NCLEX · Management of Care

A nurse is caring for four clients. Which client should the nurse assess first?

Correct answer

A client with new-onset shortness of breath and oxygen saturation of 88%

  1. A A client who is 1 hour postoperative and reports increasing surgical-site pain rated 6/10
  2. B A client requesting pain medication for chronic back pain
  3. C A client receiving routine IV antibiotics
  4. D A client with new-onset shortness of breath and oxygen saturation of 88%

Why this is the answer

Priority assessment follows the ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy of needs. Physiological needs come first, and within physiological needs, airway and breathing concerns take priority. The client with new-onset shortness of breath and O2 saturation of 88% has an acute respiratory problem that could rapidly deteriorate — this is the highest priority. Normal O2 saturation is 95% or higher; 88% indicates significant hypoxemia. The postoperative client with 6/10 pain needs assessment and intervention but is not in immediate physiological distress. Routine IV antibiotics and a chronic pain request can wait several minutes. NCLEX priority questions consistently test the ability to recognize which client is most unstable; airway and breathing issues almost always come before bleeding, pain, anxiety, and elimination concerns.
Source: NCLEX-RN Test Plan, Management of Care — Establishing Priorities

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About this topic: Management of Care

Management of care questions cover prioritisation (ABCs, Maslow, acute before chronic), case management, continuity of care, ethical practice, informed consent and the legal responsibilities of the RN. This is one of 11 RN: Safe and Effective Care Environment questions on management of care, each with a full explanation on a single study page.

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