Editing Fundamentals of Nursing – RN Practice Questions (section)

==Question 1==
A registered nurse begins the shift on a medical unit. Which patient should the nurse assess first?
# A 68 year old with chronic osteoarthritis who rates hip pain at 7 out of 10 and is due for a scheduled analgesic.
# A 74 year old admitted yesterday for pneumonia whose family reports the patient is now confused and pulling at the intravenous line.
# A 52 year old two days after a colon resection who has not had a bowel movement since surgery.
# A 45 year old with a stage 2 sacral pressure injury who is due for a dressing change.

'''Answer:''' 2. The 74 year old with new onset confusion.

''Rationale:'' New onset confusion is an acute, unexpected change from baseline and is frequently the earliest sign of hypoxia, sepsis, hypoglycemia, or another physiologic deterioration. It also creates an immediate safety risk, since the patient is pulling at lines. Airway, breathing, and circulation concerns and unexpected changes outrank expected findings. Option 1 is significant pain but it is chronic and expected, and the medication is scheduled. Option 3 is an expected postoperative finding at 48 hours and is not urgent. Option 4 is a scheduled task that can wait.