utilizes a team approach. Which clients should the RN care for? Select All That Apply

Priority nursing assessment utilizes the ABC framework alongside the identification of life-threatening complications related to anticoagulation therapy. While stable findings are expected in chronic conditions, any new symptom suggestive of internal hemorrhage requires immediate investigation. The charge nurse must prioritize patients based on the risk of hemodynamic instability or sudden physiological collapse to ensure timely medical intervention and prevent adverse outcomes.

Rationale:

A. Nephrotic syndrome is a renal disorder characterized by massive proteinuria and hypoalbuminemia, which often results in the presence of lipids in the urine. Lipiduria is a classic finding in this condition and does not indicate an acute or life-threatening change in the client's status. This client is stable and can be assessed after those with more urgent physiological needs.

B. A pain level of 6 out of 10 in a postoperative client is a distressing symptom that requires pharmacological intervention but is not immediately life-threatening. While the nurse should address the pain to promote recovery and comfort, it does not take precedence over signs of active, occult bleeding. Pain management is a high priority but secondary to circulatory stabilization and safety.

C. A change in the Glasgow Coma Scale from 11 to 13 represents a positive neurological trend and an improvement in the client’s level of consciousness. Since the client is showing signs of recovery rather than deterioration, they do not require the most immediate assessment by the charge nurse. The nurse should continue to monitor for further improvements or any sudden neurological declines.

D. Back pain in a client receiving a heparin infusion is a significant warning sign of retroperitoneal bleeding, a serious complication of systemic anticoagulation. The nurse must assess for signs of hemorrhagic shock and notify the provider immediately to prevent potential cardiovascular collapse or permanent organ damage. This client is the highest priority due to the risk of active internal hemorrhage.

Respiratory acidosis occurs when alveolar hypoventilation impairs the clearance of carbon dioxide, leading to hypercapnia. The kidneys eventually compensate through bicarbonate retention, but acute shifts cause rapid pH drops below 7.35. Obstruction or impaired gas exchange are the primary physiological triggers for this acid-base imbalance.

Rationale:

A. Oxygen administration treats hypoxemia, but the client’s PaO2 of 87 mmHg is currently within the normal 80-100 mmHg range. This intervention does not address the underlying hypercapnia or the elevated PaCO2 level. Oxygen won't improve ventilation mechanics in this specific scenario.

B. This is the priority intervention to facilitate carbon dioxide removal. Promoting lung expansion and clearance of secretions through coughing and deep breathing improves alveolar ventilation and restores acid-base balance. It addresses the root cause of respiratory acidosis directly.

C. While the provider should be informed of abnormal results, the nurse must first implement independent nursing interventions. Stabilizing the client through improved ventilation is the immediate priority before performing clerical notification. Immediate clinical action takes precedence over reporting.

D. The pulse oximetry provides a non-invasive estimate of oxygen saturation, but the ABG already confirms a normal PaO2 level. Obtaining more data on oxygenation is redundant and delays the necessary treatment for respiratory distress. Focus must remain on correcting the pH.