A nurse is caring for four clients. Which client requires immediate intervention?

Question

The question is asking the nurse to prioritize which patient to see first. This question is asking the nurse to look at Airway, Breathing, Circulation, and Dire issues.

Answer 1

A. A client with chest pain who is diaphoretic and has ST elevation on ECG

B. A client with a blood glucose of 40 mg/dL who is alert and oriented

C. A client with a DVT who is requesting to ambulate to the bathroom

D. A client with pneumonia who has a productive cough and a temperature of 101°F (38.3°C)

Answer: A

Rationale: The patient is showing signs of an acute MI and is the most critical. Rapid intervention is needed to prevent cardiac arrest. All other clients are stable or can be safely delayed. This is a Circulation and Dire problem. The patient is at highest risk for decompensation.