A Nurse’s Priority: Who Should Be Seen First?

Question

The nurse just received shift report on four clients. Based on the information provided, which client should the nurse assess first?

A. A 45-year-old with pneumonia who has a temperature of 101.2°F (38.4°C)

B. A 72-year-old post-op hip replacement patient reporting moderate pain

C. A 60-year-old with heart failure who has jugular vein distention and worsening dyspnea

D. A 50-year-old diabetic patient with a blood glucose level of 250 mg/dL (13.9 mmol/L)

Answer 1

A. A 45-year-old with pneumonia who has a temperature of 101.2°F (38.4°C)

B. A 72-year-old post-op hip replacement patient reporting moderate pain

C. A 60-year-old with heart failure who has jugular vein distention and worsening dyspnea

D. A 50-year-old diabetic patient with a blood glucose level of 250 mg/dL (13.9 mmol/L)

Correct answer: C

This is a Airway, Breathing, Circulation, prioritization question. The question is asking the student to recognize which patient is at highest risk for decompensation. Needs to be addressed immediately.

Incorrect answers:

A. You can treat the temperature with anti-pyretics, at risk of decompensation later down the road

B. Moderate pain can be relieved, would be concerned if pain gets worse.

D. Elevated BS would be expected in a diabetic, doesn't give more info if patient has well-controlled or poorly controlled diabetes.

Answer 2

Based on the answers, I see a patient with pneumonia who has a fever, which is to be expected, though it does warrant a look at. It does not take priority over the heart failure patient having worsening dyspnea. The dyspnea is alarming, pain never killed anyone so, depending on how post op we are in the hip replacement, I assume it is not dire because the hip replacement if it would have been dire, they would have given hours before the post-op remark. Therefore, I rank these as....

C B A D. I would see C first because of the worsening of his/her breathing pattern.