NCLEX Practice Test

A nurse receives change-of-shift report on 4 clients. Which client should the nurse assess first?

1. Client who experienced a transient ischemic attack 2 days ago

2. Client who had a subdural hemorrhage 36 hours ago

3. Client with a bowel resection who had 4,800 mL of urine output

4. Client with a stroke whose Glasgow Coma Scale changed from 9 to 13

The correct answer is: Client who experienced a transient ischemic attack 2 days ago

The nurse should assess the client who experienced a transient ischemic attack 2 days ago first because this indicates a recent change in condition that may require immediate intervention. The other clients have either had a longer interval since their acute events or have stable or improved conditions. The client with a subdural hemorrhage may have a more urgent condition, but the client with a transient ischemic attack should be assessed first because the symptoms may have progressed rapidly. The client with high urine output may need further evaluation, but they may have been receiving fluids, and the change in condition for the client with a stroke may not be as recent and therefore not as urgent.