The nurse is utilizing the 60-second situation assessment tool to determine which patient to see ...

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Rationale 1: The first criterion when using the 60-second situation assessment tool is “assess airway breathing circulation without touching the patient.” The patient with a respiratory rate of 8 and lethargy would be the nurse’s first priority. (See Page 114 Box 5-2 Sixty-Second Situation Assessment Tool)
Rationale 2: The first criterion when using the 60-second situation assessment tool is “assess airway breathing circulation without touching the patient.” The patient with a respiratory rate of 8 and lethargy would be the nurse’s first priority. The patient without intravenous lines and wearing oxygen would not be the nurse’s first priority even though the patient has respiratory equipment. (See Page 114 Box 5-2 Sixty-Second Situation Assessment Tool)
Rationale 3: The first criterion when using the 60-second situation assessment tool is “assess airway breathing circulation without touching the patient.” The patient with a respiratory rate of 8 and lethargy would be the nurse’s first priority. The patient lying in bed and responding to verbal stimuli would not be the nurse’s first priority. (See Page 114 Box 5-2 Sixty-Second Situation Assessment Tool)
Rationale 4: The first criterion when using the 60-second situation assessment tool is “assess airway breathing circulation without touching the patient.” The patient with a respiratory rate of 8 and lethargy would be the nurse’s first priority. The patient in bed with both side rails down and talking on the telephone would not be the nurse’s first priority even though a safety issue could occur. (See Page 114 Box 5-2 Sixty-Second Situation Assessment Tool)

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