A patient presents with shortness of breath, chest pain, and confusion. What should the nurse prioritize in the initial assessment?
Options:
A. Administer pain medication
B. Assess airway and breathing
C. Check blood pressure
D. Review recent lab results
The Correct answer and Explanation is:
In this scenario, the nurse should prioritize assessing the airway and breathing. The correct option is:
B. Assess airway and breathing
Explanation:
When a patient presents with symptoms such as shortness of breath, chest pain, and confusion, the nurse’s initial assessment should focus on the most critical aspects of the patient’s condition. In this case, the priority is to ensure that the patient’s airway is clear and that they are breathing adequately. Here’s why this is crucial:
- Airway and Breathing: Shortness of breath and confusion can be indicative of a severe underlying issue such as a respiratory or cardiovascular problem. The patient may be experiencing an obstructed or compromised airway, which can lead to hypoxia (low oxygen levels) and subsequently, confusion. Ensuring the airway is patent and assessing breathing are vital to determine if immediate intervention is required to prevent respiratory failure or other complications.
- Chest Pain: While chest pain is a significant symptom that could indicate a cardiac event like a myocardial infarction (heart attack) or pulmonary embolism, addressing airway and breathing takes precedence because if the patient is unable to breathe properly, the heart and other organs will not receive adequate oxygen, exacerbating the situation.
- Confusion: Confusion can be a sign of reduced oxygen supply to the brain, potentially due to inadequate breathing or other critical issues. By assessing and addressing the airway and breathing, the nurse can potentially reverse or mitigate the confusion by improving oxygenation.
- Checking Blood Pressure and Reviewing Lab Results: While checking blood pressure and reviewing lab results are important aspects of the assessment and can provide valuable information, they are secondary to the immediate need to ensure the patient’s airway is clear and that they are breathing effectively. Blood pressure and lab results are more relevant for ongoing assessment and management but do not address the immediate, life-threatening concerns.
In summary, prioritizing the assessment of airway and breathing is essential in this scenario to quickly address any potential life-threatening issues and stabilize the patient’s condition. Once the airway and breathing are adequately assessed and managed, the nurse can proceed to evaluate other aspects such as blood pressure and lab results to gain a comprehensive understanding of the patient’s health status.