Level: Foundational
Difficulty: Easy
Subtopic: Fluid volume excess and deficit
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to fluid volume exces…
Pathophysiology Physiological Adaptation
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to fluid volume excess and deficit. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. 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. Airway, breathing, and circulation problems before comfort or psychosocial needs.
D. Long-term teaching before treating acute physiologic risk.
B. Visitor concerns before physiologic stability.
C. Airway, breathing, and circulation problems before comfort or psychosocial needs.
D. Long-term teaching before treating acute physiologic risk.
Rationale
Correct answer: C. 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.