Editing Management of Care – RN Practice Questions (section)

==Question 2==
A registered nurse receives report on four clients. Which client should the nurse assess '''first'''?
# A client 2 days after abdominal hysterectomy who reports incisional pain rated 6 on a 0 to 10 scale.
# A client with chronic obstructive pulmonary disease whose oxygen saturation is 90% on 2 L/min by nasal cannula.
# A client with a new tracheostomy who has audible gurgling and a moist, congested cough.
# A client with type 2 diabetes mellitus whose fasting blood glucose is 168 mg/dL.

'''Answer:''' 3. The client with a new tracheostomy who has audible gurgling and a moist, congested cough.

''Rationale:'' Gurgling and a congested cough indicate secretions in the airway. Airway takes precedence over every other finding under the ABC framework, and this client needs suctioning now. Option 1 is expected postoperative pain and can be treated after the airway is addressed. Option 2 is an acceptable saturation for a client with COPD, in whom a target of roughly 88% to 92% is commonly appropriate; this is an expected finding, not a deterioration. Option 4 is an elevated but non-emergent glucose that does not threaten airway, breathing, or circulation.