A nurse on a medical surgical unit receives a report on multiple clients. Based on this report, which client should the nurse assess first?

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The ABC priority framework stands for airway, breathing, and circulation. This is the order in which clients should be assessed and treated. Smoke inhalation is the leading cause of death in burn clients as it causes thermal injury to the upper airways, chemical injury to the tracheobronchial tree, and carbon monoxide and/or cyanide poisoning. Clients should receive 100% oxygen to displace carbon monoxide and cyanide from hemoglobin. Intubation is indicated if there is evidence of upper airway edema with respiratory distress. An obstructed airway can lead to cardiac arrest if not treated immediately. (Option A) According to the ABC priority framework, this client who is bleeding after a recent colon resection should be seen after the burn client has been treated. (Option C) The client with gastroenteritis who is vomiting profusely should be assessed and given antiemetics and fluid resuscitation as ordered. However, this is not the priority in this situation. (Option D) The client experiencing severe pain from peritonitis should certainly be assessed as soon as possible, but this is not the priority according to the ABC priority framework. Educational objective: The ABC priority framework is used to quickly evaluate the order in which clients should be assessed. This framework is appropriate in all settings, both emergency and non-emergency. Airway is the priority, followed by breathing, and finally circulation. Clients with acute asthma exacerbation, tension pneumothorax, anaphylaxis/angioedema, and flail chest need emergency evaluation.

A Nurse on a Medical Surgical Unit Receives a Report