A nurse is caring for multiple patients during a busy shift. Which patient should the nurse assess first?

Question

Accepted Answer

보기 2: A 28-year-old patient with asthma who is experiencing increased shortness of breath and has an oxygen saturation of 88% on room air.

The asthmatic patient with shortness of breath and O2 sat 88% requires first assessment due to acute respiratory compromise. Other patients have non-urgent needs (discharge teaching, mild headache, dialysis question).

Answer

보기 1: A 45-year-old patient with diabetes mellitus who is scheduled for discharge today and needs final medication teaching.

Answer

보기 3: A 65-year-old patient with hypertension who is complaining of a mild headache and requests pain medication.

Answer

보기 4: A 52-year-old patient with chronic kidney disease who has missed one dialysis session and is asking about rescheduling.

Concept	Description	Application in This Question
ABC (Airway, Breathing, Circulation)	The primary survey framework for assessing any patient. Life-threatening issues with airway, breathing, or circulation must be addressed first.	The asthmatic patient has a compromised Breathing (SOB, SpO2 88%), making them the top priority.
Prioritization (e.g., Urgent vs. Non-Urgent)	The process of ranking patient problems or needs in order of importance. "First" or "Immediate" often points to an unstable ABC.	Acute respiratory distress is urgent. Discharge teaching, a mild headache, and a scheduling question are non-urgent.
Hypoxemia	Low level of oxygen in the blood. Clinically significant below 90% SpO2.	SpO2 of 88% is a clear, objective sign of hypoxemia requiring immediate intervention (e.g., supplemental oxygen, bronchodilators).
Asthma Exacerbation	Acute episode of worsening symptoms (wheezing, cough, SOB) due to bronchospasm and inflammation.	The patient's increased SOB and low SpO2 are classic signs of an exacerbation that can deteriorate quickly.

Patient Scenario	Priority Level	Rationale & Key Differentiator
Asthma, SOB, SpO2 88%	HIGHEST / IMMEDIATE	Active, life-threatening physiological instability (ABC compromise). Objective data (SpO2) confirms severity.
CKD, missed dialysis session	High / Next to Assess	Potentially serious, but patient is not in acute distress. Requires monitoring for complications (edema, K+ levels) but is not the immediate "first" assessment.
Hypertension, mild headache	Medium / Routine	Requires assessment and intervention for comfort, but no signs of hypertensive emergency (e.g., encephalopathy, chest pain).
Diabetes, discharge teaching	Low / Can be Deferred	Important for long-term health and safety, but the patient is stable. This is an educational/psychosocial need, not a physiological crisis.

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A nurse is caring for multiple patients during a busy shift. Which patient should the nurse assess first?

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