Which assessment at the beginning of the shift of the patient with a recent head injury requires the most immediate action?

Unresponsive to painful stimuli. The unresponsive patient may be experiencing circulatory collapse; therefore, further assessment of patient condition is required. Although a heart rate of 43 bpm is low, the patient’s blood pressure is adequate. The presence of a service animal in the patient’s bed may require intervention depending upon the hospital’s policy, but this is a low priority comparatively. A low oxygen saturation will require intervention, but an oxygen saturation of 87% is not life-threatening.

Which assessment at the beginning of the shift of the patient wit...

Category: Management of Care
Difficulty: 7

Topics: Delegation, Prioritization and Leadership Respiratory Cardiovascular Assessment Neurology

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The nurse is assigned to a 32-year-old male admitted with bowel obstruction status post exploratory laparotomy. Which telephone call from the nurse to the provider is most appropriate?

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The patient has been unconscious for 36 hours after a massive stroke. The nurse enters the room to see the unlicensed assistive personnel (UAP) cleaning the patient after an episode of fecal incontinence. The UAP states, “I can’t imagine not even being able to clean myself. What a sad existence.” Which response by the nurse is most appropriate?

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Which assessment requires the most immediate intervention?

Question Type: Multiple Choice - Select One
Difficulty: 6

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