Level: Clinical
Difficulty: Medium
Subtopic: Skin and wound assessment
NCLEX: A 66-year-old client in an outpatient clinic is being evaluated for skin and wound assessment during hospitalizat…
Health assessment Reduction of Risk Potential
Case Study
A 66-year-old client in an outpatient clinic is being evaluated for skin and wound assessment during hospitalization. Assessment data include respiratory rate 8/min, shallow breathing, and SpO2 86% on room air. 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.