A nurse is receiving report on a group of clients. Using the ABCD-E priority framework, which of the following clients should the nurse see first?

A client who is scheduled for discharge and has become febrile this morning

A client who has early dementia and awoke confused to their location this morning

A client who has pneumonia and has developed wheezing

A client who is postoperative and has a urine output of 50 mL for the past 4 hours

Answer and Explanation

The Correct Answer is C

Choice A reason: Fever in a discharge-ready client suggests a new infection, which is concerning but not immediately life-threatening. The ABCD-E framework prioritizes airway and breathing issues. While fever requires evaluation, it is less urgent than respiratory distress, as it does not acutely compromise vital functions like oxygenation.

Choice B reason: Confusion in early dementia is common and concerning but not an immediate threat to life. The ABCD-E framework prioritizes airway, breathing, and circulation. Confusion may indicate worsening dementia or another issue, but it is less urgent than a client with acute respiratory distress, like wheezing.

Choice C reason: Wheezing in a pneumonia client indicates airway obstruction or bronchospasm, compromising breathing (B in ABCD-E). This is a life-threatening emergency requiring immediate intervention to ensure oxygenation. Respiratory distress takes priority over fever, confusion, or low urine output, as it directly affects a vital function critical for survival.

Choice D reason: Low urine output (50 mL/4 hours) in a postoperative client suggests possible hypovolemia or renal issues, affecting circulation (C in ABCD-E). While serious, it is less urgent than airway or breathing problems. Respiratory distress, like wheezing, takes precedence, as it poses an immediate threat to life.

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Correct Answer is C

Explanation

Choice A reason: 10% Dextrose is a hypertonic solution used for caloric supplementation or hypoglycemia treatment. It can cause hyperglycemia and fluid shifts, making it unsuitable for routine preoperative hydration. Surgical patients need balanced electrolyte solutions to replace fluid losses and maintain homeostasis, which 10% dextrose does not provide effectively.

Choice B reason: 3% NaCl, a hypertonic saline, is used for severe hyponatremia or cerebral edema. It risks causing hypernatremia and fluid overload if not carefully monitored. Preoperative patients typically require isotonic fluids to maintain electrolyte balance and hydration, making 3% NaCl inappropriate for standard surgical preparation.

Choice C reason: Lactated Ringer’s is an isotonic solution containing electrolytes like sodium, potassium, and calcium, closely mimicking plasma. It is ideal for preoperative hydration, as it replaces fluid losses, maintains electrolyte balance, and supports hemodynamic stability during surgery. Its balanced composition makes it the standard choice for surgical patients.

Choice D reason: 0.45% NaCl, a hypotonic solution, is used for maintenance hydration or hypernatremia correction. It provides less sodium than needed for surgical fluid replacement and may cause hyponatremia or fluid shifts. Isotonic fluids like Lactated Ringer’s are preferred preoperatively to ensure electrolyte stability and adequate hydration.

A. Tell the client how to move the walker as the client ambulates B. Describe how the walker can improve the client’s quality of life C. Explain how the walker supports the client’s lower extremities D. Fully discuss the rationale for using the walker

Correct Answer is B

Explanation

Choice A reason: Instructing on walker movement addresses the psychomotor domain, focusing on physical skills. This does not tackle the client’s emotional disengagement or belief of being “too old.” Without addressing motivation, technical instructions may be ineffective, as the client’s psychological barrier prevents engagement, reducing the likelihood of successful learning and adoption.

Choice B reason: Describing quality-of-life benefits targets the affective domain, addressing emotions and attitudes. By emphasizing enhanced independence, safety, and mobility, the nurse can counter the client’s defeatist mindset. This approach fosters motivation, making the client more receptive to learning walker use, as it connects the intervention to personal, meaningful outcomes.

Choice C reason: Explaining walker support for lower extremities focuses on the cognitive domain, providing technical knowledge. While informative, it does not address the client’s emotional disengagement. Without motivating the client by linking the walker to personal benefits, this approach may fail to overcome their resistance, as it lacks an emotional or motivational component.

Choice D reason: Discussing the rationale for walker use targets the cognitive domain, explaining its purpose. While this may enhance understanding, it does not address the client’s emotional barrier or lack of motivation. Without engaging the client’s feelings or highlighting personal benefits, the rationale alone is unlikely to inspire willingness to learn or use the walker.

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A nurse is receiving report on a group of clients. Using the ABCD-E priority framework, which of the following clients should the nurse see first?

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A nurse is receiving report on a group of clients. Using the ABCD-E priority framework, which of the following clients should the nurse see first?