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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale: Reducing the white blood cell count is not a goal of SIRS treatment, as it would impair the immune system's ability to fight the infection.
Choice B rationale: Maintaining body temperature within normal limits is a collaborative goal to address the signs of SIRS.
Choice C rationale: Decreasing blood pressure is not typically a goal in the management of SIRS; the focus is on maintaining adequate perfusion.
Choice D rationale: Achieving a negative urine culture is a collaborative goal to address the underlying urinary tract infection.
Choice E rationale: incision free of exudate is an indicator of resolving infection and inflammation.
Correct Answer is B
Explanation
Choice A rationale: Determining which foods aggravate the client's symptoms is beyond the scope of the UAP and should be addressed by licensed healthcare providers. Choice B rationale: Elevating the head of the bed before the client begins to eat helps prevent reflux in clients with hiatal hernia, and it's a task that can be delegated to the UAP.
Choice C rationale: Teaching the client about the need to eat small, frequent meals is a nursing responsibility and should be performed by a licensed nurse.
Choice D rationale: Assessing the client for heartburn or a feeling of fullness after eating is a nursing responsibility and requires a licensed nurse's judgment.
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