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What is the order for assessing clients?

The order to assess clients:

  1. Assess clients with immediate complications first such as unconscious, airway, breathing, and circulatory issues (ABCs)
  2. Then see clients with expected and moderate to severe pain
  3. See psychosocial clients that are upset next
  4. Lastly, see clients with expected or normal symptoms of a condition that are not immediate concerns


What type of clients are discharged first?

Discharge stable clients that are not having any complications first.


What are the ABCs?

Airway, Breathing, Circulation

Clients with these complications are a high priority for being seen. Chest pain and stroke symptoms are usually a higher priority than shortness of breath. 


Immediate Complication

Unconscious clients are completely dependent on caregivers. What is the priority concern?

Make sure unconscious clients have an airway.

Immediate Complication

At what Glasgow coma score is the client typically intubated?

"Less than 8, intubate"

8 indicates a coma.

Immediate Complication

Why do burns have a high risk of airway problems?

Smoke inhalation

Always assess the airway first and give oxygen.

Immediate Complication

What is a pneumothorax?

A pneumothorax is a collapsed lung with air in the pleural space.

It is caused by trauma. The client will get chest tubes.

Immediate Complication

What is an anaphylactic reaction?

An anaphylactic reaction is an overactive response of the immune system to substances that can cause a rash or severe difficulty with breathing. 

Immediate Complication

What are the steps if a client has an anaphylactic reaction?

Steps for an anaphylactic reaction:

  • assess respiration status and maintain a patent airway
  • call HCP and rapid response team
  • give oxygen
  • start an IV and give normal saline
  • prepare to give diphenhydramine and epinephrine
  • possible intubation and ventilator
  • document the event


Immediate Complication

What is the immediate action if the tracheostomy tube dislodges?

If the tracheostomy tube dislodges:

  1. extend neck and open the tissues of the stoma
  2. pull the retention sutures to spread the opening
  3. use a tracheal dilator to hold the stoma open

Immediate Complication

What is the immediate action if the tracheostomy tube falls out within the first 72 hours?

If the tracheostomy tube falls out within the first 72 hours:

  • manually resuscitate using an Ambu bag and call the HCP.

Immediate Complication

What is an air embolism?

An air embolism is when air goes into the client's IV and goes to the lungs.

Place the client in Trendelenburg position.

Immediate Complication

What is a major complication from the fracture of a large bone?

A fat embolism occurs when a large bone such as a femur or pelvis gets fractured.

A fat embolism is a fat blob that gets released into the bloodstream and can go to the lungs causing respiratory distress.

Immediate Complication

What is flail chest?

Flail chest occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall.

There can also be rib fractures.

Immediate Complication

What is pulmonary edema?

Pulmonary edema is when fluid gets backed up into the lungs.

It can be caused by left-sided heart failure, kidney failure or liver failure.

Immediate Complication

What is hypoxia?

Hypoxia: pulse oximetry reading < 95%.

Give oxygen.

Immediate Complication

What is acute respiratory failure (ARF)?

Acute respiratory failure is when there is not enough oxygen to get to the lungs or alveoli (air sacs) and CO2 builds up in the blood.

The client becomes hypoxic and hypercapnic.


Immediate Complication

What is a pulmonary embolism?

A pulmonary embolism is when a blood clot goes to the lungs.

It is usually caused by a DVT.

Immediate Complication

What is acute respiratory distress syndrome (ARDS)?

ARDS causes inflammation and fluid to build up in the alveoli of the lungs. The client is unable to get enough oxygen.

The client will be intubated and placed on a ventilator.

Immediate Complication

What is a pneumothorax?

A pneumothorax is a collapsed lung with air in the pleural space.

It is caused by trauma. The client will get chest tubes.

Immediate Complication

What is Guillain-Barre Syndrome?

Guillain-Barre Syndrome occurs after an infection where the immune system overacts and destroys the myelin sheath (the part that connects nerves).

The client gets ascending paralysis, eventually affecting the respiratory muscles.



Immediate Complication

What is a seizure?

A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in behavior, movements or feelings, and in levels of consciousness. 

Epilepsy is a seizure disorder of two or more seizures or a tendency to have recurrent seizures.

Immediate Complication

What is an intracerebral hemorrhage?

An intracerebral hemorrhage is when a blood vessel within the brain has ruptured.

It can occur from a traumatic brain injury (TBI) or cerebral aneurysm.


Immediate Complication

What is a stroke?

A stroke is when the brain does not get enough oxygen either caused by bleeding or a blood clot.

Immediate Complication

What is a hypertensive crisis?

A hypertensive crisis is blood pressure greater than 200/120.

It not controlled, it can cause a hypertensive stroke.

Immediate Complication

What is angina?

Angina is chest pain caused by inadequate myocardial blood and oxygen supply.

Give OANM: oxygen, aspirin, nitroglycerin, and morphine.

Immediate Complication

What is an aortic aneurysm?

An aortic aneurysm is stretching of the arterial wall in the abdomen.

If it ruptures the client will experience pain, difficulty breathing and signs of shock.

Immediate Complication

What is cardiogenic shock?

Cardiogenic shock is low blood pressure caused by damage to the heart that impairs pumping ability. 

It can be from myocardial infarction, tamponade, or heart failure.

Immediate Complication

What is asystole?

Asystole is a fatal dysrhythmia:

  • start CPR
  • epinephrine
  • NO defibrillation

Immediate Complication

What is ventricular tachycardia?

Ventricular tachycardia is a fatal dysrhythmia:

  • Pulseless V-tach
    • CPR
    • defibrillate
    • epinephrine
    • amiodarone (or lidocaine)
  • With a pulse
    • amiodarone (or lidocaine)

Immediate Complication

What is ventricular fibrillation?

Ventricular fibrillation is a fatal dysrhythmia:

  • "defib the V-fib"
  • CPR
  • epinephrine
  • amiodarone (or lidocaine)

Immediate Complication

What is a myocardial infarction?

A myocardial infarction is a fatal heart condition:

  • give "OANM"
    • oxygen
    • aspirin
    • nitroglycerin
    • morphine
  • "clot busters" if caused by a clot
    • T-PA
  • cardiac catheterization if caused by plaque


Immediate Complication

What is supraventricular tachycardia?

Supraventricular tachycardia can be a fatal dysrhythmia:

  • vagal maneuvers (carotid sinus massage, beardown/Valsalva)
  • cardiovert with adenosine

Immediate Complication

What is a heart block?

Heart blocks are:

  • typically less than 60 beats per minute
  • have an elongated PR interval
  • will receive atropine if showing symptoms
  • if atropine doesn't work, client will either get cardioversion or a pacemaker.


Immediate Complication

What is an Addisonian crisis?

An Addisonian crisis can cause severe fluid and electrolyte imbalances.

It is caused by stress, infection, trauma, or abrupt discontinuation of steroids.

Immediate Complication

What is a myxedema coma?

Myxedema coma is when the client has extremely low metabolism and goes into a coma.

Immediate Complication

What is a thyroid storm?

A thyroid storm is when the client has an extremely high metabolism and can get elevated temperature, blood pressure, seizures and then a coma

Immediate Complication

What is hyperosmolar hyperglycemic syndrome (HHS) and diabetic ketone acidosis (DKA)?

HHS and DKA are extremely high blood sugar.

If not treated the client can go into a coma.  

Immediate Complication

What is compartment syndrome?

Compartment syndrome is when there is too much pressure in a cast or enclosed space due to edema. 

The client will either get a fasciotomy (cut the skin open) or the cast will be cut off.

Immediate Complication

What is hemorrhage?

Hemorrhage is severe bleeding that causes the client to go into hypovolemic shock.

The client gets a very low blood pressure and tachycardia.

Immediate Complication

What major complications can occur with fluid and electrolyte imbalances?

Severe fluid and electrolyte imbalances can cause life-threatening complications such as:

  • dysrhythmias
  • seizures
  • respiratory depression
  • coma

Immediate Complication

What is septic shock?

Septic shock is a systemic infection throughout the entire body.

It can cause very low blood pressure and tachycardia.

Immediate Complication

What is peritonitis?

Peritonitis is when the bowel perforates causing infection and eventually septic shock if not treated.

The client gets a rigid, hard abdomen.


Immediate Complication

What is acute angle-closure glaucoma?

Acute angle-closure glaucoma is sudden eye pain and possible nausea and vomiting, resulting in blindness.

The client will receive antiglaucoma meds to lower the pressure. 

Immediate Complication

What are the interventions if a client has a penetrating object in the eye such as sharp metal?

Interventions for a penetrating object in eye:

  • DO NOT remove the object
  • cover the eye with a cup and tape in place
  • no bending, no straining
  • surgery to remove object

Immediate Complication

What is the intervention if a client gets chemicals splashed in the eye?

Intervention for chemical eye burns:

  • flush eyes with water for at least 15 to 20 minutes

Immediate Complication

What is an acid-base imbalance?

An acid-base imbalance is a circulation or breathing issue where the client has a high risk of death if it becomes severe.

Immediate Complication

What is autonomic dysreflexia?

Autonomic dysreflexia is when the client with a spinal injury overreacts to stimuli such as unable to urinate or have a bowel movement.

It can cause a hypertensive crisis if it becomes severe.

Immediate Complication

What is a myasthenic crisis and cholinergic crisis?

A myasthenic crisis and cholinergic crisis is when the client with myasthenia crisis does not get the correct amount of medicine at the correct time.

This causes muscle weakness and respiratory muscle weakness if not treated. 

  • myasthenic crisis is undermedicated
  • cholinergic crisis is overmedicated

Immediate Complication

What life-threatening condition are clients at risk for after a head injury, stroke or brain surgery?

Increased intracranial pressure (ICP)

Increased pressure in the brain due to edema.

Immediate Complication

What are Steven's Johnson syndrome and toxic epidermal necrolysis?

Steven's Johnson syndrome and toxic epidermal necrolysis are really bad adverse reactions of many meds that cause a severe rash all over the body.

Always let the HCP know if you notice a rash, especially after the client starts a new med.

Immediate Complication

What is wound dehiscence and evisceration?

  • Dehiscence is when the surgical incision opens.
  • Evisceration is when the abdominal organ comes out of the incision.

Immediate intervention is to put a sterile, saline-soaked dressing over site.

Immediate Complication

What are life-threatening signs and symptoms of a blood transfusion reaction?

Signs and symptoms of a serious blood transfusion reaction:

  • respiratory distress, dyspnea, dizziness, shortness of breath
  • chills, diaphoresis
  • back or chest pain

Antibodies are attacking the red blood cells causing decreased oxygen.

Immediate Complication

What are the steps if there's a reaction to a blood transfusion?

Steps to a blood transfusion reaction:

  1. FIRST: stop the blood transfusion
  2. change out the tubing, but keep the IV line in
  3. start a new bag of normal saline, 0.9%
  4. tell the HCP and blood bank
  5. return the blood and tubing to the blood bank
  6. stay with the client
  7. may have to give epinephrine for severe symptoms such as difficulty breathing

Immediate Complication

What is suicide?

Suicide is a psychological disorder when the client wants to kill themselves.

It is an emergency and someone needs to stay with the client at all times. 

Immediate Complication

What is done if the chest tube comes out of the client's chest wall?

Pinch the opening shut and apply an occlusive sterile dressing taped on 3 sides.

Immediate Complication

When should the HCP be notified about chest tubes?

Call HCP about chest tubes if:

  • drainage is >70 - 100 mL/hour
  • drainage suddenly becomes bright red or increases in the amount
  • chest tube comes out of client

Immediate Complication

What should be kept at the bedside for a client with chest tubes?

For a client with chest tubes keep at the bedside:

  • a clamp
    • to check for leaks
  • sterile occlusive dressing
    • in case the tube comes out of the client​
  • a bottle of sterile water
    • in case the tube comes out of the CDU

Immediate Complication

What is the immediate intervention if the chest tube drainage system breaks or cracks?

Sometimes the CDU falls over and breaks.

Put the chest tube in a bottle of sterile water to act as a water seal so air doesn't go into the client.


Immediate Complication

In what order should clients be evacuated during a fire?

During a fire:

  1. evacuate clients who can walk first
  2. evacuate clients in wheelchairs next
  3. evacuate bedridden clients last

Immediate Complication

What are 3 adverse effects (reactions) of medications?

3 adverse effects (reactions):

  1. anaphylactic shock or difficulty breathing
  2. rash
  3. significant changes in vital signs or level of consciousness

Notify the HCP immediately.

Immediate Complication

What is delirium tremens?

Delirium tremens is withdrawal of alcohol that occurs 48 - 72 hours after stopping alcohol. 

Immediate Complication

What should the nurse do immediately if a client is being violent?

With violent clients:

  • approach the client calmly and communicate with a calm and clear tone of voice
  • maintain a safe distance away from client
  • maintain a non-aggressive posture
  • listen actively and acknowledge anger
  • determine what their need is
  • call security if client does not calm down

Immediate Complication

What is serotonin syndrome?

Serotonin syndrome is when a client's serotonin level increases to dangerous levels.

It is caused by taking too many sedatives at once.

Immediate Complication

What is neuroleptic malignant syndrome?

Neuroleptic malignant syndrome is a rare and fatal reaction to antipsychotics.

Immediate Complication

What is a positive/abnormal contraction stress test?

A positive/abnormal result indicates a bad finding and that late decelerations of the fetal heart rate were noted.

Late decelerations are never a good finding.

Immediate Complication

What is disseminated intravascular coagulation (DIC) during pregnancy?

Disseminated intravascular coagulation is a serious bleeding and clotting complication in a pregnant client with eclampsia, placenta abruptio, a dead fetus, placenta retention or infection. 

The clotting factors are becoming over or underactivated. 

Immediate Complication

What is HELLP syndrome?

HELLP syndrome is a condition that can cause severe bleeding in a pregnant client.

The cause is not known but associated with gestational hypertension and preeclampsia. 

Immediate Complication

What is eclampsia?

Eclampsia is the onset of seizures for a pregnant client with preeclampsia.

Immediate Complication

What are the general interventions if the mom or baby is having life-threatening distress during labor?

General interventions if mom or baby is having life-threatening distress during labor:

  • put mom in Trendelenburg position
  • give oxygen 8-10 liters by mask
  • give IV fluids
  • blood transfusion if needed
  • prepare for cesarean delivery

Immediate Complication

What is a prolapsed umbilical cord?

A prolapsed umbilical cord is when the umbilical cord drops through the open cervix into the vagina ahead of the baby.

The cord can then become trapped against the baby's body during delivery. 

Immediate Complication

What is abruptio placenta?

Abruptio placenta is when the placenta has separated off the uterine wall.

Immediate Complication

What is an amniotic fluid embolism?

Amniotic fluid embolism is when there is an escape of amniotic fluid into maternal circulation which can lead to respiratory failure and bleeding

Immediate Complication

What are the signs and symptoms of fetal distress?

Signs and symptoms of fetal distress:

  • fetal heart rate is < 110 or > 160 beats/minute
  • meconium-stained amniotic fluids
  • fetal hypo or hyperactivity
  • severe variable or late decelerations

Immediate Complication

What type of fetal heart rate decelerations are these?

Late decelerations caused by placenta compression.

There is a gradual decrease in fetal heart rate. The lowest heart rate occurs after the contraction peak. 

Immediate Complication

What are two life-threatening postpartum complications of cesarean section?

Bleeding and Infection

Immediate Complication

How many saturated pads per hour is considered hemorrhage?

Hemorrhage is:

  • > than 1 pad per hour or
  • one pad that gets saturated within 15 minutes

Immediate Complication

How much blood loss is considered hemorrhage for a vaginal delivery and a cesarean delivery?

Blood loss and hemorrhage:

  • Vaginal delivery: > 500 mL after delivery
  • Cesarean delivery: > 1000 mL after delivery

Immediate Complication

What can cause respiratory distress syndrome in an infant?

Respiratory distress syndrome is caused by the newborn unable to produce enough surfactant. It can occur in preterm infants.

Surfactant helps open up the lungs to breathe better.

Immediate Complication

What is pathological jaundice?

Pathological jaundice is an increase in bilirubin and yellowing of the skin. It is caused by a hemolytic disease such as Rh incompatibility or liver disease.

It occurs before 24 hours and is a serious life-threatening condition.

Immediate Complication

What is meconium aspiration syndrome?

Meconium aspiration syndrome is when meconium gets into the lungs and causes respiratory distress and/or pneumonia.

Immediate Complication

What are the steps for a choking infant?

Steps for a choking infant:

  1. hold infant face down with head lower than feet
  2. support head and jaw
  3. give 5 back slaps
  4. then put baby face up and give 5 chest thrusts
  5. repeat until obstruction clears

Click HERE for a video on infant CPR and Choking treatment.


Immediate Complication

What are the steps for CPR on an infant?

Steps for CPR on an infant:

  1. check for pulse with brachial artery
  2. use 2 fingers or 2 thumbs for chest compressions
  3. go down 1 1/2 inches (2 cm) for compressions
  • 1 rescuer: 30 compressions then 2 breaths
  • 2 rescuers: 15 compressions and then 2 breaths

Click HERE for a video on infant CPR and choking treatment.

Immediate Complication

What is esophageal atresia and tracheoesophageal fistula?

Esophageal atresia and tracheoesophageal fistula is when the esophagus forms an unnatural connection with the trachea causing food to enter the airway.

There is a high risk of aspiration.

Immediate Complication

What is the treatment for acetaminophen overdose?

Treatment for acetaminophen overdose:

  • give acetylcysteine
  • use activated charcoal with gastric lavage

Immediate Complication

What is the treatment for aspirin (acetylsalicylic acid) overdose?

Treatment for aspirin (acetylsalicylic acid) overdose:

  • give activated charcoal

Immediate Complication

What is the treatment for corrosive poisoning in a child, such as household cleaners, bleach, paint or batteries?

Treatment for corrosive poisoning:

  • give water or milk
  • don't induce vomiting as it can cause damage to the esophagus

Immediate Complication

What is a sickle cell anemia crisis?

A sickle cell anemia crisis is when RBCs clump together and block small blood vessels that carry blood to organs.

It causes severe pain.

Immediate Complication

What is epiglottitis?

Epiglottitis is an infection of the epiglottis which can be caused by Influenza type B or Strept.

There is a high risk of airway obstruction.

Immediate Complication

What is status asthmaticus?

Status asthmaticus is a severe asthma attack that doesn't respond to inhalers.

Intubation and ventilator may be needed.