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 level of 80 mg/dL who just received 20 units of 70/30 Novolin insulin
b. The patient with a pulse of 58 beats per minute who is about to receive digoxin [Lanoxin]
c. The patient with a blood pressure of 136/92 mm Hg who complains of having a headache
d. The patient with an allergy to penicillin who is receiving an infusion of vancomy-cin [Vancocin]
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 beats per minute, 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 mm Hg, the headache is probably not caused by hypertension. The patient with an allergy to penicillin will not have a reaction to the vancomycin.
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