Help needed with one interview question

If the pt trying to get out of bed is a fall risk, that seems like the most emergent task. I think all the bits about "post op" and "anti hypertensive meds" are to make you overthink it. Good old-fashioned horse sense tells you the pt climbing out of bed could fall and crack his head open.

Just for the future during actual practice....

delegating taking BP to a CNA is always optimal. If you didn't have a set of vitals, you would have brought the med with you, checked the BP, and if within limits given the med. No need to make one trip to take the BP and another back tot he med cart to get the med.

Also, it should be noted that we usually check a BP before giving an anti hypertensive to make sure the BP isn't too LOW. If the systolic is over 200, by all means give the BP med!

I think the most important thing is not so much to get the correct order, but to display your thinking skills out loud. Why are you making the choices you are making?

But yes, trying to get out of bed....maybe the patient has to go to the bathroom, maybe they are confused. That sounds like a safety risk to me.

Sorry, your answer was wrong.

Review Maslow's hierarcy. A patient trying to get out of bed would be your first priority... fall prevention needs to happen at the exact time the incident takes place.

Blood pressure control and IV fluid administration can wait. DON'T LET YOUR PATIENT FALL at all costs.

Someday .. you will be in this situation .. you will swoop to the fall risk patients bedside.. prevent the fall.. smoothly move to the next priority.. without missing a beat.

These kinds of scenarios.. presented to a new grad that has never had to handle this situation .. have been

developed by administrators that evaluate the situation from a cushy office chair... after the fact.

Good luck.. you CAN do this.

Yeah, these kind of priority scenarios are actually easier in real life than on paper. As you see a confused pt try to stumble out of bed you will rush in to help him before passing meds or even before checking on that new admit. That's more instinct than "nursing judgement".

Go into the fall risk room first. Delegate what you can once you assess the patient's need (inculding pain). You then can take the BP to find out if the person is WNL for hypertensive med (or delegate that as well, with you re-checking manually if BP is crazy high or low) give the med if indicated. (as you have a time frame to give the med if it is a routine med for this person).(and of COURSE in your initial assessment of the patient, you would have gotten vitals, so it would be a matter of giving the med in the appropriate time frame if indicated) Finally, hang the fluid on the post-op, assess for pain. Assuming that the patient has come to you from PACU, and has not been in a room for a un-necessary amount of time without intervention. The first two things can be initially delegated, (with you needing to actually give the med) the last can not.