NCLEX-RN

Category - Reduction of Risk

A nurse is admitting a client with productive cough. The client also complains of shortness of breath, fever, and pleuritic pain. Upon review of records, the nurse noted that the client is hypertensive with a history of angina. When planning care, which vital sign value should the nurse give first priority?
  1. Respiration rate
  2. Blood pressure
  3. Temperature
  4. Pulse rate
Explanation
Answer: A - Prioritization dictates that airway and breathing should be assessed first. Given that the client has shortness of breath, airway obstruction or chest pain should be evaluated next. If the blood pressure increases, bradycardia may ensue. All abnormal findings should be reported and documented accordingly.
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