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. “I can change who I designate as my health care proxy at any time” is correct. This reflects an accurate understanding of patient autonomy. A client has the legal right to revoke or change their health care proxy designation at any point while they are competent. This ensures that the person making decisions on the client’s behalf is someone the client trusts and feels is aligned with their values and wishes.

B. “If I become incapacitated, end-of-life choices will be made by my proxy” is correct. The health care proxy is specifically empowered to make medical decisions when the client is unable to do so, which includes decisions regarding life-sustaining treatments or palliative care if the client becomes incapacitated. This statement demonstrates understanding of the proxy’s role in decision-making during periods when the client cannot provide informed consent.

C. “I have to choose a family member as my health proxy” is incorrect and indicates a need for clarification. A health care proxy does not have to be a family member; the client may designate any competent adult whom they trust to make decisions in their best interest. Limiting this choice to family members is a common misconception that can unnecessarily restrict patient autonomy and may result in appointing someone who is not best suited to represent the client’s values or preferences. The emphasis is on trust, competence, and willingness to act responsibly, not familial relationship.

D. “The health care proxy does not go into effect until I am incapable of making decisions” is correct. This statement accurately describes when the proxy assumes authority. The proxy is activated only when the client loses decision-making capacity, ensuring that the client maintains control over their care while they are competent.

A. Include detailed past medical history unrelated to the current problem. B. Recommend specific interventions or actions to address the patient's needs based on the assessment C. Provide a concise statement describing the current problem affecting the patient. D. Analyze the patient's current condition and share assessment findings relevant to the situation. E. Offer personal opinions about the patient's prognosis without supporting data. F. Fail to introduce oneself or clarify one's role when initiating communication. G. Use medical jargon excessively to demonstrate professional knowledge.

Correct Answer is ["B","C","D"]

Explanation

Rationale:
A. Include detailed past medical history unrelated to the current problem is incorrect because SBAR is intended to provide concise, relevant information. Including unrelated history can distract from the urgent issue and reduce clarity during critical communication.

B. Recommend specific interventions or actions to address the patient's needs based on the assessment is correct because the “Recommendation” portion of SBAR allows the nurse to suggest interventions or request specific actions from the healthcare provider, facilitating timely and appropriate care.

C. Provide a concise statement describing the current problem affecting the patient is correct because the “Situation” portion of SBAR requires a brief summary of the patient’s current issue, such as respiratory distress or unstable vital signs, so the provider understands the urgency.

D. Analyze the patient's current condition and share assessment findings relevant to the situation is correct because the “Background” portion of SBAR provides context, including relevant assessment findings, recent vital signs, and treatments, helping the provider make informed decisions.

E. Offer personal opinions about the patient's prognosis without supporting data is incorrect because SBAR communication must be objective and based on factual data. Personal opinions can mislead or confuse the provider.

F. Fail to introduce oneself or clarify one's role when initiating communication is incorrect because proper introduction and role clarification are essential for effective, professional communication. Omitting this can cause confusion and delay response.

G. Use medical jargon excessively to demonstrate professional knowledge is incorrect because SBAR should be clear, concise, and understandable. Excessive jargon can hinder communication, especially in urgent situations.

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Which patient does the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which of the following statements by the client indicates a need for clarification?

Correct Answer is C

Explanation

A nurse is preparing to give an SBAR report to a healthcare provider about a postoperative patient who is showing signs of respiratory distress and unstable vital signs. Which of the following actions should the nurse take when using the SBAR technique? (Select all that apply)

Correct Answer is ["B","C","D"]

Explanation

During a mass casualty incident, a nurse must triage multiple victims using the SALT triage system. Which of the following actions demonstrate appropriate application of triage principles to optimize resource allocation and patient outcomes? (Select all that apply)

A nurse is caring for a competent adult patient who refuses a recommended medication due to personal beliefs. How should the nurse apply the ethical principle of autonomy in this situation?

A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

A nurse is preparing to implement electronic health record (EHR) documentation in a clinical setting after the enactment of the HITECH Act. Which action best aligns with the HITECH Act's enhancements to HIPAA privacy and security regulations?

A nurse is caring for a client who is scheduled for surgery. The nurse's role in regard to informed consent is which of the following?

Which of the following is an example of incivility in the workplace in nursing?

Which patient does the nurse see first?

A nurse is preparing to administer amoxicillin 250 mg PO every 8 hr. The amount available is amoxicillin 125 mg tablets. How many tablets should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)