A charge nurse on a medical-surgical unit must prioritize which client to assess first. Which client requires the most urgent assessment?
- A.A client with type 2 diabetes who reports 'feeling shaky' and has a blood glucose of 68 mg/dL
- B.A client 2 days post-hip replacement requesting pain medication (current pain 4/10)
- C.A client with community-acquired pneumonia whose temperature is 38.3°C (101°F)
- D.A client awaiting discharge who has questions about home medications
Show answer & rationale
Correct answer
A. A client with type 2 diabetes who reports 'feeling shaky' and has a blood glucose of 68 mg/dL
Rationale
A is correct: A blood glucose of 68 mg/dL represents symptomatic hypoglycemia (blood glucose below 70 mg/dL with symptoms). Untreated hypoglycemia can rapidly progress to seizure, loss of consciousness, and death. This is the most immediately life-threatening situation. B is incorrect: Pain of 4/10 two days post-op is expected and does not represent an immediate threat to life. The client can wait a few minutes. C is incorrect: A low-grade fever of 38.3°C in a client with pneumonia is expected and does not represent the same acute danger as active hypoglycemia. D is incorrect: Discharge teaching is important but is the lowest priority among these options.
Key concepts