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 B

Explanation

Choice A reason: Leg swelling (edema) is a symptom of heart failure due to fluid retention from poor cardiac output. However, it is less urgent than breathing difficulties, which indicate pulmonary edema, a life-threatening complication. Assessing breathing takes priority, as it directly affects oxygenation, a critical physiological need.

Choice B reason: Difficulty breathing (dyspnea) is a hallmark of heart failure, often due to pulmonary edema from fluid backup in the lungs. This compromises oxygenation, making it a life-threatening symptom requiring immediate assessment. The ABCD-E framework prioritizes breathing, making this the most critical question to evaluate heart failure severity.

Choice C reason: Chest pain may indicate angina or myocardial infarction, which can contribute to heart failure. However, it is less specific to heart failure than dyspnea, which directly signals pulmonary congestion. Breathing difficulties pose a more immediate threat, as they affect oxygenation, a priority in acute heart failure assessment.

Choice D reason: Heart palpitations may occur in heart failure due to arrhythmias but are less specific and urgent than dyspnea. Palpitations may indicate stress or other conditions, but breathing difficulties directly reflect pulmonary edema, a critical complication requiring immediate attention to ensure adequate oxygenation and prevent respiratory failure.

A. Urinary retention B. Decreased fluid volume risk C. Altered skin integrity D. Altered urinary elimination

Correct Answer is B

Explanation

Choice A reason: Urinary retention, the inability to empty the bladder, is unlikely with diuretics, which increase urine output. Diuretics reduce fluid volume by enhancing renal excretion, not causing retention. This concern is irrelevant, as the client’s increased output suggests effective diuresis, not bladder dysfunction or obstruction.

Choice B reason: Decreased fluid volume risk is a primary concern with diuretics, which increase urine output, potentially causing dehydration or electrolyte imbalances (e.g., hypokalemia). Education on fluid intake, monitoring weight, and recognizing dehydration symptoms is critical to prevent hypovolemia, ensuring safe diuretic use and maintaining physiological stability.

Choice C reason: Altered skin integrity may occur secondary to dehydration (dry skin) but is not the primary concern with diuretics. The main risk is fluid volume loss, which can lead to systemic complications like hypotension. Education should focus on fluid balance rather than skin, which is a secondary issue.

Choice D reason: Altered urinary elimination, such as incontinence, is not the primary concern, as diuretics increase output, not disrupt elimination patterns. While frequent urination may occur, the critical issue is fluid volume loss, which poses greater risks like dehydration or electrolyte imbalances, necessitating education on fluid management.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client and asks which of the following questions to evaluate potential heart failure symptoms?

Correct Answer is B

Explanation

A client is taking a diuretic that increases urinary output. What nursing concern is appropriate to base an educational plan?

Correct Answer is B

Explanation

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