NCLEX Questions-Prioritizing Client Care

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? a. A client scheduled for a chest x-ray b. A client requiring daily dressing changes c. A postoperative client preparing for discharge d. A client receiving nasal oxygen who had difficulty breathing during the previous shift. - 1. D- Airway is always the highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in option 1, 2, and 3 have needs that would be identified as intermediate priorities. 2. The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? a. A client complaining of muscle aches, a headache, and malaise b. A client who twisted her ankle when she fell while rollerblading c. A client with a minor laceration on the index finger sustained while cutting an eggplant d. A client with chest pain who states that he just are pizza that was made with a very spicy sauce. - 2. DIn an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a number 3 priority