Priority Questions beyond ABC

JustBeachyNurse, LPN · Oct 25, 2013

After ABC go to Maslow's Hierarchy of Needs. Pain beats hunger. The first situation is not simple. What is low BP? What is normal for the patient? Is drowsy person sleep deprived or is it a sudden onset alteration in level of consciousness?

Altered LOC would be a priority over someone with a BP that is low normal. Someone who has a normal BP of 140/90 that an hour later is 100/60 could be a more emergent situation especially if possible OD on medication/medication reaction or potential for occult hemorrhage. (I've never seen an NCLEX question that was was for prioritization with only one symptom each...such as who would you see first someone with low BP, someone hungry, someone drowsy, or a pale patient.

The questions are always " You are a nurse on a surgical floor, prioritize your patient care:

1. 1hr post op abdominal surgery patient with a BP of 90/60

2. one day post-op knee replacement, pain level is escalating from 1/10 to 4/10

3. post op day 1 gallbladder removal patient cleared for PO intake that is requesting a lunch tray

4. patient preparing for neurosurgery for coiling of a cerebral aneurysm that is very drowsy/altered LOC

souleater11 · Oct 25, 2013

After ABC go to Maslow's Hierarchy of Needs. Pain beats hunger. The first situation is not simple. What is low BP? What is normal for the patient? Is drowsy person sleep deprived or is it a sudden onset alteration in level of consciousness?
Altered LOC would be a priority over someone with a BP that is low normal. Someone who has a normal BP of 140/90 that an hour later is 100/60 could be a more emergent situation especially if possible OD on medication/medication reaction or potential for occult hemorrhage. (I've never seen an NCLEX question that was was for prioritization with only one symptom each...such as who would you see first someone with low BP, someone hungry, someone drowsy, or a pale patient.
The questions are always " You are a nurse on a surgical floor, prioritize your patient care:
1. 1hr post op abdominal surgery patient with a BP of 90/60
2. one day post-op knee replacement, pain level is escalating from 1/10 to 4/10
3. post op day 1 gallbladder removal patient cleared for PO intake that is requesting a lunch tray
4. patient preparing for neurosurgery for coiling of a cerebral aneurysm that is very drowsy/altered LOC

thanks Beachynurse, btw whats the correct answer from your nclex question above ?

JustBeachyNurse, LPN · Oct 25, 2013

Id go with Known aneurysm patient. High risk for a fatal Subarachnoid hemorrhage. If they are going for coiling they are likely risk for rupture.

The post-op patient likely has IV fluids and can likely wait a few min for the nurse to assess the neuro patient first. But a VERY CLOSE 2nd.

Real world get a coworker to assess the second patient.

Have you looked into the LaCharity PDA (priority, delegation and assignment) book?

souleater11 · Oct 25, 2013

Id go with Known aneurysm patient. High risk for a fatal Subarachnoid hemorrhage. If they are going for coiling they are likely risk for rupture.
The post-op patient likely has IV fluids and can likely wait a few min for the nurse to assess the neuro patient first. But a VERY CLOSE 2nd.
Real world get a coworker to assess the second patient.
Have you looked into the LaCharity PDA (priority, delegation and assignment) book?

Thanks again BeachyNurse, I tried LaCharity PDA but while it gives me an overview of prioritization It does not help me much in dealing priotization with multiple body system disease that found in actual nclex priority questions.

The book's priority questions are categories by the same body system disease (Endocrine, Hematology) in their chapters.

By the way, does Drug Over Dose patients are in the category of Circulation of ABC priority level ?

JustBeachyNurse, LPN · Oct 26, 2013

Depends. Opiates, benzos and other drugs that cause respiratory depression would be breathing unless so low respiratory drive airway is compromised. Tylenol OD not so much.

Cocaine can cause an AMI or arryrhmias so that would be circulation

souleater11 · Oct 26, 2013

Depends. Opiates, benzos and other drugs that cause respiratory depression would be breathing unless so low respiratory drive airway is compromised. Tylenol OD not so much.
Cocaine can cause an AMI or arryrhmias so that would be circulation

Thanks JBN,

Is respiratory depression cause by Drug Adverse effects considered an Actual or Potential Problem ?

JustBeachyNurse, LPN · Oct 26, 2013

Depends. If you have a heroin overdose patient with a RR of 6 in the ER it's actual.

If you have a drug naive patient on a morphine of dilaudid PCA pump post surgery that has a RR of 14 and pulse ox of 97% on room air it would be a potential problem

souleater11 · Oct 26, 2013

thanks a lot, i learn a lot from you tonight :)

btw, speaking about drug over dose, can the RN delegate to LPN the administration of opiate antidote ?

JustBeachyNurse, LPN · Oct 26, 2013

\ said:

thanks a lot I learn a lot from you tonight 🙂 btw, speaking about drug over dose, can the RN delegate to LPN the administration of opiate antidote?

Pretty much no as Narcan is usually given IVP in an acute overdose & usually in a critical care area. Most state nurse practice acts do not permit LPNs to administer IV push medications.

souleater11 · Oct 27, 2013

hi JBN, in nclex world, if a patient manifest s/s of drug toxicity.

Does the RN prioritize in assessing the patient or implementing to give IV antidote?

I read somewhere that ALL drug administration in nclex world is not a nursing priority because it requires a doctor's order. is this true ?

JustBeachyNurse, LPN · Oct 27, 2013

\ said:

hi JBN in NCLEX world, if a patient manifest s/s of drug toxicity. Does the RN prioritize in assessing the patient or implementing to give IV antidote? I read somewhere that ALL drug administration in NCLEX world is not a nursing priority because it requires a doctor's order. is this true?

It depends on the wording of the question.