Answer: C. New restlessness with an oxygen saturation of 88% points to hypoxia, a breathing problem that can get worse quickly. Using the ABCs (airway, breathing, circulation), this client comes first.
- A. A low grade fever is an expected finding with pneumonia. Follow up, but it is not the most urgent.
- B. Moderate pain the day after surgery is expected. Treat it soon, once the unstable client is assessed.
- C. Restlessness is an early sign of low oxygen. Assess airway and breathing now and intervene.
- D. This glucose needs follow up per the plan of care, but it is not immediately life threatening.
Strategy: when every client needs something, look for the problem that is new, unexpected, or affects airway, breathing or circulation.