The patient: A 65 yr old male
The situation: the family brings the patient to the emergency room because he just took an
entire bottle of pills.
The question: what action should the nurse take first?
determine the patients level of consciousness
The patient: an 80 yr old male who has used continuous oxygen for the past 3 years.
The situation: while making a home visit, the wife tells the nurse that her husband was doing
well on 2 liters of oxygen per min until late last night when he developed severe shortness of
breath on the way to the bathroom.
The question: what action should the nurse take first?
assess the patients oxygen saturation by pulse oximeter
Brainpower
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The patient: 41 y/o male
The situation: the patient is complaining of severe stomach pain and states that he has been
"vomiting all the time".
The question: what should the nurse do first?
administer a prescribed pain medication
The patient: the wife of a wealthy owner of towns bank.
The situation: the patient and her husband arrive on the unit. While orienting the patient to
the hospital room, the nurse notices that the patient has places a large amount of cash and
some expensive earrings in the drawer of the bedside table.
The question: what is the best action for the nurse to take?
advise the patient to have her husband take the items home when he leaves
, The patient: A 45 y/o female who is 5`2`` tall, weighs 200 lbs and has smoked since age 21
The situation: the patient comes to the clinic with a complaint of "leg pain"
The question: it is most important for the nurse to obtain information about which pervious
occurrence?
a pervious blood clot in the leg
The patient: 61 y/o female
situation: the patient has a fever of unknown origin. The nurse administered a fever-reducing
medication 30 mins ago. At this time there has been no decrease in the patients fever.
The question: what action would be best for the nurse to take?
sponge the patient with cool water
The patient: 70 y/o make who is relatively healthy
The situation: a liquid medication is prescribed for this patient
The question: prior to administering the prescribed medication, what intervention has the
highest priority?
determine if the patient is allergic to the medication
the patient: 58 y/o female
the situation: while the nurse is offering the patient her morning medication, she tells the
nurse she does not recall ever taking a pill that was pink colored.
The question: what should the nurse do in response to the patients comment?
withhold the medication until the prescription is verified
The patients:
1. 63 y/o with burn on the left lower leg who is complaining of pain.
2. a 45 y/o with pneumonia, complaining of shortness of breath
3. 31 y/o with abdominal pain who has just vomited blood.
4. 88 y/o who has right sided paralysis and wants to be helped to the bathroom immediately
Situation: the nurse is caring for these patients
The questions: who should the nurse see 1st?
45 y/o with pneumonia, complaining of shortness of breath
(ABCs- Airway, Breathing, Circulation)
The patients
1. a 13 y/o female with a kidney infection who reports that there is "lots of blood in her urine".
2. 18 y/o male with acute alcohol poisoning who is seeing "bugs on the walls"
3. a 21 y/o female with inflammatory bowel disease who has soaked dressing 3 hrs after
surgery
4. a 25 y/o male who is sobbing in his room after being told that he has testicular cancer
Situation: the nurse is caring for these 4 patients
Question: who should the nurse see first?