Common adult medical-surgical conditions with the priority nursing assessment or intervention for each.
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- A patient reports sudden chest pain. What is the priority nursing action?
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Obtain a 12-lead ECG immediately- What should be monitored daily in a patient with heart failure to track fluid status?
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Body weight, taken at the same time each day- What position should a patient in acute pulmonary edema be placed in?
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High Fowler's position- Why is oxygen given at a low flow rate (1 to 2 L/min) to a COPD patient?
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To avoid suppressing the hypoxic drive to breathe- What is the priority medication during an acute asthma exacerbation?
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A short-acting beta agonist such as albuterol, given by nebulizer- In diabetic ketoacidosis, what is given before insulin therapy is started?
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IV fluid replacement with normal saline- What should be given first to a conscious, alert patient with hypoglycemia?
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15 to 20 grams of a fast-acting oral carbohydrate- What is the priority assessment for a patient with suspected ischemic stroke?
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The time the patient was last known well (symptom onset)- What head-of-bed position is used to help manage increased intracranial pressure?
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Head of bed elevated 30 degrees- During a seizure, what is the nurse's priority action?
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Protect the patient from injury without restraining them- Why should nothing be placed in the mouth of a patient having a seizure?
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It can cause airway obstruction or dental/oral injury- What is the priority assessment for a patient with an upper GI bleed?
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Vital signs, to detect early signs of hypovolemic shock- What diet order is prioritized for a patient with acute pancreatitis?
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NPO status, to rest the pancreas- What should be measured daily in a patient with cirrhosis and ascites?
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Abdominal girth- What medication is given to reduce ammonia levels in hepatic encephalopathy?
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Lactulose
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