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1. A nurse is caring for four patients in a medical-surgical unit. The
patients have the following conditions: a) a post-operative patient who had
a cholecystectomy yesterday and has a low-grade fever, b) a patient with
chronic obstructive pulmonary disease (COPD) who is experiencing
dyspnea and wheezes, c) a patient with diabetes mellitus who has a blood
glucose level of 250 mg/dL and is scheduled for insulin administration,
and d) a patient with hypertension who has a blood pressure of 160/90
mmHg and is due for an antihypertensive medication. Which patient
should the nurse attend to first?
a) The post-operative patient
b) The patient with COPD
c) The patient with diabetes
d) The patient with hypertension
*Answer: b) The patient with COPD*
Rationale: The patient with COPD has the most urgent problem that
requires immediate intervention. Dyspnea and wheezes indicate
respiratory distress that can lead to hypoxia and respiratory failure. The
other patients have less acute problems that can be managed later.
2. A nurse is working in an emergency department and receives four
patients at the same time. The patients have the following conditions: a) a
25-year-old male who was involved in a motor vehicle accident and has an
open fracture of the left femur, b) a 50-year-old female who has chest pain
radiating to the left arm and jaw, c) a 35-year-old male who has abdominal
pain, nausea, and vomiting, and d) a 40-year-old female who has a severe
headache, blurred vision, and slurred speech. Using the ABCDE (airway,
breathing, circulation, disability, exposure) principle, which patient should
the nurse prioritize?
a) The 25-year-old male
b) The 50-year-old female
c) The 35-year-old male
d) The 40-year-old female
*Answer: b) The 50-year-old female*
Rationale: The 50-year-old female has the most life-threatening condition
that could indicate a myocardial infarction (heart attack). Chest pain
radiating to the left arm and jaw is a classic sign of cardiac ischemia. TheÂÂ
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