72. Which client should be the first priority for a telephone advice RN? A client who reports:
. Headache, vomiting, and fever.
. Ankle swelling and shortness of breath.
. Productive cough.
. Palpitations.
Test-Taking Tip
Think ABCs as priority and select "B"—breathing. Look for the client who is most unstable, or the clinical indications that signal a potentially urgent need.
Content Area: Adult Health, Triage; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
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Answer 1 is incorrect because a possible cause, such as dehydration or influenza, while potentially a concern, is not as serious as the potential of heart failure. Answer 2 is correct because these are signs and symptoms associated with heart failure. Answer 3 is incorrect because a productive cough alone without a high fever is not the first priority. Answer 4 is incorrect because palpitations without chest pain would not be a priority.