Assignment: Client | Diagnosis | Latest data; Room 401 | Pneumonia, day 3 | Temp 38.1 °C, SpO2 93% on 2 L/min, HR 96/min; Room 402 | Type 1 diabetes | Glucose 64 mg/dL at 0645, alert, eating breakfast tray now; Room 403 | Post-op day 1 total knee | Pain 7/10, last oxycodone 0300, HR 92/min; Room 404 | GI bleed | Two maroon stools overnight, HR 88 → 118/min, BP 102/60 mm Hg The nurse receives handoff on four clients at 0700. Which client should the nurse assess first?

NCLEX prioritization question: which client to see first

Management of Care · Multiple choice · Clinical judgment step: Prioritize hypotheses

Client record

Client	Diagnosis	Latest data
Room 401	Pneumonia, day 3	Temp 38.1 °C, SpO2 93% on 2 L/min, HR 96/min
Room 402	Type 1 diabetes	Glucose 64 mg/dL at 0645, alert, eating breakfast tray now
Room 403	Post-op day 1 total knee	Pain 7/10, last oxycodone 0300, HR 92/min
Room 404	GI bleed	Two maroon stools overnight, HR 88 → 118/min, BP 102/60 mm Hg

The nurse receives handoff on four clients at 0700. Which client should the nurse assess first?

Show the answer and rationales

Answer: C

Trends matter: rising heart rate with ongoing GI bleeding is compensating shock and takes priority over expected or self-correcting problems.

A. Incorrect. Pain needs treatment but is not life-threatening.
B. Incorrect. A low-grade fever with SpO2 93% on oxygen is expected in pneumonia and stable.
C. Correct. Correct. Ongoing bleeding with a rising heart rate and narrowing blood pressure indicates early hypovolemic shock; this client is the least stable.
D. Incorrect. Mild hypoglycemia in an alert client who is eating is being corrected; recheck in 15 minutes.

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