HSRT Patient Care 2 — Questions and Answers
Question 1: A nurse enters a patient's room and finds the patient has fallen out of bed. The patient is conscious and reports hip pain. Which action should the nurse prioritize FIRST?
- Assess the patient's airway, breathing, circulation, and level of consciousness before moving them (Correct answer)
- Immediately help the patient back into bed to prevent further discomfort
- Call the patient's family member to notify them of the fall
- Document the fall in the incident report before any clinical assessment
Correct answer: Assess the patient's airway, breathing, circulation, and level of consciousness before moving them
The first priority after a fall is clinical assessment (ABCs and neurological status) before any movement that could worsen an unidentified injury.
Post-fall management requires a systematic approach: first, assess airway, breathing, circulation, and level of consciousness, then check for injury (head, spine, hip fracture — particularly in elderly patients on anticoagulants). Moving the patient before assessment could worsen a cervical fracture or exacerbate bleeding. Family notification and documentation are important but secondary to immediate clinical assessment. The primary nurse role is clinical: assess → stabilize → document → report. Incident reports follow, not precede, clinical care.
Question 2: A patient with diabetes asks a healthcare provider: 'What is my blood sugar result?' The provider notices the result is 380 mg/dL but hesitates to share the result. What principle of patient care is MOST relevant?
- Transparency and informed consent — patients have the right to know their own clinical data (Correct answer)
- Beneficence — withholding distressing information may protect the patient
- Non-maleficence — sharing a high blood sugar may cause psychological harm
- Fidelity — the provider must be loyal to the physician's interpretation first
Correct answer: Transparency and informed consent — patients have the right to know their own clinical data
Patients have the right to access their own clinical information (informed consent and autonomy). Withholding results undermines trust and the therapeutic relationship.
Patient autonomy and transparency are foundational to ethical patient care. Patients have a legal and ethical right to know their own clinical data. Withholding a blood glucose result 'to avoid distress' is paternalistic — it denies the patient information needed to understand their condition and participate in decision-making. While communication must be compassionate and contextualized (explaining what the result means and what steps follow), the default is disclosure. Beneficence and non-maleficence may justify withholding in very specific contexts (e.g., terminal prognosis communication with documented advance directive preferences), but this is not one of them.
Question 3: A healthcare worker is about to administer a blood transfusion. Before starting the transfusion, which verification step is MOST critical for patient safety?
- Confirm two patient identifiers and match them to the blood product label at the bedside with a second licensed professional (Correct answer)
- Check the patient's allergy list for penicillin reactions before transfusing
- Verify the transfusion order with the blood bank over the phone
- Ensure the IV access is patent before checking patient identification
Correct answer: Confirm two patient identifiers and match them to the blood product label at the bedside with a second licensed professional
Blood product administration requires two-person bedside verification of two patient identifiers against the blood product label to prevent ABO-incompatible transfusion reactions, which can be fatal.
Transfusion-related fatalities from ABO incompatibility (wrong blood to the wrong patient) are a leading cause of transfusion-associated mortality. The Joint Commission requires bedside verification of at minimum two patient identifiers (name + date of birth or MRN) matched to the blood product label by two licensed professionals. Penicillin allergy is irrelevant to transfusion safety. Phone verification with the blood bank is part of the ordering process, not bedside safety checks. IV patency is important but must follow, not precede, patient/product identity verification.
Question 4: A 72-year-old patient post-hip replacement reports severe pain (9/10) 6 hours after the last analgesic dose. The pain medication is ordered PRN (as needed). The nurse should:
- Assess the pain thoroughly, administer the PRN medication per protocol, and reassess for effectiveness within 30–60 minutes (Correct answer)
- Wait until the patient's next scheduled vital sign check to address the pain report
- Contact the physician before administering any PRN medication
- Advise the patient that severe pain is expected after hip replacement
Correct answer: Assess the pain thoroughly, administer the PRN medication per protocol, and reassess for effectiveness within 30–60 minutes
PRN (as needed) medications exist precisely for breakthrough pain. Assessment, administration, and follow-up assessment are the standard of care.
Pain management is a standard of care issue and a patient right. PRN (pro re nata: as needed) orders give the nurse authority to administer within defined parameters without calling the physician first — this is the purpose of PRN orders. Nursing management of pain requires: assess (PQRST), administer within the order parameters, document, and reassess for effectiveness and adverse effects (respiratory rate, sedation) within 30–60 minutes. Waiting without reason, requiring physician contact for every PRN, or normalizing 9/10 pain as expected all represent inadequate pain management and potential violations of patient rights.
Question 5: During morning medication rounds, a nurse realizes she administered Medication A to Patient X but then discovers the medication was prescribed for Patient Y (same room, adjacent bed). Which action should occur IMMEDIATELY?
- Assess Patient X for any adverse effects from Medication A and notify the prescribing physician immediately (Correct answer)
- Document the error in the chart and proceed with rounds
- Notify the pharmacy to cancel the dispensing
- Administer the correct medication to Patient Y before reporting the error
Correct answer: Assess Patient X for any adverse effects from Medication A and notify the prescribing physician immediately
The immediate priority is patient safety: assess the patient who received the wrong medication for adverse effects and notify the physician so appropriate intervention can be arranged.
Medication errors require immediate patient-focused response: (1) Assess the patient who received the wrong medication for adverse effects — this includes vital signs, allergies, drug interactions, and the specific pharmacological action of the administered drug; (2) Notify the prescribing physician immediately so they can order monitoring, reversal agents, or other interventions; (3) Document and complete an incident report; (4) Notify the patient and family as part of transparency and disclosure obligations. Proceeding with other patients' care before addressing the acute safety issue is negligent. Documentation and pharmacy notification follow clinical stabilization.
Question 6: A hospice nurse visits a terminally ill patient at home who says: 'I want to stop taking all my medications.' The nurse's MOST appropriate response reflects which patient care principle?
- Respect for patient autonomy — the competent patient's right to refuse treatment must be honored, with support for comfort-focused care (Correct answer)
- Beneficence — the nurse should convince the patient to continue medications for their own benefit
- Non-maleficence — stopping medications may cause harm, so the nurse must prevent this decision
- Justice — discontinuing medications is unfair to the family who wants treatment continued
Correct answer: Respect for patient autonomy — the competent patient's right to refuse treatment must be honored, with support for comfort-focused care
A competent patient has the absolute right to refuse medical treatment, including medications. The nurse's role is to support this decision, ensure informed choice, and provide comfort-focused care.
Patient autonomy — the right of a competent adult to make their own healthcare decisions, including refusal of treatment — is a cornerstone of medical ethics and law. In a hospice context, stopping medications is often appropriate: symptom-focused medications (opioids, anxiolytics) may continue while disease-modifying treatments (statins, antihypertensives, diabetic medications) may be appropriately withdrawn. The nurse's role is to: confirm decision-making capacity, ensure the patient understands the implications, document the decision, and support the shift to comfort-focused care. Overriding a competent patient's wishes violates autonomy and may constitute battery under law.
HSRT Patient Care 2
A nurse enters a patient's room and finds the patient has fallen out of bed.
The patient is conscious and reports hip pain.
Which action should the nurse prioritize FIRST?