Colby Community College
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Nurse Tara is admitting Ms. Simpson. Which of the following is the priority action for 
Tara to take? 
 Option 3: Assess respiratory status 
o Rational: The priority action the nurse should take when using the ABC 
approach to the client is to assess respiratory status of a client who is 
experiencing SOB and tachypnea. 
2. Nurse Tart is assessing Ms. Simpson. Which of the following assessment scales is an 
appropriate tool for Tara to use? 
 Option 1: Hamilton- A 
o Rational: the nurse sh...