Question

nclex question of the day
09/10/25

the nurse has been made aware of the
following client situations.
the nurse should first assess the client

• a. with chronic obstructive pulmonary

disease (copd) who has diminished lung
sounds

• b. who had a hip replacement yesterday

and is restless with a petechial rash on
the neck

• c. who had an indwelling urinary catheter

discontinued 6 hours ago and has not yet
voided

• d. with chronic liver cirrhosis who has a

prolonged prothrombin time and low
platelet count

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Explanation:

To determine the client the nurse should assess first, we analyze each option for urgency:

• Option A: Diminished lung sounds in COPD is a chronic issue, not immediately life - threatening.
• Option B: Restlessness and petechial rash after hip replacement may indicate a pulmonary embolism (PE), a life - threatening condition. PE is a medical emergency as it can obstruct blood flow to the lungs, leading to hypoxia and potential cardiac arrest.
• Option C: Not voiding 6 hours after catheter removal is common; the bladder may take time to regain function, and it's not an immediate emergency.
• Option D: Prolonged prothrombin time and low platelets in cirrhosis are chronic lab findings, not an acute emergency requiring immediate assessment.

So, the client with the most urgent, life - threatening situation is in Option B.

Answer:

B. Who had a hip replacement yesterday and is restless with a petechial rash on the neck