The nurse assigned to four clients reviews client data at the beginning of the shift. Which information is assessed as the highest priority?
1. Hemoglobin, 12.2 g/dL
2. Potassium level, 3.6 mEq/L
3. Pulse oximetry reading, 89%
4. Urine output, 240 mL/8 hr
3
Rationale: Priorities are classified as high, intermediate, and low. Setting priorities requires a sound nursing knowledge base. The pulse oximetry is well below normal and indicates the high-est priority. Inadequate oxygenation to tissues is life-threatening. The hemoglobin level and the potassium level are within normal range, and these are low priorities. The urine output reading is marginal: 240 mL in an 8-hour period would indicate adequate but low urine output; this presents an intermediate priority.
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