When a patient develops sudden hypotension, what is the nursing priority?

• A. Assess and secure airway/breathing/circulation (ABC) and notify the team while stabilizing vitals.
• B. Increase IV fluids immediately.
• C. Call physician and wait for orders.
• D. Document vitals and observe.

Answer: (A)

When sudden hypotension occurs, the first priority is preserving life-supporting functions: airway, breathing, and circulation. The nurse should rapidly assess and secure ABCs and stabilize vital signs, all while notifying the medical team. This approach addresses the most immediate threat to perfusion and oxygen delivery to tissues.

Airway and breathing come first because a compromised airway or inadequate ventilation can rapidly worsen hypoxia and shock. Provide oxygen as needed and be ready to intervene if the patient shows signs of airway obstruction or respiratory failure. For circulation, obtain rapid IV access and begin measures to support perfusion, such as fluid resuscitation per protocol or orders, while continuously monitoring blood pressure, heart rate, skin color, and mental status. Communicating with the team promptly ensures that appropriate orders for fluids, vasopressors, diagnostic tests, or further interventions are issued without delay.

Delaying action to wait for orders or focusing only on documentation misses the urgent need to stabilize the patient. While fluids may be part of the plan, they should be given in the context of securing the airway and stabilizing circulation, not in isolation.