Sentinel U Prioritization of Care® v.2 Adult
Medical Care – Questions (POCSS) | Complete
100% Passed Simulation Report | 2026 Updated.
SECTION 1: PATIENT PRIORITIZATION & CLINICAL
JUDGMENT
Question 1
A nurse receives shift report on four medical-surgical patients. Which patient should the
nurse assess FIRST?
A) A patient with COPD with an oxygen saturation of 89% on 2 L/min nasal cannula
B) A patient with diabetes mellitus who has a blood glucose of 180 mg/dL
C) A patient with heart failure who has new-onset confusion and O₂ sat 88% on room air
D) A patient post-operative day 2 requesting pain medication for 4/10 pain
Answer: C
Rationale: New-onset confusion combined with hypoxemia (88%) in a heart failure
patient signals acute decompensation and potential respiratory failure. This is a life-
threatening priority following the ABCs (Airway, Breathing, Circulation) framework. The
COPD patient with 89% on 2L is stable on supplemental oxygen. Blood glucose of 180
mg/dL is elevated but not emergent. Pain management is important but not
immediately life-threatening.
Question 2
,According to the Sentinel U® prioritization framework, what is the first step in
prioritizing patients?
A) Complete all documentation tasks before patient contact
B) Identify patients at the highest risk for injury or clinical instability
C) Administer medications in the order they appear on the MAR
D) Answer all family questions before assessing any patient
Answer: B
Rationale: The core of the Prioritization of Care® series is identifying which patient
requires immediate attention based on risk and instability. Patient safety is the priority,
focusing on those with new-onset conditions (e.g., seizures, acute confusion, respiratory
distress) or unstable vital signs before stable patients.
Question 3
A nurse is caring for a patient who was admitted with chest pain. The patient suddenly
becomes unresponsive and pulseless. What is the priority nursing action?
A) Call a code blue
B) Begin chest compressions
C) Check the patient's blood pressure
D) Administer oxygen
Answer: B
Rationale: In a pulseless, unresponsive patient, high-quality chest compressions are the
priority. CPR should be initiated immediately (compressions at 100-120 per minute,
depth 2-2.4 inches). Calling for help (code blue) should be done simultaneously, but
compressions should not be delayed. Checking blood pressure and administering
oxygen are secondary to compressions.
,Question 4
A nurse has received report on four patients. Which patient should be assessed FIRST?
A) A patient with diabetes mellitus type 1 who has a blood glucose of 55 mg/dL and is
alert and oriented
B) A patient with deep vein thrombosis on heparin infusion with a PTT of 120 seconds
C) A patient with urinary tract infection who has a fever of 100.4°F
D) A patient with chronic back pain requesting a PRN analgesic
Answer: A
Rationale: The patient with a blood glucose of 55 mg/dL is hypoglycemic. Although the
patient is alert, hypoglycemia can rapidly progress to unconsciousness. This patient
requires immediate intervention (oral glucose or IV dextrose). The PTT of 120 seconds is
elevated (therapeutic range 60-100 seconds) but not immediately life-threatening. Fever
of 100.4°F is low-grade. Pain management is important but not emergent.
Question 5
A nurse is using Maslow's hierarchy of needs to prioritize patient care. Which patient
need should be addressed FIRST?
A) The need for pain management after surgery
B) The need for oxygen due to shortness of breath
C) The need for social interaction with family
D) The need for education about discharge medications
Answer: B
Rationale: Maslow's hierarchy places physiological needs (oxygen, food, water, shelter)
at the base as the most fundamental needs. Breathing (oxygen) is the highest priority
among physiological needs. Pain management is also physiological but after airway and
, breathing. Safety and security (medication education) and love/belonging (social
interaction) are higher-level needs that come after physiological needs are met.
Question 6
A nurse is caring for four patients. Which patient should be assessed FIRST?
A) A patient with pneumonia who has a fever of 38.3°C (101°F) and chills
B) A patient with heart failure who has new-onset confusion and O₂ sat 88% on room air
C) A patient post-operative day 2 requesting pain medication for 4/10 pain
D) A patient with diabetes and a blood glucose of 210 mg/dL
Answer: B
Rationale: New confusion + hypoxemia in heart failure signals acute decompensation
and potential respiratory failure. This is a life-threatening priority (ABCs).
Question 7
A nurse is assessing a patient with a new tracheostomy. The patient has stridor and an
oxygen saturation of 85%. What is the priority nursing action?
A) Suction the tracheostomy
B) Call a rapid response
C) Assess the cuff pressure
D) Reposition the patient
Answer: A
Rationale: Stridor is a high-pitched sound indicating upper airway obstruction, which is
a life-threatening emergency. This patient requires immediate airway assessment and
intervention. Suctioning is the immediate life-saving intervention (Airway first).
Medical Care – Questions (POCSS) | Complete
100% Passed Simulation Report | 2026 Updated.
SECTION 1: PATIENT PRIORITIZATION & CLINICAL
JUDGMENT
Question 1
A nurse receives shift report on four medical-surgical patients. Which patient should the
nurse assess FIRST?
A) A patient with COPD with an oxygen saturation of 89% on 2 L/min nasal cannula
B) A patient with diabetes mellitus who has a blood glucose of 180 mg/dL
C) A patient with heart failure who has new-onset confusion and O₂ sat 88% on room air
D) A patient post-operative day 2 requesting pain medication for 4/10 pain
Answer: C
Rationale: New-onset confusion combined with hypoxemia (88%) in a heart failure
patient signals acute decompensation and potential respiratory failure. This is a life-
threatening priority following the ABCs (Airway, Breathing, Circulation) framework. The
COPD patient with 89% on 2L is stable on supplemental oxygen. Blood glucose of 180
mg/dL is elevated but not emergent. Pain management is important but not
immediately life-threatening.
Question 2
,According to the Sentinel U® prioritization framework, what is the first step in
prioritizing patients?
A) Complete all documentation tasks before patient contact
B) Identify patients at the highest risk for injury or clinical instability
C) Administer medications in the order they appear on the MAR
D) Answer all family questions before assessing any patient
Answer: B
Rationale: The core of the Prioritization of Care® series is identifying which patient
requires immediate attention based on risk and instability. Patient safety is the priority,
focusing on those with new-onset conditions (e.g., seizures, acute confusion, respiratory
distress) or unstable vital signs before stable patients.
Question 3
A nurse is caring for a patient who was admitted with chest pain. The patient suddenly
becomes unresponsive and pulseless. What is the priority nursing action?
A) Call a code blue
B) Begin chest compressions
C) Check the patient's blood pressure
D) Administer oxygen
Answer: B
Rationale: In a pulseless, unresponsive patient, high-quality chest compressions are the
priority. CPR should be initiated immediately (compressions at 100-120 per minute,
depth 2-2.4 inches). Calling for help (code blue) should be done simultaneously, but
compressions should not be delayed. Checking blood pressure and administering
oxygen are secondary to compressions.
,Question 4
A nurse has received report on four patients. Which patient should be assessed FIRST?
A) A patient with diabetes mellitus type 1 who has a blood glucose of 55 mg/dL and is
alert and oriented
B) A patient with deep vein thrombosis on heparin infusion with a PTT of 120 seconds
C) A patient with urinary tract infection who has a fever of 100.4°F
D) A patient with chronic back pain requesting a PRN analgesic
Answer: A
Rationale: The patient with a blood glucose of 55 mg/dL is hypoglycemic. Although the
patient is alert, hypoglycemia can rapidly progress to unconsciousness. This patient
requires immediate intervention (oral glucose or IV dextrose). The PTT of 120 seconds is
elevated (therapeutic range 60-100 seconds) but not immediately life-threatening. Fever
of 100.4°F is low-grade. Pain management is important but not emergent.
Question 5
A nurse is using Maslow's hierarchy of needs to prioritize patient care. Which patient
need should be addressed FIRST?
A) The need for pain management after surgery
B) The need for oxygen due to shortness of breath
C) The need for social interaction with family
D) The need for education about discharge medications
Answer: B
Rationale: Maslow's hierarchy places physiological needs (oxygen, food, water, shelter)
at the base as the most fundamental needs. Breathing (oxygen) is the highest priority
among physiological needs. Pain management is also physiological but after airway and
, breathing. Safety and security (medication education) and love/belonging (social
interaction) are higher-level needs that come after physiological needs are met.
Question 6
A nurse is caring for four patients. Which patient should be assessed FIRST?
A) A patient with pneumonia who has a fever of 38.3°C (101°F) and chills
B) A patient with heart failure who has new-onset confusion and O₂ sat 88% on room air
C) A patient post-operative day 2 requesting pain medication for 4/10 pain
D) A patient with diabetes and a blood glucose of 210 mg/dL
Answer: B
Rationale: New confusion + hypoxemia in heart failure signals acute decompensation
and potential respiratory failure. This is a life-threatening priority (ABCs).
Question 7
A nurse is assessing a patient with a new tracheostomy. The patient has stridor and an
oxygen saturation of 85%. What is the priority nursing action?
A) Suction the tracheostomy
B) Call a rapid response
C) Assess the cuff pressure
D) Reposition the patient
Answer: A
Rationale: Stridor is a high-pitched sound indicating upper airway obstruction, which is
a life-threatening emergency. This patient requires immediate airway assessment and
intervention. Suctioning is the immediate life-saving intervention (Airway first).
