Difficulty: Medium
Average Score: 75%
Simulated
Passage / Scenario
Nurses' NotesDiagnostic Results
0800:
Client 1 is admitted with right hip pain following a fall.
Client 2 has a history of hyperlipidemia.
Client 3 has a history of congestive heart failure.
Client 4 has hypertension and a new prescription for furosemide.
Client 5 has a stage 2 pressure injury on the sacrum.
Client 6 is admitted with a new diagnosis of diabetes mellitus.
The first client the nurse should assess is ___ followed by ___
Correct answer
A,D
Rationale
The correct answer is A,D. The rationale is to prioritize immediate life-threatening conditions. Pulmonary edema (A) requires urgent assessment due to potential respiratory compromise. Hip fracture (D) should be assessed next to prevent further injury. Other choices are not as urgent. Glycemic control (B) and low potassium (E) are important but not immediate. Hypoalbuminemia (C), malnutrition (F) can be assessed later unless there are specific concerns.