A nurse working in an emergency department is performing triage. To which of the following clients should the nurse assign priority?
A client who reports night sweats and fever for the last week
A client who has compound fractures of the tibia and humerus
A client who reports severe vomiting and diarrhea
A client who has soot markings around each naris following a house fire
The Correct Answer is D
a. A client who reports night sweats and fever for the last week:
Night sweats and fever can be indicative of various underlying conditions, including infections. While these symptoms may require medical attention, they do not necessarily indicate an immediately life-threatening condition compared to other options.
b. A client who has compound fractures of the tibia and humerus:
Compound fractures involve broken bones that penetrate through the skin, leading to a risk of severe bleeding, infection, and other complications. This client's injuries are significant and require immediate attention to prevent further complications and provide pain management and stabilization.
c. A client who reports severe vomiting and diarrhea:
Severe vomiting and diarrhea can lead to dehydration, electrolyte imbalances, and other complications, especially if prolonged or accompanied by other symptoms such as fever. While this client requires prompt assessment and treatment, the urgency may not be as high as for other conditions.
d. A client who has soot markings around each naris following a house fire:
Soot markings around the nares (nostrils) suggest inhalation injury, which can lead to airway compromise, respiratory distress, and other serious complications. This client requires immediate assessment and intervention to ensure airway patency, oxygenation, and respiratory support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. A client who has just returned from the PACU:
Vital signs for a client who has just returned from the Post-Anesthesia Care Unit (PACU) are usually obtained by licensed nursing staff due to the potential for complications and the need for close monitoring.
b. A client who has a blood pressure of 110/68 mm Hg:
This client has stable vital signs, and obtaining blood pressure measurements within normal range is a routine task suitable for delegation to assistive personnel.
c. A client who is experiencing chest pain:
Clients experiencing chest pain require immediate assessment by licensed nursing staff or a healthcare provider. This is not a task appropriate for delegation to assistive personnel.
d. A client who has a fasting blood glucose of 104 mg/dL:
Monitoring blood glucose levels is typically within the scope of licensed nursing staff. Delegating tasks related to clients with diabetes or glucose monitoring to assistive personnel may not be appropriate.
Correct Answer is C
Explanation
a. Establishing communication between providers:
Telehealth can facilitate communication between healthcare providers, allowing them to consult, collaborate, and share information about patient care remotely. This includes discussing patient cases, sharing test results, and coordinating treatment plans.
b. Developing client treatment protocols:
While telehealth may involve the use of protocols and guidelines to guide care delivery, its primary objective is to provide healthcare services remotely rather than developing treatment protocols specifically.Treatment protocols are typically established during a comprehensive assessment, which telehealth can be a part of, but it's not the sole purpose of a client call
c. Assessing client needs:
This is a core objective of telehealth. It allows healthcare professionals to evaluate the client's current health status, gather relevant information, and determine the necessary next steps in their care remotely.
d. Providing medication reconciliation:
Telehealth can facilitate medication reconciliation by allowing healthcare providers to review a patient's medication list remotely, update medication records, and reconcile any discrepancies during virtual appointments.
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