A nurse is assigned to care for four patients. Which patient should the nurse assess first?

A 50-year-old male with a blood pressure of 140/90 mmHg is complaining of a mild headache.

A 35-year-old female who is 1 day post-appendectomy, with a temperature of 100.4°F (38°C).

A 45-year-old female with a respiratory rate of 28 breaths per minute, complaining of shortness of breath.

A 60-year-old male post-abdominal surgery, with a pain level of 8 out of 10, is requesting pain medication.

Answer and Explanation

The Correct Answer is C

Patient prioritization relies on the Airway-Breathing-Circulation (ABC) framework to identify life-threatening physiological instability. Tachypnea and dyspnea indicate potential hypoxemia or respiratory failure, necessitating immediate intervention to prevent cardiac arrest. This approach ensures that the most hemodynamically compromised patients receive urgent clinical evaluation to maintain vital organ perfusion and oxygenation.

Rationale:

A. A blood pressure of 140/90 mmHg represents Stage 2 hypertension but does not constitute a hypertensive crisis. A mild headache is a common finding that does not suggest immediate neurological compromise. This patient is hemodynamically stable and does not take priority over a patient with acute respiratory distress.

B. a temperature of 100.4 F (38 C) on the first postoperative day is a frequent finding, often related to atelectasis or the inflammatory response to surgery. While it requires monitoring, it is not an acute emergency. Encouraging deep breathing and incentive spirometry is appropriate, but respiratory stability remains the higher priority.

C. A respiratory rate of 28 breaths per minute combined with subjective shortness of breath indicates respiratory distress. This requires immediate assessment of oxygen saturation and lung sounds to rule out pulmonary embolism or pneumonia. According to ABC priorities, breathing concerns must be addressed before pain or mild vital sign deviations.

D. A pain level of 8 out of 10 is significant and requires timely pharmacological intervention for comfort and recovery. However, pain is considered a psychosocial or "level 2" priority compared to the "level 1" status of respiratory compromise. The nurse must stabilize the patient who has difficulty breathing before administering analgesics to others.

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Correct Answer is C

Explanation

Intramuscular analgesic administration involves deposition of medication into skeletal muscle tissue allowing systemic absorption through capillary perfusion, producing onset dependent on drug class, lipid solubility, and circulation with expected analgesic effect occurring within defined pharmacokinetic time window requiring reassessment.

Rationale:

A. 10 minutes after intramuscular injection is too early for most analgesics to reach therapeutic plasma concentration. IM absorption requires vascular uptake and systemic distribution. Pain relief is usually not fully established at this time, making assessment premature and unreliable for efficacy evaluation.

B. 2 hours may be appropriate for some long-acting analgesics, but it exceeds the recommended initial reassessment window for most IM pain medications. Delayed evaluation risks prolonged untreated pain. Clinical guidelines emphasize earlier reassessment to ensure timely dose adjustment or additional intervention if needed.

C. Within 1 hour is the standard reassessment time for most IM analgesics as peak effect typically occurs within this period depending on drug type. This allows evaluation of analgesic efficacy and detection of inadequate pain control for timely clinical intervention or dose adjustment.

D. Once a shift is inappropriate for acute pain management following IM administration. Pain must be reassessed shortly after drug absorption begins, not at prolonged intervals. This approach risks uncontrolled pain, delayed response evaluation, and failure to meet effective pain management standards in clinical care.

A. History of frequent earwax impaction B. History of seasonal allergies and sinus infections C. History of working in a factory with loud machinery D. History of recurrent otitis media with tympanic membrane scarring

Correct Answer is C

Explanation

Sensorineural hearing loss results from permanent damage to the cochlear hair cells or the vestibulocochlear nerve pathways. Chronic exposure to high-intensity sound waves induces metabolic exhaustion and mechanical strain, leading to the apoptosis of the organ of Corti. This irreversible condition disrupts the transduction of mechanical vibrations into electrical neural impulses.

Rationale:

A. Earwax impaction causes conductive hearing loss by physically obstructing the external auditory canal. It prevents sound waves from reaching the tympanic membrane but does not damage the inner ear. This is a reversible condition and is not classified as a sensorineural pathology.

B. Seasonal allergies and sinus infections typically lead to Eustachian tube dysfunction and fluid accumulation in the middle ear. This results in conductive impairment due to inhibited ossicle vibration. These inflammatory processes do not typically affect the neurosensory components of the auditory system located within the bony labyrinth.

C. Prolonged exposure to occupational noise is the leading cause of acquired sensorineural deficits. High decibel levels cause oxidative stress and structural shearing of the delicate stereocilia. This finding is the most significant risk factor for permanent damage to the sensory receptors of the inner ear.

D. Recurrent otitis media and tympanic scarring, or tympanosclerosis, interfere with the mechanical transmission of sound through the middle ear. These issues cause conductive loss by reducing the compliance of the eardrum. They are structural issues of the conducting apparatus rather than the neural processing units of the ear.

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A nurse is assigned to care for four patients. Which patient should the nurse assess first?

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Correct Answer is C

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