Level: Clinical
Difficulty: Medium
Subtopic: Endocrine disorders
NCLEX: A 45-year-old client in the emergency department is being evaluated for uncontrolled hyperglycemia. Assessment da…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for uncontrolled hyperglycemia. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. Which nursing action is the priority to keep the client safe?
Question
A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Complete nonurgent tasks first because the client appears calm.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Complete nonurgent tasks first because the client appears calm.
Rationale
Correct answer: A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.