RELATED TOPIC:
NCLEX QUESTION TYPE TUTORIAL
Which client is the priority for a nurse to evaluate rapidly for respiratory distress?
This is a prioritization question: Which of the four patients needs the nurse’s attention most urgently, specifically for the issue of respiratory distress?
In your first pass through the answer options, focus on the basics: Is this patient at a high risk for respiratory distress – yes or no? For the answers you are not eliminating immediately, use a comparison system: For example, if patient A is at a high risk for respiratory distress, then compare them to answer B – Is this patient at a higher risk or at a lower risk? If lower, eliminate answer B, if higher, B becomes your new baseline for comparing the rest of the answers to.
Tip: It is vital you are clear about WHY you are eliminating an answer at all times. Use your scratch paper to note down your thoughts about each answer choice!
Let’s keep an eye on this client for now, since even though a blood sugar of 250 is not exceptionally high, they could be on their way into DKA.
Since answer A was not immediately eliminated, let’s compare answer B to answer A. Client A is “breathing quickly,” but there is no actual number given. Client B, on the other hand, has a respiratory rate of 28, which is higher than the normal range for an adult. Adding the shallow breathing, the chest pain, and the history of a car accident where the airbags went off and hit the patient right in the chest, this patient is probably having more severe respiratory problems than client A. Let’s keep it for now.
Now, compare this answer to the current “front runner,” answer B. While the pursed-lip breathing and oxygen saturation of 93% is not a good finding, COPD patients may have values like this on a very frequent basis. Assessing this client is necessary, but not more urgent than looking at the patient in answer B.
Last, we will compare the client in answer D to the client in answer B, who, so far, is our priority.
The stroke is, of course, very significant and the client is getting oxygen through the cannula, but the oxygen saturation of this client is within normal range. Dysarthria when speaking is also not a sign of respiratory distress. This one can be eliminated as not urgent.
Therefore, the client in answer choice B is the highest priority to evaluate for respiratory distress, and is the correct answer.
The client in answer B has been in a car accident receiving a direct hit to their chest wall. The person is breathing fast and shallow, reporting pain, which shows you they are already getting into distress. This is the client you should see first.
RELATED TOPIC:
Free Download
Benefit from a unique study combination of a concise summary paired with video lectures.
USMLE™ is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). MCAT is a registered trademark of the Association of American Medical Colleges (AAMC). NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc (NCSBN®). None of the trademark holders are endorsed by nor affiliated with Lecturio.
Your free account gives you access to:
or
