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A nurse is performing telephone triage at the clinic office. Which client has the most acute problem and should be scheduled for the first available appointment?

A 21-year-old with a history of a kidney transplant. Today the client reports "flu-like" symptoms with a fever of 100.4° F (38° C).

A 42-year-old male who hurt his back while lifting yesterday. Today he has non radiating, low-back pain rated at 10 on a scale of 0 to 10.

A client at 3-weeks gestation who today noted a small amount of bright red blood on the toilet paper after passing stool.

A 2-year-old girl with a history of a "cold." Today she is tugging on her ear and has a fever of 102 F (38.9° C).

Answer and Explanation

The Correct Answer is D

Choice A rationale: The client with a kidney transplant experiencing "flu-like" symptoms can be evaluated for urgency but may not require the first available appointment.
Choice B rationale: The client with non-radiating, low-back pain rated at 10 on a scale of 0 to 10 should be assessed, but it may not be an immediate concern compared to the other options.
Choice C rationale: The client at 3-weeks gestation with a small amount of bright red blood after passing stool requires evaluation, but it may not be as urgent as the client in Choice D.
Choice D rationale: The 2-year-old girl with a history of a "cold," tugging on her ear, and a fever of 102 F (38.9° C) may have an ear infection, which could be an acute problem requiring prompt evaluation.

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Correct Answer is C

Explanation

Choice A rationale: Verifying with the client that the blood was drawn is a good practice, but it might not provide immediate information about the current glucose level. The nurse needs a timely assessment to determine whether the client can safely receive the scheduled breakfast.

Choice B rationale: Checking when insulin was last administered is important, but it doesn't provide real-time information about the current glucose level. The nurse needs this information before deciding on breakfast administration.

Choice C rationale: Performing a capillary glucose test is a quick way to obtain current blood glucose levels, allowing the nurse to make an informed decision about administering the breakfast tray. This action is consistent with assessing the client's immediate status.

Choice D rationale: Giving the client the breakfast tray without knowing the current glucose level could be unsafe and against the prescribed plan of care. Assessing the glucose level is a necessary step before administering meals, especially in clients with diabetes.

A. Determine staff opinion of current healthcare insurance costs. B. Announce the new plan at a special employee wellness event. C. Survey the nurses to see who wants to keep the old benefits plan. D. Be available to all shifts to discuss the changes in health benefits.

Correct Answer is D

Explanation

Choice A rationale: While understanding staff opinions on healthcare insurance costs is valuable, being available to discuss changes in health benefits is more directly related to the implementation of the new plan.

Choice B rationale: Announcing the new plan at a special employee wellness event is important, but being available to discuss the changes on all shifts ensures that all staff members have the opportunity to understand and address their concerns.

Choice C rationale: Surveying nurses to see who wants to keep the old benefits plan may not be as effective as being available to all shifts for direct communication about the changes.

Choice D rationale: Being available to all shifts to discuss the changes in health benefits is crucial for effective communication and addressing any concerns or questions that may arise during the implementation of the new plan.

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A nurse is performing telephone triage at the clinic office. Which client has the most acute problem and should be scheduled for the first available appointment?

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Naxlex Comprehensive Predictor Exams

Breakfast trays have arrived on the unit, but the daily serum glucose level is not available on the chart of a client with type 1 diabetes mellitus. Which action should the nurse take?

Correct Answer is C

Explanation

Several nurses are elected by their peers to serve on a negotiating committee to recommend new healthcare benefits. After the new benefits plan is developed and approved, which action is most important for the nurses working on this committee to implement?

Correct Answer is D

Explanation

The nurse determines that an intravenous (IV) vesicant chemotherapy infusion is infiltrated. In responding to this finding, which task can the nurse delegate to the unlicensed assistive personnel (UAP)?

Four clients are scheduled to receive IV infusions, but there are only three IV pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?

The nurse manager conducts regular audits of patient care medication records and notices that the amount of narcotic pain medications administered during the evening shift on a postsurgical unit is higher than usual. Which action should the nurse manager take first?

While walking down the hallway, the nurse finds a female client yelling, swinging her hands, and pushing a male visitor away from her hospital bed. Which intervention should the nurse implement first?

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The nurse-manager overhears a nurse complaining to a co-worker about the time being required to attend an in-service session for bioterrorism preparedness. How should the nurse-manager respond?