# Four clients arrive at an urgent care clinic. Which client should the nurse assess first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396577&lang=en  
> language: en  
> subject: Establishing Priorities  
> category: MOC

## Question

Four clients arrive at an urgent care clinic. Which client should the nurse assess first?

## Option

1. A client with a low-grade fever and nasal congestion that began two days ago
2. A client requesting a refill of prescribed blood pressure medication without other symptoms
3. A client with an ankle sprain after a sports injury, rating pain as 6 on a 0-10 scale
4. A client with new shortness of breath and difficulty speaking in full sentences **✔ Correct answer**

**Correct answer: 4**

## Explanation

Airway and breathing problems take priority. New shortness of breath with inability to speak full sentences suggests respiratory distress and requires immediate assessment. The other clients need care but do not show the same immediate threat.

## In-depth explanation

Clinical Judgment
Use the client cues, timing, labs, and safety risks to select the response that best fits Triage respiratory priority.

Memory Tip
Match the strongest cue cluster to the safest nursing judgment.

KR vs US
NCLEX items reward cue-based priority thinking rather than isolated recall.

## Clinical scenario

Clinical Practice Guide
For Triage respiratory priority, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Triage** — Sorting clients by urgency of assessment and treatment needs.
- **Respiratory Distress** — Increased work of breathing that can threaten oxygenation.
- **Priority Setting** — Selecting the most urgent nursing action based on risk and client stability.

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