Which client should the nurse on a medical-surgical unit assess first?

A. A client with a urinary tract infection whose temperature is 100.4°F (38°C)
B. A client with cellulitis who wants to shower
C. A client with pneumonia whose SpO2 dropped from 95% to 88% in the past hour
D. A client with diabetes who wants to discuss meal choices

Show answer and rationale

Correct answer: C

A falling oxygen saturation in a client with pneumonia signals worsening gas exchange and needs immediate assessment. The others are stable.

Source: Lewis's Medical-Surgical Nursing, 13th ed. (prioritization)

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This question is one of 193 Management of Care items in NCLEXSim. On the NCLEX-RN, this category makes up 15–21% of the exam.

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Study tip

Work every 'who first' item through the same ladder: airway, breathing, circulation; then unstable before stable, acute before chronic, actual before potential.
Delegation: the RN keeps initial assessment, care planning, teaching, evaluation, and any unstable client. LPNs take stable, predictable clients. Assistive personnel take routine tasks such as vital signs on stable clients, hygiene, feeding without swallowing risk, and ambulation.

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Which client should the nurse on a medical-surgical unit assess first?

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