Adult health / medical-surgical nursing · practice question

A 45-year-old client in the emergency department is being evaluated for uncontrolled hyperglycemia. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. Which nursing action is the priority to keep the client safe?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026adult-health-med-surg

Apply the first intervention in the policy manual without a current assessment.Leave the client alone to promote independence while finishing charting.Complete nonurgent tasks first because the client appears calm.Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.

Answer and explanation

Correct answer

D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.

Why

Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.

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A 45-year-old client in the emergency department is being evaluated for uncontrolled hyperglycemia. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. Which nursing action is the priority to keep the client safe?

Correct answer

Why

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