A nurse is prioritizing client care after receiving a change-of-shift report. Which of the following clients should the nurse plan to see first?
A client who told an assistive personnel he is short of breath
A client who has a prescription for discharge
A client who received oral pain medication 30 minutes ago
A client who is scheduled for an abdominal x-ray and is awaiting transport
The Correct Answer is A
Choice A reason (client care): A client reporting shortness of breath may be experiencing a life-threatening situation that aligns with the ABCs (Airway, Breathing, Circulation) of patient prioritization. This client requires immediate assessment and intervention.
Choice B reason (client care): While discharge is important, it does not take precedence over a client with potential respiratory distress.
Choice C reason (client care): A client who received pain medication 30 minutes ago is likely stable and can be seen after more urgent cases are addressed.
Choice D reason (client care): A client waiting for an abdominal x-ray is not a priority over a client with respiratory issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Placing suction equipment at the bedside is a preparatory measure but not a preventive intervention for pulmonary complications.
Choice B reason: Performing ROM exercises is beneficial for overall mobility but does not directly prevent pulmonary complications.
Choice C reason: Administering an expectorant may help clear secretions but is not the primary preventive measure for pulmonary complications.
Choice D reason: Encouraging the use of incentive spirometry is a proven intervention to prevent pulmonary complications by promoting lung expansion and preventing atelectasis, especially in patients with a history of smoking.
Correct Answer is C
Explanation
Choice A reason: While a stable ECG rhythm is important, it is not the immediate concern post-AMI.
Choice B reason: The ability to verbalize causes and effects of CHD/CAD is an educational goal, not an immediate care priority.
Choice C reason: Adequate relief of pain is a priority to reduce stress on the heart and improve patient comfort.
Choice D reason: Compliance with prescribed bedrest is important but secondary to pain relief.
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