A female client who reports urinary frequency and burning with urination.
Urinary tract infections are common in female clients with diabetes mellitus (DM). The client has a physical need, but there is another client who is a higher priority.
A client with a BP of 90/60 mm Hg and whose skin is hot and dry to touch. (Correct Answer)
The lower blood pressure and hot, dry skin indicate dehydration caused by hyperglycemia. This is the first stage of diabetic ketoacidosis (DKA). This client has a circulatory concern and is the highest priority.
A client with a BP of 120/50 mm Hg and who reports frequent urination and thirst.
Frequent urination and thirst are symptoms of DM and suggests that the client's blood glucose is not well-controlled. However, the client is not currently unstable and is not the highest priority. This client's mean arterial pressure (MAP) is 73 mm Hg; a MAP of at least 65 mm Hg is required for cells to receive adequate nutrients and oxygenation. A quick way to manually calculate a client's MAP is to double the diastolic blood pressure (e.g., 100), add the sum to the systolic blood pressure (100 + 120), and divide by 3 (220/3 = 73).
A client who reports experiencing constant hunger.
Constant hunger is a symptom of DM and suggests that the client's blood glucose is not well-controlled. However, the client is not currently unstable and is not the highest priority.
Decision Tree:
This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.
This is a "Who Do You See First" Question.
Terminology that is used here is often phrased as, "Who does the nurse see first?" Use these steps, based on the Kaplan Decision Tree, to determine the correct answer.
STEP 1: Can you identify the topic of the question?
STEPS 2-4: These steps are not relevant to this type of question because you do not need to use the rules for Who Do You See First questions. Move to Step 5.
STEP 5: Read each answer choice and use the Who Do You See First rules.
Who Do You See First Rules:
- Is the client stable or unstable? Eliminate the stable clients.
- Is the client experiencing an expected or unexpected finding? Eliminate expected findings.
- Are the remaining answer options referring to airway, breathing, or circulation (ABCs)? Eliminate each non-priority answer option using the ABCs.
- Are the remaining answers options referring to acute or chronic situations? Eliminate the chronic situation answer options.
- Are the remaining answer options real (actual) or potential problems? Eliminate the potential problem answer options.
- Look at each answer option that remains and ask, what outcome do you want for this client?
- Does this answer option make sense in this situation? If yes, keep this answer option.
- Will this answer option help the client? If yes, keep this answer option.
- Will this answer option hurt the client? If yes, eliminate this answer option.
Unstable vs. Stable
- A female client who reports urinary frequency and burning with urination. Stable, yet unexpected. Eliminate.
- A client with a BP of 90/60 mm Hg whose skin is hot and dry to touch. Unstable
- A client with a BP of 120/50 mm Hg who reports frequent urination and thirst. Stable, yet unexpected. Eliminate.
- A client who reports experiencing constant hunger. Stable, yet unexpected. Eliminate.
Select the best choice
Is #2 the correct answer? Yes, this client is demonstrating signs of dehydration and DKA and should be assessed immediately.
Does #2 make sense? Yes, this is the most unstable client and should be seen first. Though client #1 may require treatment for a urinary tract infection and clients #3 and 4 require blood glucose monitoring, client #2 has objective signs of dehydration.
