A nurse in an emergency department is triaging clients following a natural disaster. In which of the following categories should the nurse place a client who reports severe chest pain?

Rationale:

A. Set an automated blood pressure cuff for every 5 min: Frequent blood pressure measurements can increase the risk of bleeding and hematoma formation, especially if cuff inflation is excessive. Monitoring should be done, but not at such short intervals unless specifically ordered.

B. Administer IM morphine for pain as needed: IM injections are contraindicated in clients who have received thrombolytics because they increase the risk of bleeding and hematoma at the injection site. Pain relief should be managed through safer routes, such as IV.

C. Apply an ice pack to stop minor bleeding: Applying an ice pack may not be sufficient or appropriate for managing bleeding in a client who has received thrombolytics. Pressure and notifying the provider are more appropriate responses to bleeding.

D. Minimize the number of venipunctures the client receives: Thrombolytic therapy increases the risk of bleeding. Therefore, minimizing invasive procedures like venipunctures helps reduce the risk of internal or external hemorrhage in these clients.

Rationale:

A. Norming: Norming is the stage where group members begin to establish trust, set group norms, and start working more collaboratively. This phase comes after members have had a chance to get acquainted and address initial conflicts.

B. Storming: Storming is the second stage and involves conflict or competition as group members assert their opinions or roles. While essential for growth, it is not the first stage in group development.

C. Forming: Forming is the initial stage of group development where members are introduced, roles are discussed, and goals are clarified. It sets the foundation for interprofessional collaboration and defines the group’s purpose and structure.

D. Performing: Performing is the advanced stage where the group functions effectively toward achieving its goals. It occurs only after earlier stages like forming, storming, and norming have been successfully navigated.