NCLEX RN Prioritization Questions Related

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In which order should the nurse take the following actions for an older patient with new onset confusion who is normally alert and oriented?

  • A. Obtain the oxygen saturation, Check the patient's pulse rate, Notify the health care provider, Document the change in status
  • B. Obtain the oxygen saturation, Check the patient's pulse rate, Document the change in status, Notify the health care provider
  • C. Document the change in status, Notify the health care provider, Check the patient's pulse rate, Obtain the oxygen saturation
  • D. Document the change in status, Check the patient's pulse rate, Obtain the oxygen saturation, Notify the health care provider
Correct Answer: B

Rationale: The correct order of actions for the nurse in this scenario is to first obtain the oxygen saturation to assess the patient's airway and oxygenation status. Next, checking the patient's pulse rate helps in evaluating circulation. Subsequently, documenting the change in the patient's status is important for maintaining an accurate record of care. Finally, notifying the health care provider is crucial to ensure timely intervention and further management. Choices A, C, and D are incorrect because assessing oxygen saturation should precede checking the pulse rate to address potential physiological causes of confusion. Additionally, documentation should follow patient assessment and notification of the healthcare provider for appropriate record-keeping and communication.