The nurse is caring for four patients on a medical-surgical unit.
Which patient should the nurse assess first?
A 65-year-old diabetic patient whose blood glucose is 210 mg/dL and is awaiting breakfast.
A 72-year-old with chronic obstructive pulmonary disease (COPD) who is requesting assistance to the bathroom.
A 40-year-old receiving a blood transfusion who reports feeling anxious and has chills.
A 56-year-old postoperative patient reporting pain rated 8/10 who is scheduled for pain medication in 15 minutes.
The Correct Answer is C
Choice A rationale
Diabetes management requires monitoring glucose levels to prevent complications. A blood glucose of 210 mg/dL is elevated, but the normal fasting range is 70 to 99 mg/dL. This patient is stable and waiting for breakfast, which will likely be followed by insulin administration. While hyperglycemia is concerning, it does not present an immediate life-threatening emergency compared to acute transfusion reactions or respiratory distress in surgical settings.
Choice B rationale
Patients with chronic obstructive pulmonary disease often have baseline respiratory challenges and need assistance with mobility to prevent falls. Assisting a patient to the bathroom is a standard nursing task but does not take priority over an acute medical crisis. While safety and comfort are important, this patient's condition is chronic and stable. The nurse should address this need after managing any unstable patients who require immediate life-saving interventions.
Choice C rationale
Anxiety and chills during a blood transfusion are classic early signs of a hemolytic or febrile transfusion reaction. These reactions can rapidly progress to cardiovascular collapse, disseminated intravascular coagulation, or renal failure. Because this represents an acute, potentially fatal event, the nurse must assess this patient first to stop the infusion and initiate emergency protocols. This patient is the most unstable and requires the most urgent clinical intervention to ensure safety.
Choice D rationale
Severe postoperative pain rated 8/10 requires timely intervention but is generally not life-threatening. Pain management is a priority for patient comfort and recovery, yet it follows the stabilization of airway, breathing, and circulation. Since the medication is scheduled in 15 minutes, the nurse can address more critical issues first. Pain is subjective and, while urgent, does not carry the same immediate mortality risk as an adverse reaction to a blood product.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Leadership in nursing involves influencing others to achieve a common goal, often through the coordination of resources or the direction of a team. While the nurse showed initiative by identifying the conflict, the prompt specifically asks for the role the nurse is assuming by supporting the unit manager's plan and the provider's decisions. In this specific interaction, the nurse is acting under the guidance of the unit manager rather than directing the management of the unit.
Choice B rationale
The nurse is acting as a follower in this scenario by cooperating with the unit manager's plan. Effective followership is a skilled role where the nurse supports the leadership and the healthcare team to ensure cohesive care. By agreeing to support the provider's discussion and the manager's arrangement, the nurse ensures that the family receives a consistent message. Followership is essential in clinical settings to maintain order and implement the collective strategy for managing complex family dynamics.
Choice C rationale
Evidence based practice involves the integration of the best research evidence with clinical expertise and patient values. While the nurse's concern for the patient's wishes aligns with patient centered care, the act of supporting a manager's organizational decision is not a direct application of evidence based research. The scenario describes a behavioral and professional role within a hierarchy rather than the application of a specific clinical protocol or a research finding to a medical treatment.
Choice D rationale
Patient advocacy involves speaking up for the patient's rights and ensuring their wishes are respected. The nurse initially acted as an advocate by bringing the conflict to the manager's attention. However, the question asks for the role the nurse is playing when the manager asks them to support the provider's decisions. At that specific moment, the nurse transitions into a collaborative role within the organizational structure, following the plan laid out by the leadership.
Correct Answer is A
Explanation
Choice A rationale
The Safety competency within QSEN focuses on minimizing risk of harm to patients through both system effectiveness and individual performance. By pausing the administration of a medication that the patient questioned, the nurse is actively preventing a potential medication error. Verifying the order with the pharmacy ensures that the right drug is being given. This behavior directly aligns with the goal of providing a safe environment and preventing adverse events during clinical practice.
Choice B rationale
Teamwork and Collaboration involves functioning effectively within nursing and inter-professional teams, fostering open communication and shared decision-making. While the nurse did communicate with the pharmacy, the primary driver of the action was not to build a team relationship but to verify the accuracy of a medication. The core focus of this specific interaction was the prevention of an error, which is more accurately categorized under the Safety competency rather than team dynamics.
Choice C rationale
Informatics is the use of information and technology to communicate, manage knowledge, mitigate error, and support decision-making. Although the nurse may use a computer system to verify the pharmacy order, the fundamental action described is the clinical judgment used to stop a potential error. The nurse's cognitive process and decision to pause based on patient feedback are human safety checks. Informatics provides the tools, but the act of pausing for verification is a safety-first behavior.
Choice D rationale
Evidence-Based Practice is the integration of best current evidence with clinical expertise and patient values for delivery of optimal health care. While checking a medication order is a standard of practice supported by evidence, this scenario specifically highlights the nurse's immediate response to a potential risk. The priority in the nurse's action was the immediate protection of the patient from a wrong medication, which is the hallmark of the Safety competency in a clinical setting.
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