The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client?
1. Self-Care Deficit
2. Disturbed Body Image
3. Ineffective Airway Clearance
4. Risk for Falls
Correct Answer: 3
Rationale 1: After surgery, a client may have a Self-Care Deficit however this is not the priority.
Rationale 2: Depending upon the type of surgery, the client may have Disturbed Body Image however this is not the priority.
Rationale 3: When prioritizing, the nurse should remember the ABCs. Airway should always be the priority.
Rationale 4: A client recovering from surgery may be at Risk for Falls however this is not a priority.
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