Difficulty: Medium
Average Score: 81%
Simulated
A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?
Correct answer
B
Rationale
The nurse should assess the client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL first. Hypoglycemia (low blood sugar) can lead to serious complications, including confusion, seizures, and loss of consciousness. Immediate intervention is necessary to prevent further deterioration. Choice A could indicate hematuria, which also requires attention but is not immediately life-threatening. Choices C and D do not present immediate life-threatening situations.