Nursing Prioritization Delegation Assignment Q 75
A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first?
A. Administer pain medications
B. Administer IV fluids
C. Administer dopamine
D. Administer oxygen via nasal cannula
Correct Answer: D. Administer oxygen via nasal cannula.
The promotion of adequate oxygenation is the most vital to life and therefore should be given the highest priority by the nurse. When the nurse needs to prioritize patients, Maslow’s hierarchy of needs theory is used to decide which patient is to be seen first. A part of Maslow’s hierarchy of needs is airway, breathing, and circulation (ABC), which are physiological elements that are needed for the body to survive and help determine one’s level of health.
Option A: The 2nd priority needs include MAAUAR which is mental status, acute pain, acute impaired urinary elimination, unresolved and unaddressed needs, abnormal diagnostic test results, and risks. The 3rd level priorities include all concerns and problems addressed with the 2nd level priority needs.
Option B: Maslow’s Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority. Administering IV fluids belong in Maslow’s physical and biological needs, but still after airway.
Option C: Dopamine (DA) is a peripheral vaso stimulant used to treat low blood pressure, low heart rate, and cardiac arrest, especially in acute neonatal cases via a continuous intravenous drip. For stimulation of the sympathetic nervous system, the indication is for a continuous intravenous drip administration.