NCLEX-RNManagement of CareEasy
A nurse is assigned to four clients at the start of the shift. Which client should the nurse assess first?
- AA client 2 days postoperative from abdominal surgery who reports incisional pain rated 6/10
- BA client with COPD who is using accessory muscles to breathe and states, "I can't catch my breath"
- CA client with type 2 diabetes whose morning fingerstick glucose is 182 mg/dL
- DA client scheduled for discharge teaching later this morning who has questions about home medications
Show answer & explanationAnswer & explanation
Correct answer: B. A client with COPD who is using accessory muscles to breathe and states, "I can't catch my breath"
Using the ABC (airway, breathing, circulation) framework, the client with new-onset respiratory distress and accessory muscle use is at highest risk for rapid deterioration and must be assessed first. The other clients have stable, non-emergent needs.
Why the other options are wrong
- A. Pain is important but not immediately life-threatening.
- C. A glucose of 182 mg/dL is mildly elevated but not an emergency.
- D. Discharge teaching can wait until the client's physiologic needs are addressed.
ABC Prioritization
When prioritizing care among multiple clients, always address airway and breathing problems before other concerns such as pain, minor lab abnormalities, or teaching needs.
- Airway and breathing take priority over circulation and other needs
- New or worsening respiratory distress signals urgent assessment
- Stable chronic issues can be addressed after acute threats are resolved
Memory trick: Airway first, always — breathe before everything else.