Safe, Effective Care Environment
25. Which client should a nurse assess first?
. Client with pancreatitis complaining of jaw pain, 4 on a scale of 10.
. Client dependent on insulin who complains of feeling shaky and hungry.
. Client who is confused, who has activated the bed alarm used to prevent falls.
. Client with "red-colored urine" drainage in Foley bag following TURP surgery.
Test-Taking Tip
Top priority in this situation is a client with a potentially life-threatening condition (cardiac).
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
Safe, Effective Care Environment
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Answer 1 is correct because jaw pain is not a typical pain pattern for pancreatitis; therefore, the client needs to be assessed for myocardial ischemia. Answer 2 is incorrect because this client would be seen third. The client is able to recognize and verbalize symptoms of hypoglycemia and the need to eat. The client could call the nurse if symptoms were increasing. Answer 3 is incorrect because this client would be seen second. This client is at high risk for falling. The reason for the alarm needs to be assessed. Answer 4 is incorrect because this client would be assessed last. Red-colored urine is normal after a transurethral resection of the prostate (TURP), and the presence of urine in the bag indicates the urine is flowing.