A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

Rationale:

A. The patient who needs to use the restroom is incorrect as the first priority because this is primarily a comfort and safety issue, not an immediate threat to life or organ function. While assisting the patient is important to prevent falls or incontinence, it does not take precedence over a patient with compromised circulation or potential shock.

B. The patient with blood pressure of 80/40 is correct because this hypotensive reading indicates a potentially life-threatening condition. Blood pressure this low can compromise perfusion to vital organs, including the brain, heart, and kidneys, and may signal shock, internal bleeding, dehydration, or other acute complications. According to Maslow’s hierarchy of needs and the ABC (Airway, Breathing, Circulation) framework, circulation issues are the highest priority, and interventions should be immediate to prevent deterioration. The nurse should assess the patient’s level of consciousness, heart rate, perfusion, and other vital signs, and implement interventions such as fluid resuscitation or notification of the provider.

C. The patient whose phone fell is incorrect because this represents a non-urgent, low-acuity concern. Retrieving a phone is primarily a convenience issue and does not impact patient safety or physiologic stability.

D. The patient with recurrent burning sensation in the chest is incorrect as the first priority because while chest discomfort can indicate cardiac or gastrointestinal issues, the scenario specifies recurrent burning rather than acute, severe, or worsening chest pain. Acute cardiac events would take higher priority, but in this scenario, the hypotensive patient is at the greatest immediate risk.

Rationale:
A. Respect the patient's decision and provide all necessary information to support informed consent is correct because the ethical principle of autonomy emphasizes the patient’s right to make informed decisions about their own healthcare. The nurse must ensure that the patient understands the purpose, benefits, risks, and alternatives of the medication, allowing them to make an informed choice, even if it conflicts with the nurse’s personal or professional opinion. Respecting autonomy means honoring the patient’s decision without coercion.

B. Delay care until the patient consents to treatment to avoid conflict is incorrect because delaying care without addressing the patient’s questions or concerns does not support informed decision-making. It may also create ethical and legal issues if the patient is not fully informed.

C. Notify the family immediately and override the patient's decision for their safety is incorrect because competent adults have the legal and ethical right to make their own healthcare decisions. Family input may be helpful for support, but it cannot override the patient’s autonomous choice unless the patient lacks decision-making capacity.

D. Administer the medication despite the patient's refusal to ensure beneficence is incorrect because forcing treatment violates the patient’s autonomy and could constitute assault. While beneficence focuses on doing good, it must be balanced with respect for the patient’s right to make decisions about their own care.