A nurse is receiving a report on a group of clients. Using ABCs priority framework or Maslow's Hierarchy of Needs, which client should the nurse see first?

A client who is postoperative and has lower-than-expected urine output

A client who is scheduled for discharge and has a 38.4 C (101.1 F) temperature this morning.

A client who has pneumonia and has developed wheezing.

Answer and Explanation

The Correct Answer is C

A. A postoperative client with low urine output (oliguria) indicates a potential circulation issue or acute kidney injury that requires timely intervention. However, according to the ABC priority framework, circulatory concerns are addressed only after airway and breathing are secured. While this patient is a high priority, they do not take precedence over an immediate respiratory threat.

B. A temperature of 38.4 C (101.1 F) in a client scheduled for discharge suggests a new infectious process that must be investigated before the patient can safely leave. While this requires the nurse's attention and likely a notification to the provider, it is a physiological need that is not immediately life-threatening. This patient is lower on the priority list compared to those with acute physiological instability.

C. A client with pneumonia who develops wheezing is exhibiting signs of acute airway constriction or obstruction, which directly impacts the "B" (Breathing) in the ABC priority framework. Wheezing suggests narrowed bronchioles and potentially compromised gas exchange, which can rapidly progress to respiratory distress. This patient requires the most immediate assessment and intervention to ensure adequate oxygenation.

D. Confusion regarding location in a patient with early dementia may represent a baseline symptom or a mild delirium, which falls under the category of safety or psychosocial needs. In Maslow's Hierarchy, physiological stability must be prioritized over psychological or cognitive concerns. Unless the confusion is accompanied by acute physiological distress, this patient is seen after those with compromised ABCs.

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Correct Answer is ["A","C","D","E"]

Explanation

A.Visual impairment significantly increases fall risk by preventing the patient from identifying environmental hazards, such as spills or furniture. Reduced depth perception and peripheral vision make it difficult to navigate uneven surfaces or changes in flooring levels. Maintaining adequate lighting and ensuring the use of corrective lenses are critical nursing interventions for this population.

C.Older age is a major risk factor due to physiological changes such as decreased muscle mass, slower reaction times, and orthostatic hypotension. These factors, combined with a higher prevalence of chronic conditions, make elderly individuals more susceptible to loss of balance. Age-related changes in the vestibular system also compromise the body's ability to maintain an upright posture.

D.Cognitive impairment, including dementia or acute delirium, prevents patients from recognizing their physical limitations or the need for assistance. They may attempt to ambulate without help despite being unstable or forget to use assistive devices like walkers. Impaired judgment and impulsivity in cognitively impaired patients make them one of the highest-risk groups for inpatient falls.

E.Impaired mobility, resulting from musculoskeletal disorders, neurological deficits, or deconditioning, directly impacts a patient's center of gravity and gait stability. Difficulty with weight-bearing or poor coordination increases the likelihood of a trip or stumble during ambulation. Assessing the need for assistive devices and physical therapy is essential for managing this specific risk factor.

A. Constipation B. Expected grieving C. Inadequate airway clearance D. Insufficient tissue perfusion

Correct Answer is C,D,A,B

Explanation

C.Inadequate airway clearance is the highest priority (number 1) because it represents a threat to the "Airway" in the ABC (Airway, Breathing, Circulation) hierarchy. Without a patent airway, oxygenation cannot occur, leading to rapid physiological collapse and death within minutes. Ensuring the patient can clear secretions or maintain an open passage is the most fundamental requirement for life.

D.Insufficient tissue perfusion is the second priority (number 2) as it corresponds to "Circulation" in the ABC framework. Once the airway and breathing are secured, the heart must be able to deliver oxygenated blood to the vital organs and peripheral tissues. Poor perfusion can lead to organ failure and systemic shock, making it a critical physiological need that must be addressed immediately.

A.Constipation is the third priority (number 3) because it is an actual physiological problem, but it is not immediately life-threatening. According to Maslow's Hierarchy of Needs, physiological needs like elimination are important, but they fall below the urgent requirements of oxygenation and circulation. It requires intervention to prevent long-term complications, but it does not take precedence over respiratory or cardiac stability.

B.Expected grieving is the lowest priority (number 4) in this specific list because it is a psychosocial diagnosis. While emotional and spiritual health are essential components of holistic nursing care, they must be addressed after the patient is physiologically stable. In a prioritization scenario, life-sustaining physical needs always outweigh the psychological responses to illness or loss.

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A nurse is receiving a report on a group of clients. Using ABCs priority framework or Maslow's Hierarchy of Needs, which client should the nurse see first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D","E"]

Explanation

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Correct Answer is C,D,A,B

Explanation

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