The nurse is caring for a patient with the following vital signs:
Temperature: 98.9°F
Pulse: 94
Respirations: 20
Blood pressure: 144/94
Pulse oximetry: 94%
What is the priority action of the nurse?

Ask the patient about his usual blood pressure results.

Apply a cool washcloth to the patient's forehead.

Administer oxygen at 2 L/minute via nasal cannula.

Document the findings in the patient's medical record.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is an incorrect choice because asking the patient about his usual blood pressure results is not a priority action. The patient's blood pressure is elevated, but not dangerously high. The nurse should monitor the blood pressure and report any significant changes to the physician, but this is not an urgent intervention.

Choice B reason: This is an incorrect choice because applying a cool washcloth to the patient's forehead is not a priority action. The patient's temperature is normal, and there is no indication of fever or heat stroke. The nurse should ensure the patient is comfortable and hydrated, but this is not an urgent intervention.

Choice C reason: This is the correct choice because administering oxygen at 2 L/minute via nasal cannula is a priority action. The patient's pulse oximetry is low, indicating hypoxia or inadequate oxygenation of the tissues. The nurse should provide supplemental oxygen to improve the patient's oxygen saturation and prevent further complications.

Choice D reason: This is an incorrect choice because documenting the findings in the patient's medical record is not a priority action. The nurse should document the patient's vital signs and any interventions performed, but this is not an urgent intervention. The nurse should prioritize the patient's safety and well-being over documentation.

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Correct Answer is B

Explanation

Choice A reason: This is an incorrect choice because exposure-related accident is not the type of error when the wrong type of medication is administered to the patient. Exposure-related accident is an incident that occurs when a person is exposed to a harmful substance or environment, such as radiation, chemicals, or extreme temperatures.

Choice B reason: This is the correct choice because procedure-related accident is the type of error when the wrong type of medication is administered to the patient. Procedure-related accident is an incident that occurs when a person is harmed by a medical or surgical procedure, such as a wrong-site surgery, a medication error, or a catheter infection.

Choice C reason: This is an incorrect choice because organization-related accident is not the type of error when the wrong type of medication is administered to the patient. Organization-related accident is an incident that occurs due to a failure of the system or the management of an organization, such as a lack of communication, a poor policy, or a staffing shortage.

Choice D reason: This is an incorrect choice because equipment-related accident is not the type of error when the wrong type of medication is administered to the patient. Equipment-related accident is an incident that occurs due to a malfunction or misuse of a device or a machine, such as a ventilator, a defibrillator, or a syringe.

A. The nurse requests that the primary health care provider examines the patient. B. The patient has a fractured right leg with a cast that was applied 2 days ago. C. The patient’s toes are cool and pale and the patient reports that the foot feels numb. D. The patient is reporting severe pain 1 hour after pain medication was given.

Correct Answer is B

Explanation

Choice A reason: This is an incorrect choice because the nurse requests that the primary health care provider examines the patient is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The nurse's request is part of the “R”, which stands for recommendation, which is the action that the nurse suggests or requests.

Choice B reason: This is the correct choice because the patient has a fractured right leg with a cast that was applied 2 days ago is the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's fracture and cast are part of the patient's background that the nurse should share with the primary health care provider.

Choice C reason: This is an incorrect choice because the patient’s toes are cool and pale and the patient reports that the foot feels numb is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's toes and foot are part of the patient's current condition that the nurse should report for the “S”, which stands for situation, which is the reason for the communication and the patient's status.

Choice D reason: This is an incorrect choice because the patient is reporting severe pain 1 hour after pain medication was given is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's pain and medication are part of the patient's current condition that the nurse should report for the “S”, which stands for situation, which is the reason for the communication and the patient's status.

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The nurse is caring for a patient with the following vital signs:Temperature: 98.9°FPulse: 94Respirations: 20Blood pressure: 144/94Pulse oximetry: 94%What is the priority action of the nurse?

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The nurse is caring for a patient with the following vital signs:
Temperature: 98.9°F
Pulse: 94
Respirations: 20
Blood pressure: 144/94
Pulse oximetry: 94%
What is the priority action of the nurse?