# A nurse arrives at the start of a morning shift on a medical-surgical unit with six assigned patients. Which patient situations require immediate priority assessment and intervention before completing routine tasks? Select all that apply.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372693&lang=en  
> language: en  
> subject: Assignment/Delegation/Supervision  
> category: MOC

## Question

A nurse arrives at the start of a morning shift on a medical-surgical unit with six assigned patients. Which patient situations require immediate priority assessment and intervention before completing routine tasks? Select all that apply.

1

A 45-year-old with type 1 diabetes whose finger-stick blood glucose just registered 38 mg/dL with diaphoresis and confusion

2

A 72-year-old reporting new-onset shortness of breath with O2 saturation 86% on room air

3

A 55-year-old asking about discharge teaching for a low-fat diet after laparoscopic cholecystectomy

4

A 60-year-old with chronic stable hypertension awaiting scheduled morning antihypertensive medication

5

A 28-year-old post-op patient reporting "the worst chest pain I've ever had" radiating to the left arm with diaphoresis

6

A 70-year-old requesting assistance with morning hygiene before breakfast

## Explanation

Correct: 1, 2, 5. (1) A blood glucose of 38 mg/dL with diaphoresis and confusion is an immediate neurologic and safety threat. Assess the client's ability to swallow and treat promptly per protocol: give fast-acting oral carbohydrate only if swallowing is safe; otherwise use IV dextrose or glucagon as ordered. (2) New dyspnea with an oxygen saturation of 86% on room air is an acute breathing problem that requires immediate assessment, oxygen support as indicated, and rapid evaluation of the cause. (5) New severe chest pain radiating to the left arm with diaphoresis suggests acute coronary syndrome and requires immediate assessment, a 12-lead ECG, and activation of the emergency protocol. Incorrect: (3) Discharge teaching can be deferred until urgent physiologic problems are stabilized. (4) A scheduled antihypertensive for stable chronic hypertension is important but not the first priority in this scenario. (6) Morning hygiene can be deferred or delegated to appropriately trained assistive personnel after the nurse assesses the client's stability. The priority sequence is acute airway, breathing, circulation, or glucose compromise before stable chronic care, routine care, and teaching.

## In-depth explanation

Prioritize new physiologic instability. The client with glucose 38 mg/dL and confusion needs immediate assessment and treatment; oral carbohydrate is appropriate only when the client can swallow safely, while IV dextrose or glucagon is used when oral treatment is unsafe or ineffective. The client with new dyspnea and oxygen saturation 86% has an acute breathing problem. The client with severe radiating chest pain and diaphoresis may have acute coronary syndrome and needs rapid ECG-based evaluation. Discharge teaching, a routine scheduled medication for stable hypertension, and morning hygiene remain necessary but can wait until these time-sensitive threats are addressed.

## Clinical scenario

Medical-surgical unit, morning shift handoff. Six assigned patients with varied acuity: respiratory distress + new hypoxia, severe hypoglycemia with neuroglycopenic symptoms, stable chronic HTN awaiting scheduled meds, post-op chest pain with MI features, hygiene assistance request, and discharge teaching question.

## Key concepts

- **Maslow Hierarchy of Needs** — Five-tier framework prioritizing physiologic needs (oxygen, food, water, elimination) above safety, love/belonging, esteem, and self-actualization; nurses address lower-tier physiologic needs first when life-threatened
- **ABCs (Airway-Breathing-Circulation)** — Resuscitation priority sequence: secure Airway, support Breathing, restore Circulation; any threat to ABCs supersedes all other clinical priorities and is the foundation of emergency triage
- **Acute vs Chronic Priority** — Distinguishing principle: new/unstable physiologic changes (acute deterioration) outrank stable chronic conditions; routine scheduled care for stable patients can be safely deferred while new emergencies are addressed

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