The nurse working on a high acuity medical-surgical unit is prioritizing care for four patients who were just admitted. Which patient should the nurse assess first?
a. The NPO patient with a blood glucose of 80 who just received 20 units of 70/30 Novolin insulin
b. The patient with a pulse of 58 who is about to receive digoxin (Lanoxin)
c. The patient with a blood pressure of 136/92 with complaints of a headache
d. The patient with a mild allergy to penicillin who is receiving an infusion of cefa-zolin (Ancef)
A
The NPO patient with hypoglycemia who just received 70/30 Novolin insulin takes priority, be-cause this patient needs to consume a good source of glucose immediately, or perhaps the NPO status will be discontinued for this shift.
The digoxin may be withheld for the patient with a pulse of 58, but this is not a priority action.
The patient with a headache needs to be followed up, but because the blood pressure is 136/92, the headache is not life threatening.
The patient with the mild PCN allergy probably will not have a reaction to the cefazolin, because the PCN allergy is only mild. It is not a life-threatening situation if the nurse cannot immediately discontinue the cefazolin.
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