Level: Foundational
Difficulty: Easy
Subtopic: Respiratory disorders
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for pneumonia with increased work of breathing…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for pneumonia with increased work of breathing. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. Using ABCs and Maslow, which need should the nurse address first?
Question
A. Airway, breathing, and circulation problems before comfort or psychosocial needs.
B. Pain relief before checking airway and breathing.
C. Visitor concerns before physiologic stability.
D. Long-term teaching before treating acute physiologic risk.
B. Pain relief before checking airway and breathing.
C. Visitor concerns before physiologic stability.
D. Long-term teaching before treating acute physiologic risk.
Rationale
Correct answer: A. Airway, breathing, and circulation problems before comfort or psychosocial needs.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.