ATI Ns 117 Fundamentals Exam

Extract:

Question 1 of 5

A nurse is receiving report on a group of clients. Using the ABCDE priority framework, which of the following clients should the nurse see first? A. A client who is postoperative and has a urine output of 50 ml for the past 3 hr. B. A client who is scheduled for discharge and has a 38.4° C (101.1° F) temperature this morning. C. A client who has pneumonia and has developed wheezing. D. A client who has early dementia and awoke confused to their location this morning. Which of the following clients should the nurse see first?

A. A client who is postoperative and has a urine output of 50 ml for the past 3 hr. B. A client who is scheduled for discharge and has a 38.4° C (101.1° F) temperature this morning. C. A client who has pneumonia and has developed wheezing. D. A client who has early dementia and awoke confused to their location this morning.

Correct Answer: C

Rationale: The correct answer is C: A client who has pneumonia and has developed wheezing. In the ABCDE priority framework, airway (
A) is the top priority. Wheezing indicates potential airway obstruction or narrowing, necessitating immediate assessment and intervention to ensure adequate oxygenation. The other options do not pose an immediate threat to the client's airway or breathing. A: Low urine output postoperatively may indicate dehydration but does not compromise the airway. B: A mildly elevated temperature in a client scheduled for discharge is concerning but not as urgent as compromised airway. D: Confusion in a client with early dementia is important to assess for, but it does not directly impact airway or breathing. By prioritizing the client with pneumonia and wheezing, the nurse can address the most critical issue first to ensure the client's safety.

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ATI Ns 117 Fundamentals Exam | Nurselytic

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ATI RN

ATI RN