After receiving report which of the following patients should the nurse see first?

OSSSC Nursing Officer-2023

Medical & Surgical Nursing

Hard

Appeared in: OSSSC Nursing Officer-2023

Explanation

The patient in a sickle-cell crisis is experiencing a vaso-occlusive event, which is an acute circulation problem.
Essential, time-sensitive treatments for this condition include intravenous (IV) hydration and analgesics.
An infiltrated IV means this life-sustaining treatment has been interrupted, putting the patient at immediate risk for worsening ischemia, organ damage, and severe pain.
This situation represents an unstable patient with a high-priority physiological need (Circulation) that requires immediate nursing intervention to re-establish IV access.

Option B: This patient is considered stable. The most critical period for a transfusion reaction is the first 15 minutes. Since half the unit has been infused, this period has passed. The need is for monitoring, not immediate crisis intervention.
Option C: A scheduled procedure implies the patient is stable and not in any acute distress. Routine preparation can wait until after life-threatening issues are addressed.
Option D: A leaky colostomy bag is a hygiene and comfort issue, not a physiological emergency. It does not pose an immediate threat to the patient's life.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Nursing Prioritization in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Prioritization is a fundamental skill for nurses to ensure patient safety and manage workload effectively. Using frameworks like ABCs helps in making sound clinical judgments.
Failure to correctly prioritize can lead to adverse patient outcomes, especially when a life-sustaining treatment is interrupted.
What if? - If the patient receiving the blood transfusion (Option B) reported sudden shortness of breath and lower back pain, they would immediately become the highest priority. These are classic signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency.

How to Approach the Question

First, read the question carefully to identify that it is a prioritization question ('which patient should the nurse see first?').
Analyze each option by applying a prioritization framework. The ABC (Airway, Breathing, Circulation) framework is the most effective for physiological problems.
Evaluate each patient's condition: Is it acute or chronic? Is the patient stable or unstable?
Identify the most unstable patient with the most life-threatening condition. In this case, the interruption of a critical therapy (IV fluids) for an acute circulation problem (sickle cell crisis) makes this patient the highest priority.
Compare this to the other options, which represent more stable situations or non-life-threatening problems, to confirm your choice.

Concept Tested & Keywords

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E6 Nursing Fundamentals Potter Perry 12e Part 2 pp. 22-24, 72-74