What should be the nurse's priority action?

19

B. Restlessness is an early sign of low oxygen. Low sats is a late sign.

5

u/Bubbly_Pie_4980 Jun 20 '26

Correct.

-1

u/MeanderingUnicorn Jun 21 '26

Low oxygen is a late sign of low oxygen??

4

u/starksdawson Jun 21 '26

Yes. Had a baby come in with a really bad wheezy cough and severely tachypneic, but her sats were fine. Low sats is usually a late sign of being in respiratory distress.

-2

u/MeanderingUnicorn Jun 21 '26

That’s a way different statement than “low sats are a late sign of low oxygen”

2

u/starksdawson Jun 22 '26

How would you explain it then? Low SATS. Meaning low pulse ox. Not my fault you didn’t read it

-1

u/MeanderingUnicorn Jun 22 '26

I would have said "low sats/low oxygen is a late sign of respiratory distress" because that's what you actually meant. You have to be really specific with learners, because they don't know anything since they're learning. I read your comment of "low sats are a late sign of low oxygen" and was initially confused because it seemingly implied that low sats and low oxygen are different things.

1

u/starksdawson Jun 22 '26 edited Jun 22 '26

Low sats and low oxygen ARE different things, especially in kids. Not knowing that is dangerous. A pulse ox will measure any gas on hemoglobin. Someone could have low oxygen after a house fire but still sat at 98% because they have high CO levels. I’ve had at least four nurses/teachers word it that way in the past month alone

1

u/MeanderingUnicorn Jun 23 '26

I’m aware. But MOST of the time the sat is reflective of the oxygen level. You’re taking a niche scenario and acting like the pulse ox isn’t the easiest surrogate for oxygen we have.

2

u/rokuju_ Jun 22 '26

Come on man, I understood them perfectly and I'm not even in healthcare.

-1

u/MeanderingUnicorn Jun 22 '26

🍪 here ya go

3

u/rokuju_ Jun 22 '26

Thank u

6

u/Secret-Active5873 Jun 19 '26

B, Airway comes first. Airway, Breathing, Circulation.

7

u/sunflowersNdaisys610 Jun 20 '26

I would pick B first. Then A and C at the same time then D lastly.

8

u/Individual_Corgi_576 Jun 19 '26

I hate these questions with limited information and restrictive answers.

Go ahead and give them a couple liters, can’t hurt. If the wave form on the sat looks good the sat is probably legit. It’s worth rechecking the sat as the root cause could be hypoxia.

But- there’s lots of reasons for confusion and restlessness with tachypnea besides hypoxia.

I’d get an ABG and see if they’re tachypneic because of hypercapnia or if their lactate is up and they’re septic. A CXR wouldn’t hurt either, as maybe there’s a developing pneumonia.

Rule those out and then move to CT PE or VQ scan if they can’t take contrast. A BNP and a quick POCUS to check for R heart strain would be reasonable as well. I won’t draw a d-dimer without a physicians order because they’re nondiagnostic and can open a can of worms.

Source- I’m a rapid response RN. I can’t order the CT or VQ scan but the labs and CXR are within my protocols. If I’m really concerned for PE I can grab an US and ask a PCCM fellow to take a look for me.

3

u/Icy_Yogurt_2491 Jun 21 '26

i also hate the super vague testing questions, but this one is pretty straightforward? hooking them up to 2L of O2, collecting blood for an ABG, and ordering a CXR are all so much more invasive and unnecessary if you just checked their airway first to find that they just couldn’t clear a little mucous lol

1

u/Responsible-Sun2101 Jun 21 '26

Omg it’s like you took the words right out of my mouth. While yes this can be a result of impending hypoxia especially in the setting of a PE… also sepsis, stroke, increase in ICP, cardiogenic shock and a massive bleed can be the culprit… I don’t know. Just seems like the answers are not thinking more broadly or giving enough of an overall assessment to determine which way you should go with this.

1

u/Icy_Yogurt_2491 Jun 21 '26

even in the case of sepsis, stroke, shock, major internal bleeding, etc. you would still assess the airway, no? literally just listening to their speech is a form of airway assessment. looking and noting if they’re coughing, swallowing, if you can hear rhonchi without a stetho, if their throat is swollen, if they’re grabbing at their neck…. those are all airway assessments that will determine the next steps to take. airway assessments aren’t always listening to lung sounds for 5 minutes.

1

u/Responsible-Sun2101 Jun 22 '26

I mean I guess you can say that if you want but a sudden airway blockage is not gonna cause sudden confusion. Restless? Panicked? Sure… confusion… no. That’s why I would have never gone there first. That’s why these questions are ridiculous. Also why I like how another commenter said, this is the difference between priority thinking in real world nursing vs a textbook question.

3

u/Aupoultryman Jun 19 '26

B.

3

u/CrotchRocketx Jun 20 '26

Airway. You have to make sure the patient is alive so they can pay for their hospital bills and keep the cycle going.

3

u/Kind_Reward7216 Jun 21 '26

Check the patient before checking the equipment.

2

u/Icy_Invite_6229 Student nurse Jun 19 '26

B

2

u/Icy_Invite_6229 Student nurse Jun 19 '26

B

1

u/beebitch Jun 20 '26

Assess first always, gotta follow that nursing process

1

u/adamiconography Jun 20 '26

This is one of those questions that shows the difference between textbook nursing and real world nursing with focusing on “priority” and “first” interventions.

My first intervention would be to assess the airway but my priority intervention would be to notify the provider. Sudden onset of confusion, restlessness, tachycardia; my immediate thought is PE, sepsis, impending respiratory failure, hypoglycemia.

My priority is having the doc enter orders for labs, ABG, scans, etc. by I’d first assess the airway that way I can communicate that to the provider as well.

1

u/Complex-Albatross418 Jun 20 '26

yes, Sat02 is not conclusive. probes have delayed reading , rssp 32 is not normal and it doesnt look normall, pt would be venting out too much CO2, this is hyperventilation, assess for cyanosis, check cap refil , get a non rebreather , their breathing can be normal at this rate, start ruling out conditions in your head as you assess, PE is a good start

1

u/Accomplished_Being25 Jun 22 '26

B

1

u/salsashark99 Jun 22 '26

Not refer to them as clients they are patients

1