After receiving report, which patient should the nurse see first?
1) Mr. Jones, a 57 year old man with a history of pancreatitis, going through alcohol withdrawal and has a heart rate of 107.
2) Ms. Smith, a 87 year old with COPD who is recovering from hip surgery and needs to ambulate in the hall.
3) Ms. Brown, a 24 year old admitted for sickle cell crisis who is complaining of body aches and wants pain medication.
4) Mr. Thomas, a 82 year old admitted for pneumonia whose oxygen saturation reads at 95% on oxygen at 3 liters per minute via nasal cannula.
*I thought it would be a good idea to start a thread where members could post NCLEX style questions for us to learn from and discuss.*
I would go with 1. 2 and 4 are relatively stable. In my mind, 3 is experiencing would I would expect for someone with SCC. Yes, there could be more to the situation, and I would see him 2nd, but I would be more concerned for 1. If he is going through etOH withdraw, it basically is acute. Is there even such a thing as "chronic" alcohol withdraw? Being tachy, that already gives him "points" on a withdraw scale without knowing anything else. I would go to him first, assess him for other signs of withdraw (temp, tremors, clouded sensorium, etc.), make sure seizure precautions are in place, and medicate him if necessary. While I do care about 3's pain, it is not as important as the safety risks 1 has.
I am probably wrong, but I would go to 3 first. Here is my reasoning: 2 is obviously not a priority, it needs to be done, but it is not too time sensitive. 1 and 3 need to be seen and are currently stable, but could turn into lengthy visits, delaying a simple pain treatment for the sickle cell pt. I would want to tx her pain before risking allowing her pain to get significantly worse before I can get to her after seeing pts 1 then 4.
I am probably wrong, but I would go to 3 first. Here is my reasoning: 2 is obviously not a priority, it needs to be done, but it is not too time sensitive. 1 and 3 need to be seen and are currently stable, but could turn into lengthy visits, delaying a simple pain treatment for the sickle cell pt. I would want to tx her pain before risking allowing her pain to get significantly worse before I can get to her after seeing pts 1 then 4.
I am probably wrong, but I would go to 3 first. Here is my reasoning: 2 is obviously not a priority, it needs to be done, but it is not too time sensitive. 1 and 3 need to be seen and are currently stable, but could turn into lengthy visits, delaying a simple pain treatment for the sickle cell pt. I would want to tx her pain before risking allowing her pain to get significantly worse before I can get to her after seeing pts 1 then 4.
If you prioritize correctly, ABCs first, then you would go with ETOH withdrawal with tachycardia. If you don't consider that Circulation, then you would then go with Maslows hierarchy of needs which again would put the ETOH first due to physiological and safety needs which fall first on the heirarchy.
The pain is definitely a priority but I don't think it's the highest priority in this scenario.
If you were going ABCs wouldn't you visit 4 first... Airway and breathing, 95% does not always= 95%... Tachycardia is circulation, c, right?
no - 95% does not always equal 95% -- BUT there is nothing in the question here to indicate that the patient has any acute change in their condition or is in any distress.
Hard lesson I also learned -- you have to stop thinking like a paramedic in nursing school... :)
I was just asking bc you said follow ABCs. But that would mean airway/ breathing first. So I wouldn't follow ABCs for an NCLEX question? And actually, my husband is a medic too and he said 4 first and I said "but this isn't medic, this is nursing, so reasoning and situation isn't going to be the same."
I was just asking bc you said follow ABCs. But that would mean airway/ breathing first. So I wouldn't follow ABCs for an NCLEX question? And actually, my husband is a medic too and he said 4 first and I said "but this isn't medic, this is nursing, so reasoning and situation isn't going to be the same."
You do follow ABCs during assessments and they assist you with questions such as this when prioritizing in which order you should see patients.
for example -- IF patient 4 had a SpO2 of 85% and all the other patients remained exactly the same, then yes this patient would now be priority because of breathing ---
The important thing when approaching questions like this is to realize you can't be distracted simply because they have added information -- you are thinking that the inclusion of the dx of pneumonia and the mention of Pulse Ox reading = airway and breathing -- BUT this patient is actually stable in this question and thus would fall on the prioritization list.
I always attempt to identify which patient had an acute change in status or are not presenting as expected to be.... Since in this question you can easily narrow down the choices to between 2 patients --- pain and tachycardia -- then using ABCs tachycardia wins...
I hear ya however, number 4 is not in acute distress. It does not say the airway is compromised or that there is any alteration in breathing. He has PNA and has some LOW flow oxygen on. Most of my patients have oxygen, some always. The A and B of the ABCs are applied first when their is acute distress like Low oxygen saturation especially refractory to higher oxygen rates and Dyspnea etc.....
psu_213, BSN, RN
3,878 Posts
I would go with 1. 2 and 4 are relatively stable. In my mind, 3 is experiencing would I would expect for someone with SCC. Yes, there could be more to the situation, and I would see him 2nd, but I would be more concerned for 1. If he is going through etOH withdraw, it basically is acute. Is there even such a thing as "chronic" alcohol withdraw? Being tachy, that already gives him "points" on a withdraw scale without knowing anything else. I would go to him first, assess him for other signs of withdraw (temp, tremors, clouded sensorium, etc.), make sure seizure precautions are in place, and medicate him if necessary. While I do care about 3's pain, it is not as important as the safety risks 1 has.