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. Documenting the finding in the patient’s medical record is an important step, but not the most appropriate first action of the nurse. The nurse should first confirm the irregularity by counting the apical pulse.

Choice B reason: This is incorrect. Assessing the brachial pulse for a pulse deficit is a useful technique, but not the most appropriate first action of the nurse. A pulse deficit is the difference between the apical and radial pulse rates. The nurse should first count the apical pulse before comparing it with the radial pulse.

Choice C reason: This is incorrect. Notifying the health care provider immediately is a necessary step, but not the most appropriate first action of the nurse. The nurse should first gather more information by counting the apical pulse and determining the type and severity of the irregularity.

Choice D reason: This is correct. Counting the patient’s apical pulse for one full minute is the most appropriate first action of the nurse. The apical pulse is the most accurate way to measure the heart rate and rhythm. The nurse should listen to the heart sounds at the apex of the heart, which is located at the fifth intercostal space, left midclavicular line. The nurse should count the number of beats and note any irregularities, such as skipped, extra, or uneven beats.

Choice A reason: This is the correct choice because accountability is the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Accountability refers to the expectation and requirement to report and explain the actions taken and the results achieved. The nurse is accountable for the accuracy and completeness of the documentation and for the quality and safety of the patient care⁴. By correcting the assessment information, the nurse demonstrates accountability for their own mistake and prevents potential harm to the patient.

Choice B reason: This is an incorrect choice because responsibility is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Responsibility refers to the obligation and duty to perform the assigned tasks and achieve the desired results. The nurse is responsible for conducting and documenting the assessment and for providing appropriate care for the patient⁴. By correcting the assessment information, the nurse is not fulfilling their responsibility, but rather rectifying their error.

Choice C reason: This is an incorrect choice because empowerment is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Empowerment refers to the ability and right of individuals or groups to make their own decisions without interference from others. The nurse is empowered to use their own judgment and expertise to solve problems and improve performance⁴. By correcting the assessment information, the nurse is not exercising their empowerment, but rather admitting their fault.

Choice D reason: This is an incorrect choice because delegation is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Delegation refers to the process of assigning tasks or activities to other staff members based on their scope of practice, competence, and availability. The nurse is responsible for delegating tasks safely and effectively and for supervising and evaluating the delegated staff⁴. By correcting the assessment information, the nurse is not delegating any task, but rather correcting their own work.