NCLEX Practice Test

Which client should the nurse see first?

1. Client with a right-sided ischemic stroke who is confused and is repeatedly getting out of bed without assistance

2. Client with an asthma exacerbation who was administered albuterol 15 minutes ago and has a heart rate of 110/min

3. Client with diabetes who has a blood glucose of 290 mg/dL (16.1 mmol/L) and has a scheduled dose of insulin aspart due

4. Client with obstructive sleep apnea who is 12 hours postoperative and maintaining an oxygen saturation of 92% on room air

The correct answer is: Client with a right-sided ischemic stroke who is confused and is repeatedly getting out of bed without assistance

The priority in this scenario hinges on patient safety and urgent medical needs. The client with a right-sided ischemic stroke is experiencing confusion and is at risk of falling or injuring themselves due to getting out of bed without assistance. This indicates a high level of risk, as confusion can impair judgment and coordination. Immediate intervention is required to prevent potential injury and address the complications associated with the stroke. While all clients presented have varying degrees of medical concerns, the situation involving the stroke client presents an immediate safety risk that necessitates a higher level of concern. In the case of the other clients, while their conditions are important to monitor and address, they do not pose an imminent danger to their safety at that moment. Therefore, prioritizing the confused stroke patient allows for timely intervention and support necessary to maintain safety and stability.