Level: Advanced
Difficulty: Hard
Subtopic: Emergency deterioration
NCLEX: A client with pneumonia has temperature 101.8°F (38.8°C), heart rate 118/min, respirations 28/min, blood pressure…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A client with pneumonia has temperature 101.8°F (38.8°C), heart rate 118/min, respirations 28/min, blood pressure 88/54 mm Hg, and confusion. What is the priority?
Question
A. Assess airway and breathing, provide oxygen, establish IV access, and notify the provider.
B. Complete routine morning hygiene before reassessment.
C. Offer a snack because the client may be weak from fever.
D. Schedule ambulation to prevent deconditioning.
B. Complete routine morning hygiene before reassessment.
C. Offer a snack because the client may be weak from fever.
D. Schedule ambulation to prevent deconditioning.
Rationale
Correct answer: A. Assess airway and breathing, provide oxygen, establish IV access, and notify the provider.
Rationale: Confusion, hypotension, and tachypnea suggest sepsis or shock; ABCs and rapid escalation take priority.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Confusion, hypotension, and tachypnea suggest sepsis or shock; ABCs and rapid escalation take priority.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.