Nursing Priority vs First nursing action

[NurseLoveJoy88]

We had an exam today and I struggled with one of the answers. The nurse is caring for pt. with HF who is experiencing dyspnea , and bilateral crackles, and pulmonary edema. What is the nurses priority intervention:

Give PRN oxygen or give lasix as ordered.

The answer is apply oxygen but I chose to give lasix. I know all about ABC's and Maslow. However, the reason why I chose to give Lasix as ordered is because the sx are caused by pulmonary edema and the underlying cause needs to be addressed.

If the question would of asked what would should the nurse do FIRST... I would have picked to apply Oxygen.

There is a difference between priority and what to do first. I'm a nurse in LTC ( LPN) and I have taken care many of residents with HF exacerbation. My first nursing action for any resident with SOB secondary to pulmonary edema is to apply oxygen. However, my priority is to make sure that the underlying cause is addressed in order to prevent and treat symptoms. Most of the time that priority interventions includes getting an order for IM lasix if not already ordered.

Oxygen alone will provide temporary relief however it will not get rid of the pulmonary edema.

Please help me to understand how oxygen is a priority instead of a first nursing action. Thanks.

[criticalRN10]

If you haven't done any kind of test prep I recommend Hurst review with Marlene Hurst- she's HILARIOUS and gives you awesome tips on how to think like NCLEX wants you to think- it helps a lot in nursing school too since they try to make their tests a lot like NCLEX to prepare you. I watched all of her videos before my finals last semester and we had 3 HESI's (med/surg, pedi, and psych) and I did really well. I watched them again just before our exit HESI and did really well again. It's a GREAT test taking review :)

[MunoRN, RN]

The key to nursing tests is to not think too much, in fact think as little as possible. This question is a good example. The ABC's (now CAB's) are useful for a patient who lacks any or all of those three, but otherwise it is not an appropriate way of prioritizing without taking into account severity (mild congestion is technically an airway threat but that doesn't mean I'm going to get their mucomyst before I treat their symptomatic VT.) But even if we do look at ABC's you could easily argue that lasix actually comes first. 'Airway' includes every airspace from the mouth to the alveoli, in pulmonary edema the alveoli are saturated with fluid which impairs gas exchange, the purpose of lasix is to remove that fluid and re-open the alveoli portion of the airway. You could also easily argue that oxygen fits more into circulation than anything else; the purpose of supplemental O2 is improve oxygen perfusion of tissues, ie circulation, plus O2 won't help maintain an airway or cause a person to breathe.

If I only had one choice, to give either O2 or lasix, I'd choose lasix, hands down. Without intervention in what sounds like flash pulmonary edema (based on the fact that this sounds like a very sudden change if the patient was not already on O2), giving only O2 will not change the outcome, with O2 only you'll just end up with a dead patient wearing an oxygen mask.

But remember, that's way too much thinking. Just think (minimally); I'm in the room, I find these symptoms, there's a cannula/NRB/Bipap right there, do I put it on them? Of course, so that's your answer, just remember to stop thinking there. I only aced two tests in nursing school, and one of them was because I forced myself not to think about any question for more than 3 seconds.

[leslie :-D]

to the op, no offense, but whether you want to use it as a noun or an adjective, oxygen here, would beat out lasix in every one of those commonly accepted word definitions. given your sentiment by the statement of "there is a difference between priority and what to do first..." it is evident that perhaps your definition is tad different than everyone else's. in your own universe, that won't be an issue. but if you're going to get along with the rest of the world of nursing, imho, i would suggest that you revisit your understanding of the word.

emergency, keep in mind it is natural for students to read into these nsg exam questions...

that we tend to analyze and overanalyze its hidden and true meaning, right?

op, just by virtue of your 1st action being the o2, you had already exhibited what your priority was.

1st actions = priority...that's the bottom line.

leslie

[llg, PhD, RN]

You are really splitting hair on this, and, well, sorry to tell you, your logic is just wrong here. Long term, yes, your want to treat the underlying problem...short term, save their life! (Lasix isn't going to do it in the short term) Your priority nsg. dx is impaired gas exchange. Your priority intervention is to apply O2. Your first intervention = your priority intervention. Yes, given the lasix ASAP after that, but, even if it is IV, it will take a bit to take effect. Apply the O2 first.

I strongly agree with the approach taken by psu_123. The OP's belief that treating the underlying cause of something is of higher priority than saving their life is simply wrong. Keeping a patient alive in the short term is always more important than treating a longer term treatment of the underlying problem.

[Emergency RN]

thank you for all the replies and i have a greater understanding of the test questions. emergency rn not sure what you were trying to say here but thanks for your 2cents.

"there is a difference between priority and what to do first..." (your understanding)

"there is no difference between priority and what to do first..." (what everyone else assumes)

so the question becomes:

"what is the nurses first intervention: give prn oxygen or give lasix as ordered?"

in other words, priority means first is how most nurses would understand the meaning. and at leslie, you're absolutely right in that many people over think a question and wind up choosing the wrong answers. i recall our nursing class president, who was a nursing aide for years and 4.0 honors student, who unbelievably failed the boards. who wudda thunk it? sometimes, if you think too much, you wind up burying yourself.

[MunoRN, RN]

You are really splitting hair on this, and, well, sorry to tell you, your logic is just wrong here. Long term, yes, your want to treat the underlying problem...short term, save their life! (Lasix isn't going to do it in the short term) Your priority nsg. dx is impaired gas exchange. Your priority intervention is to apply O2. Your first intervention = your priority intervention. Yes, given the lasix ASAP after that, but, even if it is IV, it will take a bit to take effect. Apply the O2 first.

If only it could be that straightforward. Impaired gas exchange is to due to the pulmonary edema, not a lack of O2 supply. O2 will help in some ways related to impaired gas exchange (as a supportive measure for the input side), but it won't due squat for the respiratory acidosis that develops when the output side of gas exchange is impaired.

[MunoRN, RN]

I'm sorry, but I must respectfully disagree with you. When I think of priority, I automatically think of 1st, 2nd, 3rd, so that, like you said I would apply oxygen. Sure, you can have six things that are priority, but you must realize the true meaning of these questions. These questions are indeed asking what you need to do first. That's just how they word the questions.

I think, however, the question would have been most clear if it used the word first. It is true that oxygen is only a temporary stabilizing measure, but you mentioned the rationale in your post: ABCs. No matter what you do in nursing, ensuring the ABCs always comes first. Oxygen qualifies under the airway or A part. To me, Lasix fits in under circulation, the C, since it would help the body get rid of the fluid volume excess associated with HF.

That's how I would work the question.

How is oxygen "airway"?

[GM2RN]

How is oxygen "airway"?

Technically it would be "breathing," I suppose, but the point is understood.

[shoegalRN, RN]

I would have given the oxygen FIRST.

IV Lasix takes about 3-5 minutes to push via IV. When someone is SOA, you don't have 3-5 minutes.

That's MY opinion.

[GHGoonette, BSN, RN]

By the time the doc gets to write the Lasix up, I would hope that the patient would be receiving oxygen. Administering Lasix is a task delegated to the nurse by the doctor; that is his/her intervention and the nurse carries it out. The nurse's first intervention is that which is within his/her scope of practice. No nurse needs a dr's script to administer O2, therefore O2 is the first nursing intervention.

Always read your question carefully; you are asked what is the nurse's priority intervention. O2 first, correct positioning immediately afterwards.

[NurseLoveJoy88, ASN, RN]

I strongly agree with the approach taken by psu_123. The OP's belief that treating the underlying cause of something is of higher priority than saving their life is simply wrong. Keeping a patient alive in the short term is always more important than treating a longer term treatment of the underlying problem.

Correction. I don't believe that treating the underlying cause is more important to saving the patients life. It was a test question that I read into that is all. In real life as a LPN I have had many residents with CHF exacerbation with SOB and my FIRST action and priority was to give oxygen. However, I have a hard time with test questions at times and the wording.

[NurseLoveJoy88, ASN, RN]

By the time the doc gets to write the Lasix up, I would hope that the patient would be receiving oxygen. Administering Lasix is a task delegated to the nurse by the doctor; that is his/her intervention and the nurse carries it out. The nurse's first intervention is that which is within his/her scope of practice. No nurse needs a dr's script to administer O2, therefore O2 is the first nursing intervention.

Always read your question carefully; you are asked what is the nurse's priority intervention. O2 first, correct positioning immediately afterwards.

I get why I answered it wrong. BTW- The Lasix answer said the order was already on file.