Nursing Prioritization, Delegation and Assignment NCLEX Practice Quiz #2

Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first? • A. A client with diabetes was discharged today. • B. A 35-year-old male with tracheostomy and copious secretions. • C. A teenager scheduled for physical therapy this morning. • D. A 78-year-old female client with a pressure ulcer that needs a dressing change. Correct Answer: B. A 35-year-old male with tracheostomy and copious secretions. The patient with an airway problem should be given the highest priority. The ABCs identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order. • Option A: The client who was discharged today is not a priority because he is stable enough to be sent home. Maslow’s Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority. • Option C: The teenager who will undergo physical therapy is under Maslow’s safety and physiological needs. The psychological or emotional, safety, and security needs include needs like low level stress and anxiety, emotional support, comfort, environmental and medical safety and emotional and physical security. • Option D: The client needing a dressing change for her pressure ulcer belongs to Maslow’s physical and biological needs. Some physical needs include the need for the ABCs of airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene and elimination