Level: Advanced
Difficulty: Hard
Subtopic: Medication reconciliation
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for transfer from another facility with multip…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for transfer from another facility with multiple home medications. Assessment data include the client reports dizziness, blood pressure 92/58 mm Hg, and heart rate 118/min after the morning dose. 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.