Difficulty: Medium
Average Score: 77%
Simulated
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?
Correct answer
C
Rationale
The correct answer is C: A client who has asthma and a respiratory rate of 40/min should be assessed first. This client is at risk for respiratory distress or failure due to the high respiratory rate, indicating possible respiratory distress. Prompt assessment and intervention are crucial to prevent respiratory compromise.
Choice A is incorrect because although dehydration with a urine output of 40mL/hr is concerning, it does not pose an immediate threat to the client's airway or breathing.
Choice B is incorrect as pain, while important, does not indicate an immediate threat to the client's airway or breathing.
Choice D is incorrect as a fasting blood glucose of 100 mg/dL, while important in diabetes management, does not indicate an immediate threat to the client's airway or breathing.
Choice A is incorrect because although dehydration with a urine output of 40mL/hr is concerning, it does not pose an immediate threat to the client's airway or breathing.
Choice B is incorrect as pain, while important, does not indicate an immediate threat to the client's airway or breathing.
Choice D is incorrect as a fasting blood glucose of 100 mg/dL, while important in diabetes management, does not indicate an immediate threat to the client's airway or breathing.