What is the priority action of the nurse as the assessment process is started for a patient who came to the hospital with acute shortness of breath?

Choice A reason: This is incorrect. The Agency for Healthcare Research and Quality is a federal agency that supports research and improvement of health care quality and safety, but it does not provide treatment guidelines for acetaminophen overdose.

Choice B reason: This is correct. The American Association of Poison Control Centers is a national organization that provides poison information and treatment recommendations through a network of poison centers. The nurse can call the poison center at 1-800-222-1222 to get expert advice on how to manage the patient who took 60 acetaminophen tablets.

Choice C reason: This is incorrect. The Centers for Disease Control and Prevention is a federal agency that monitors and prevents diseases and public health threats, but it does not provide treatment guidelines for acetaminophen overdose.

Choice D reason: This is incorrect. The Institute for Safe Medication Practices is a nonprofit organization that promotes safe medication practices and error prevention, but it does not provide treatment guidelines for acetaminophen overdose.

Choice A reason: This is an incorrect choice because the nurse braids the patient’s long hair to prevent tangles is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Braiding the patient’s hair is a personal care task that does not require the nurse to use their own judgment or expertise.

Choice B reason: This is the correct choice because the nurse checks the policy manual before changing the central line dressing is an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Checking the policy manual before changing the central line dressing shows that the nurse is responsible for following the evidence-based guidelines and standards of practice for this procedure.

Choice C reason: This is an incorrect choice because the nurse counts the patient’s pulse before administering digoxin is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Counting the patient’s pulse before administering digoxin is a routine task that is prescribed by the physician and does not involve the nurse’s own decision making.

Choice D reason: This is an incorrect choice because the nurse directs the nursing assistant to obtain the patient's weight is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Directing the nursing assistant to obtain the patient's weight is a task that is delegated by the nurse and does not reflect the nurse’s own authority or initiative.