Level: Foundational
Difficulty: Easy
Subtopic: Autonomy and informed consent
NCLEX: A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to autonomy and infor…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to autonomy and informed consent. Assessment data include provider order for a medication the client is allergic to on the chart. Using ABCs and Maslow, which need should the nurse address first?
Question
A. Pain relief before checking airway and breathing.
B. Airway, breathing, and circulation problems before comfort or psychosocial needs.
C. Visitor concerns before physiologic stability.
D. Long-term teaching before treating acute physiologic risk.
B. Airway, breathing, and circulation problems before comfort or psychosocial needs.
C. Visitor concerns before physiologic stability.
D. Long-term teaching before treating acute physiologic risk.
Rationale
Correct answer: B. 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.