Level: Clinical
Difficulty: Medium
Subtopic: Dysphagia and aspiration risk
NCLEX: A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to dysphagia and aspi…
Nutrition Basic Care and Comfort
Case Study
A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to dysphagia and aspiration risk. Assessment data include the client has potassium 5.9 mEq/L while asking about salt substitutes. 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.