The nurse receives reports on four clients. Which client sho… | MyMerci
MyMerci — full questions and rationale, freeStart for free
Establishing PrioritiesMOC
Question
The nurse receives reports on four clients. Which client should the nurse assess first?
1A client with chest pressure, diaphoresis, and nausea✓ Correct answer
2A client with chronic arthritis requesting help with a meal tray
3A client scheduled for discharge who needs prescription teaching
4A client with a history of insomnia who slept 4 hours last night
Explanation
Chest pressure with diaphoresis and nausea suggests possible acute coronary syndrome and requires immediate assessment. Meal assistance, insomnia, and discharge teaching are important but less urgent. Use ABCs, acute change, and potential instability to prioritize.
Memory Tip Chest pressure plus sweating equals assess first.
Clinical scenario
Clinical Practice Guide Acute coronary symptoms may include chest discomfort, sweating, nausea, shortness of breath, and pain radiating to the arm, jaw, or back.
Caution Do not wait for classic crushing chest pain before assessing possible cardiac ischemia.
Key concepts
Triage — Sorting clients by urgency and risk to determine care priority.
Diaphoresis — Profuse sweating that can occur with pain, shock, or cardiac ischemia.
Acute Coronary Syndrome — A spectrum of conditions caused by sudden reduced blood flow to the heart.