32. A nurse has just received morning report and is organizing and prioritizing the client assignment. Prioritize the nurse's actions by placing each client in the correct order.
32. A nurse has just received morning report and is organizing and prioritizing the client assignment. Prioritize the nurse's actions by placing each client in the correct order.
. The client with depression scheduled for discharge to the partial care program in 3 hours.
. The client who is in alcohol withdrawal with a serum sodium of 150 mEq/L.
. The client with an anxiety disorder complaining of chest discomfort.
. The client with aphasia requesting a piece of writing paper.
Test-Taking Tip
In ranking which client to assess from first to fourth priority, the nurse always considers physiological safety first, customer service second, non–life-threatening concerns third and the client who has needs that can be met later (e.g., discharge or teaching) last.
Content Area: Mental Health, Management of Care; Integrated Process: Nursing Process, Planning; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
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Answer 3 is correct because the nurse should assess the third client with the chest discomfort first as this client is at greatest risk for a potentially life-threatening condition. Answer 4 is correct because the nurse will be able to assess the fourth client second, quickly checking in with the client and providing the requested item if the care plan allows. Answer 2 is correct because the nurse will assess the second client experiencing a problem with homeostasis third, and will need to assess for signs and symptoms associated with hypernatremia. Answer 1 is correct because the nurse will assess the first client, who is being discharged, last. More tasks and teaching are required with the process, and the nurse will be able complete these actions as a last priority.