can't find the prioritization answer - page 5

by Helenz

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Q: you have give Morphine sulfate 4mg IV to a client who has an acute MI. when you evaluate the client's response 5 mins after giving the medication, which of these indicates a need for immediate further actions? A: 1. the... Read More


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    The question is asking for your immediate response. If #4 is the correct answer, how would you immediately respond? Giving more Morphine or NTG would cause a severe drop in blood pressure because they are vasodilators. I'm sticking to #2 because you can encourage breathing or provide supplemental oxygen. Anyone saying #2, what is your immediate response and rationale?
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    Opps! Anyone saying #4, what is your immediate response and rationale as a competent nurse.
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    Don't fall into the trap of only looking for ABC's or Maslows. Remember to simply answer the question and nothing more. These questions will try to lure you by saying "a change" or "drop." This is more of an intervention and evaluation question. The morphine was the intervention and and the evaluation was the pain scale. The evaluation indicated that the intervention was not effective and chest pain with acute MI has to be dealt with properly.

    Respiratory rate or saturation answers are there to entice you. The idea that "any answer that anything to do with breathing is the right answer " is completely false and a myth. The right answer is the answer to the question. The respiratory rate could be the right answer, but a respiratory rate of 12 is within normal range. It was a trick answer because it said the word "drop." A rate from 18 to 12 is totally acceptable. A rate of 6 would be concerning...not 12. Don't go by the fact that is was a resp answer. Relieving chest pain in an acute MI is a HUGE deal and the fact that the pt still had chest pain was ten times more concerning than a respiratory rate that was still completely normal.

    The last thing that should have been a dead give away was a word used in the answer. The word "STILL." The pt STILL had chest pain. If an intervention was carried out and the evaluation stated "still," that means the intervention was not effective.....regardless of the fact that it was only a 1/10. The NCLEX does not care what the number is. 1, 2, 3, 4, 5, 6...it doesn't matter. The pt still had chest pain and the intervention was not acceptable.

    You shouldn't take an answer and say "if this happens, then this could happen, which could lead to this." The question used the word "immediate further action," which is also a lure. You see "immediate" and it makes you want to jump to the respiratory choice. This is where priority comes in. If I had to choose between a respiratory drop and 1/10 scale, I would choose the resp drop if the drop was out of normal range. If the drop was a rate of 6, then the answer would have been two, but it was within normal limits. So, the answer then became choice four because it better described the evaluation to the intervention.

    Using the ABC's, Maslows, safety, or any prioritization should only come into play after you have realized the question. Figure out if it is an assessment, intervention, or evaluation. Then, move onto to prioritizing your answer choices. I'm telling you, if you pick the answer that has highest priority by just looking at the choices, without realizing the type of question it's asking, your computer screen is not going to shut off after 75.
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    Quote from OrNurrse03
    The question is asking for your immediate response. If #4 is the correct answer, how would you immediately respond? Giving more Morphine or NTG would cause a severe drop in blood pressure because they are vasodilators. I'm sticking to #2 because you can encourage breathing or provide supplemental oxygen. Anyone saying #2, what is your immediate response and rationale?
    Most of the time, in the ER, we would be giving NTG even after the drop in BP from the morphine....
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    Quote from OrNurrse03
    Opps! Anyone saying #4, what is your immediate response and rationale as a competent nurse.
    "When is the cath lab going to be ready for the patient?"

    Point is, given the four choices, none of them are particularly ominous, and, as a competent nurse, I realize that the "definitive" tx is reperfusion.
    Last edit by psu_213 on Nov 18, '12
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    For me the answer is #2. Because the patient now has a minimal pain 1 of scale of 10, and pain doesn't kill anybody. But respiratory rate has fallen quick and this patient respiration can be compromise. For me this is the priority.
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    Before the respiratory rate drop to 6 you have to intervene quick, because respiration rate in 12 is the borderline the normal respiration rate is between 12-18 your don't want that respiration rate drop more. That why I think the priority here is respiration not pain because you already gave to the patient Morphine for pain if now you'll give more pain medication to the patient what is going to happen? the blood pressure is going to drop more and the respiration rate too . Respiration is the priority here after give pain medication.
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    It's not asking if resp are more important than pain. It's an intervention and evaluation question. The pain answer says "still," which means the intervention was not effective in a pt having an acute MI. The number on the pain scale is irrelevant. If someone "still" has something going on after an intervention, that's needs "immediate action". The immediate actions is a lure to make people want to pick breathing b/c they know nurses in the real world will pick resp over pain any day. That's the point. There is no action to take for someone having a resp of 12. You can't think about the respiration leading to something else b/c that's what happens in the real world. The question stated that morphine was given and you are evaluating its effectiveness. The pt "still" had pain, so number 4 is correct. If one of the option was "a decrease in heart rate from 100 to 62" that wouldn't be the correct answer either, but that could be argued that the rate dropping could lead to cardiac arrest later down the road. But, that is not what the question is asking and a heart rate of 62 is still considered normal. I've seen students get questions wrong b/c they went with real world experience. Nurses going back to school often have trouble taking NCLEX type exams b/c the answers don't make sense (based on what really happens). You have to understand what the question is asking. You have to think outside the box. If the pain answer had 7/10, more people would have picked that, but 7/10 or 1/10 is irrelevant. The fact that the pt "still" had pain signals an ineffective intervention.


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