NCLEX Archer Prioritization Practice Test

Session length

1 / 20

When preparing for initial rounds, which client should the nurse assess first?

The client with diabetes who is being discharged today

A 32-year-old female with a tracheostomy experiencing copious secretions

Assessing the client with a tracheostomy who is experiencing copious secretions is the priority in this scenario due to the immediate risk to their airway. Clients who have a tracheostomy are at a higher risk for airway obstruction, especially if they are producing excessive secretions that can hinder breathing. The vital nature of maintaining a clear airway means that this client's situation requires urgent attention to prevent complications, such as respiratory distress or hypoxia.

The other clients also have needs that require care, but they do not present the same level of immediate risk. For instance, the client with diabetes who is being discharged does require careful assessment to ensure all discharge instructions are understood, but this is not an acute situation. The 16-year-old scheduled for physical therapy is likely stable and can be assessed after clients with more pressing concerns. Similarly, while the 80-year-old male with a decubitus ulcer requires a dressing change, this is more of a routine care issue that can be attended to later once immediate airway concerns are addressed. Prioritizing clients based on the severity of their condition is essential in nursing practice, particularly when it comes to life-threatening issues such as compromised airways.

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A 16-year-old scheduled for physical therapy

An 80-year-old male with a decubitus ulcer needing a dressing change

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