RN Nursing · Priority Setting and Time Management · Practice question
A nurse has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first?
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A client who has pneumonia and was treated for a temperature of 38.9° C (102° F) at 0400
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A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose of famotidine at 0800
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A client who had a blood glucose reading at 0650 of 70 mg/dL after receiving 50% dextrose for a hypoglycemic episode
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✓
A client who was admitted for chest pain and is reporting a new onset of indigestion
Answer & explanation
Correct: A client who was admitted for chest pain and is reporting a new onset of indigestion
Priority setting using frameworks such as the ABCs (airway, breathing, circulation) and the concept of acute versus resolved problems guides the nurse in determining who to assess first. A client admitted for chest pain who is now reporting a new onset of indigestion requires immediate assessment because new symptoms in this context could represent evolving myocardial ischemia or infarction. Indigestion can be a manifestation of cardiac ischemia, particularly in certain populations, and any change in symptoms for a cardiac client must be evaluated without delay. The client with pneumonia had a fever that was treated at 0400 and does not have a current acute complaint described. The client who pulled out an IV catheter needs a new line but famotidine is not a time-critical medication and this situation, while requiring action, is not immediately life-threatening. The client with a blood glucose of 70 mg/dL after receiving 50% dextrose has already been treated; while continued monitoring is needed, the glucose level is at the lower end of normal and does not represent an unresolved acute emergency. The chest pain client with a new symptom represents the most immediately potentially dangerous situation and should be assessed first.
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