The client who should get priority in nursing care is one who has?

Appeared in: BSF Staff Nurse - 2015

Explanation

Ventricular fibrillation (VF) is a lethal cardiac arrhythmia where the heart quivers ineffectively, resulting in no blood being pumped to the body.
This condition is a form of cardiac arrest, which is the most immediate threat to life, taking precedence over all other clinical situations.
According to triage principles (ABCs/CAB), a complete loss of circulation (as seen in VF) requires immediate intervention to prevent irreversible brain damage and death.
The definitive treatment for VF is immediate CPR and electrical defibrillation. Survival rates drop significantly for every minute that treatment is delayed.

Option A: A fractured patella is a musculoskeletal injury. While painful, it does not pose an immediate threat to the patient's airway, breathing, or circulation and is therefore a lower priority.
Option B: Abdominal pain is a symptom with a wide range of causes. Without signs of hemodynamic instability (like shock from internal bleeding), it is not as urgent as an active cardiac arrest.
Option C: A head injury is a serious condition and a high priority, but it is secondary to a patient who has no circulation. The patient with a head injury is still alive with a functioning heart, whereas the patient in VF is in cardiac arrest.

Clinical Relevance

Nursing practice connection: Use the key finding related to Triage and Prioritization of Nursing Care to guide bedside assessment, documentation, and the next nursing action.
The ability to rapidly triage patients using the ABCs (Airway, Breathing, Circulation) or CAB (Circulation, Airway, Breathing for cardiac arrest) framework is a fundamental nursing skill that directly determines patient survival.
Nurses must be able to instantly recognize lethal cardiac rhythms like VF on a monitor and initiate the emergency response protocol (e.g., 'Code Blue') without hesitation.
This scenario underscores the importance of Advanced Cardiac Life Support (ACLS) training for nurses in acute care settings.

How to Approach the Question

First, identify the question as a priority-setting question. It asks which client should receive care first.
Recall the fundamental principle of triage in nursing: Airway, Breathing, Circulation (ABCs). The condition that poses the most immediate threat to life takes the highest priority.
Evaluate each option against the ABC framework.
A fractured patella is a bone/limb issue, not an immediate ABC problem.
Abdominal pain is a symptom; its priority depends on whether it's affecting circulation (e.g., internal bleeding), which isn't stated.
A head injury is serious and can affect ABCs, but it's not as immediately fatal as a complete cessation of circulation.

Concept Tested & Keywords

QDTyHjlUZ61FNngYKXvZMn

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 3 p. 120-122

E6 Nursing Fundamentals Potter Perry 12e Part 2 p. 22-24

Practise the full BSF Staff Nurse - 2015

Attempt every question from this paper in a timed mock, then review the full solution for each one.