Which patient does the nurse see first?

The patient who needs to use the rest room

The patient with blood pressure of 80/40

The patient whose phone fell

The patient with recurrent burning sensation in the chest

Answer and Explanation

The Correct Answer is B

Rationale:

A. The patient who needs to use the restroom is incorrect as the first priority because this is primarily a comfort and safety issue, not an immediate threat to life or organ function. While assisting the patient is important to prevent falls or incontinence, it does not take precedence over a patient with compromised circulation or potential shock.

B. The patient with blood pressure of 80/40 is correct because this hypotensive reading indicates a potentially life-threatening condition. Blood pressure this low can compromise perfusion to vital organs, including the brain, heart, and kidneys, and may signal shock, internal bleeding, dehydration, or other acute complications. According to Maslow’s hierarchy of needs and the ABC (Airway, Breathing, Circulation) framework, circulation issues are the highest priority, and interventions should be immediate to prevent deterioration. The nurse should assess the patient’s level of consciousness, heart rate, perfusion, and other vital signs, and implement interventions such as fluid resuscitation or notification of the provider.

C. The patient whose phone fell is incorrect because this represents a non-urgent, low-acuity concern. Retrieving a phone is primarily a convenience issue and does not impact patient safety or physiologic stability.

D. The patient with recurrent burning sensation in the chest is incorrect as the first priority because while chest discomfort can indicate cardiac or gastrointestinal issues, the scenario specifies recurrent burning rather than acute, severe, or worsening chest pain. Acute cardiac events would take higher priority, but in this scenario, the hypotensive patient is at the greatest immediate risk.

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Correct Answer is C

Explanation

Rationale:

A. Physical endurance, to manage long shifts and physically demanding tasks, is incorrect because while stamina is helpful for sustaining work, it does not directly facilitate communication, collaboration, or team cohesion in high-stress situations.

B. Authoritative decision-making, to enforce strict compliance with protocols, is incorrect because an overly authoritative style can inhibit open communication and reduce team engagement. Effective leadership during stress relies on collaboration rather than rigid control.

C. Empathy, to understand team members' feelings and perspectives, is correct because empathy is a key soft skill for nurse leaders. Demonstrating empathy helps the leader recognize and validate the emotions of team members under stress, promotes psychological safety, encourages staff to speak up with concerns or ideas, builds trust and cohesion which enhances effective collaboration and problem-solving, and reduces conflict and prevents burnout by acknowledging workload challenges.

D. Technical proficiency, to ensure all clinical tasks are performed correctly, is important for patient safety but is considered a hard skill, not a soft skill. While valuable, it does not directly address team communication and collaboration.

A. Delivering meal trays to clients in their rooms B. Delivering a routine urine specimen to the laboratory C. Assisting a client who has difficulty seeing the foods on the tray while eating D. Observing a postoperative client who is confused

Correct Answer is D

Explanation

Rationale:
A. Delivering meal trays to clients in their rooms is incorrect because this is a non-clinical task focused on patient comfort and basic support. It does not require nursing knowledge, assessment skills, or critical thinking, making it appropriate for delegation to a volunteer. Completing this task helps ensure timely nutrition delivery but does not impact immediate patient safety.

B. Delivering a routine urine specimen to the laboratory is incorrect because it is considered a non-clinical, logistical task. Volunteers can transport specimens safely without needing to assess or interpret patient conditions. This delegation allows nursing staff to focus on tasks requiring clinical judgment.

C. Assisting a client who has difficulty seeing the foods on the tray while eating is incorrect because this is a supportive activity that facilitates nutrition and independence. Volunteers can help with orientation to food items, utensil use, and positioning, but the task does not involve monitoring for complications or making clinical decisions.

D. Observing a postoperative client who is confused is correct because this involves critical nursing responsibilities, including ongoing assessment, recognition of early signs of complications, and immediate intervention if needed. Postoperative confusion can indicate serious issues such as hypoxia, infection, electrolyte imbalance, pain, or medication effects. Monitoring a confused patient requires clinical judgment, the ability to interpret subtle changes in mental status, and prompt escalation of care, all of which are beyond a volunteer’s training. Assigning this task to a volunteer could delay identification of a life-threatening problem and compromise patient safety.

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Which patient does the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse leader is managing a multidisciplinary team during a high-stress situation on the unit. Which soft skill should the nurse leader prioritize to effectively facilitate communication and collaboration among team members?

Correct Answer is C

Explanation

A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer?

Correct Answer is D

Explanation

Which of the following is a common strategy used to misrepresent data in nursing or healthcare, and how can it be identified?

As a nurse receiving a bomb threat call, which of the following actions should you take to ensure safety and assist authorities? (Select all that apply)

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A nurse is teaching a newly licensed nurse about methods to reduce costs of client care. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?