QLexNursing

🔷 The client is post-stroke, immobile, and requires full assistance, which significantly increases the risk of alveolar collapse (atelectasis) due to shallow breathing and decreased lung expansion.

🔷 The nurse notes bilateral breath sounds decreased at the bases, which is a classic early finding for atelectasis or hypoventilation, especially in a client who is mostly in bed.

🔷 Under ABC (Airway, Breathing, Circulation) priorities, any threat to ventilation and oxygenation is addressed before gastrointestinal or skin integrity problems.

🔷 Although the client’s oxygen saturation is 93% on room air and improves to 95% on 2 L/min via nasal cannula, the decreased breath sounds show an ongoing respiratory complication risk that must be addressed early with interventions like turning, deep breathing, incentive spirometry, and coughing.

🔷 By first addressing the risk for atelectasis, the nurse helps prevent progression to pneumonia, hypoxemia, and further respiratory compromise, which are more immediately life-threatening than constipation or pressure injury.

Constipation

🔷 The client has hypoactive bowel sounds, and immobility can certainly predispose to constipation, but this is not as immediately critical as a breathing-related complication.

🔷 Constipation is important to address but falls below respiratory issues in priority according to ABC and Maslow frameworks.

Pressure injury

🔷 The client is immobile and dependent for turning, and the low prealbumin (13 mg/dL) indicates poor nutritional status, which does increase the risk for pressure injury.

🔷 However, while serious, skin breakdown is less immediately life-threatening than a developing respiratory complication like atelectasis, so it is not the first priority.

Prealbumin level

🔷 A prealbumin level of 13 mg/dL (below the normal 15–36 mg/dL) indicates malnutrition and increased risk for impaired wound healing and pressure injuries, not primarily respiratory compromise.

🔷 While important for long-term skin and recovery outcomes, it does not represent the most urgent ABC issue in this early post-stroke, immobile client.

Decreased bowel sounds

🔷 Hypoactive bowel sounds suggest reduced GI motility and risk for constipation or ileus, especially in a client with limited mobility and recent illness.

🔷 This is a valid concern but is lower priority than findings related directly to breathing and lung expansion (i.e., decreased breath sounds at the bases).