A nurse in a medical-surgical unit is caring for 6 clients. Exhibits Complete the following sentence by using the lists of options. The first client the nurse should assess is dropdownfollowed bydropdown
Explanation & Rationale
The first client the nurse should assess is Client 3 (Pulmonary Edema) followed by Client 1 (Hip Fracture). Rationale: Client 3 (Pulmonary Edema) – Highest Priority: Pulmonary edema is a life-threatening condition that can impair oxygenation. The client has a history of congestive heart failure (CHF) and a chest x-ray confirming pulmonary edema. Immediate assessment is required to evaluate for respiratory distress, oxygenation status, and potential need for diuretics or oxygen therapy. Client 1 (Hip Fracture) – Second Priority: The x-ray confirms a fractured femoral neck, which can cause severe pain, bleeding, and immobility. The nurse must assess for circulation, sensation, and movement (CSM) of the affected limb and manage pain. While this is urgent, it is not as immediately life-threatening as pulmonary edema. Priority Order (Using ABCs & Maslow’s Hierarchy): Client 3 – Pulmonary Edema (Airway/Breathing concern) 2. Client 1 – Hip Fracture (Risk for bleeding, pain, mobility issues) 3. Client 4 – Low Potassium (Risk for cardiac arrhythmias, needs electrolyte management) 4. Client 6 – Poor Diabetes Control (HbA1c 9%, requires education & glucose monitoring) 5. Client 5 – Malnutrition (Prealbumin 12 mg/dL, needs nutrition support for wound healing) 6. Client 2 – Hyperlipidemia (Not an immediate concern, requires long-term management)