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...
Ya, those were the two I had originally narrowed it down to. I just don't see 107 as such an emergency that he needs to come before a quick med pass for pain. But I get what you are saying and why he really should come first. Thank you for your clarification. Are you an instructor? You explain very well.
Ya, those were the two I had originally narrowed it down to. I just don't see 107 as such an emergency that he needs to come before a quick med pass for pain. But I get what you are saying and why he really should come first. Thank you for your clarification. Are you an instructor? You explain very well.
no -- not an instructor --- going into my 5th and final semester of nursing school... if all goes well will graduate in December... woohoo
Ya, those were the two I had originally narrowed it down to. I just don't see 107 as such an emergency that he needs to come before a quick med pass for pain. But I get what you are saying and why he really should come first. Thank you for your clarification. Are you an instructor? You explain very well.
We are not looking at single number HR:107. It is the fact that the client's admitting Dx is Alcohol Withdrawal and with that being said, we have to consider the presenting Sx as a diagnostic criteria. In this case, tachycardia is related to the autonomic hyperactivity-- we will eventually see grand mal seizures if not treated. We are also looking at the fact that binge drinking rarely causes DT and therefore we can safely assume that his electrolyte may have some abnormalities from the chronic alcoholism. You would want to prevent Wernicke's encephalopathy in this case.
#1. Because safety always comes first at the NCLEX Hospital.
COPD'er at 95% is good. If sickle cell patient said severe pain, that would change things.
***try to look at all questions like this....at the NCLEX Hospital, you can only do ONE THING, then you have to go home. It really helps narrow down your answers.
I would agree with the other posters that the first patient going through alcohol withdrawal with the elevated heart rate would be the first patient to see. The fact that this patient is being treated for alcohol withdrawal in the hospital would signify to me that they are at higher risk.
While you would want to treat the patient with pain, to me the term body aches is generalized and would be an expected symptom of sickle cell crisis.
Patient 4 with pneumonia is at this time stable and would not require immediate attention along with the patient who needs to ambulate.
Just FYI - sonething to consider re pt #1. DT's start about 48 hour after the last drink; confusion, restlessness and irritability start sooner.
Seizure activity & safety were my first concern.
When choosing bet 2 & 4, anybody with O2 delivery carries more import for me to check. Neither pts were described in any distress, I want to know that the O2 is really at 3L. I'll bet we all have walked into rooms and found the flowmenter wrong (and IV/GT pumps wrong).
I can then comfortably give my undivided attn to the pt needing ambulation which may take some time. Unless there were some time-specific order to walk the pt, I would not be reading too much into the order.
Answer is patient number 1. He is having a circulation issues, actively withdrawing and there are safety concerns. Next is the sickle cell patient who is having pain, which is expected of patients with sickle cell disease. There was mention of acute chest, which is a concern with sickle cell crisis, but there is no mention of dyspnea or chest pain. Patient number 4 is a respiratory patient, but he is stable. He would be seen 3rd. Patient number 3 would be seen last. Ambulating the patient can be delegated to the UAP.
Can anyone else come up with an NCLEX style question?
I'm taking this from memory, the question stood out to me.
A stable patient on the medical unit in a hospital unexpectedly dies. The nurse needs to inform the significant other on the phone. What statement does she make?
1. "I'm very sorry, but your loved one has died."
2. "Can you come to the hospital right away? The client is not doing well."
3. "The HCP has asked me to call to report the death of your family member."
4. "May we discuss organ donation and your loved ones wishes?"
I'm taking this from memory, the question stood out to me.
A stable patient on the medical unit in a hospital unexpectedly dies. The nurse needs to inform the significant other on the phone. What statement does she make?
1. "I'm very sorry, but your loved one has died."
2. "Can you come to the hospital right away? The client is not doing well."
3. "The HCP has asked me to call to report the death of your family member."
4. "May we discuss organ donation and your loved ones wishes?"
1. direct and to the point as well as showing compassion for the situation
2. by stating "not doing well" would offer some false reassurances - also potentially put the person in a dangerous situation if they chose to drive based on your instructions and are not in a mental state to be driving.
3. makes the nurse seem uncaring about the situation or the family members feelings by diverting attention to the physical's orders
4. while requesting information about donation is necessary and mandated by law - this does not offer the necessary information to the family member
I would have to go with option 1 if this were a question on one of my exams.
brandiep1982
236 Posts
Ya, those were the two I had originally narrowed it down to. I just don't see 107 as such an emergency that he needs to come before a quick med pass for pain. But I get what you are saying and why he really should come first. Thank you for your clarification. Are you an instructor? You explain very well.