Level: Foundational
Difficulty: Easy
Subtopic: Justice and fairness
NCLEX: A 58-year-old client on a telemetry unit is being evaluated for nursing care related to justice and fairness. Ass…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 58-year-old client on a telemetry unit is being evaluated for nursing care related to justice and fairness. Assessment data include new chest pain rated 8/10 with diaphoresis. Using ABCs and Maslow, which need should the nurse address first?
Question
A. Pain relief before checking airway and breathing.
B. Visitor concerns before physiologic stability.
C. Long-term teaching before treating acute physiologic risk.
D. Airway, breathing, and circulation problems before comfort or psychosocial needs.
B. Visitor concerns before physiologic stability.
C. Long-term teaching before treating acute physiologic risk.
D. Airway, breathing, and circulation problems before comfort or psychosocial needs.
Rationale
Correct answer: D. 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.