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 A
Explanation
Choice A rationale: Placing an isolation cart outside the room is important, because mumps is a contagious viral infection that can be transmitted by respiratory droplets from coughing or sneezing. This intervention prevents the spread of infection and protects other clients and staff from exposure.
Choice B rationale: Instructing the child's parents about the need for transmission precautions is essential for preventing the spread of mumps to other individuals but the most important intervention is to place an isolation cart outside the room. Choice C rationale: Scheduling bedside playtime with the occupational therapist may be beneficial for the child but is not the most critical intervention in preventing transmission.
Choice D rationale: Assigning the child to a room close to the nurse's station may facilitate monitoring but does not directly address the prevention of transmission.
Correct Answer is C
Explanation
Choice A rationale: Asking the nurse to explain thoughts on the need for an in-service program encourages open communication and allows the nurse-manager to address specific concerns.
Choice B rationale: Choosing to send another nurse may not address the concerns of the nurse expressing dissatisfaction and may not promote a collaborative approach. Choice C rationale: Encouraging the nurse to share concerns and discuss ways to prepare for emergencies fosters open communication and allows for constructive dialogue.
Choice D rationale: Informing the nurse that in-service is not optional and attendance is mandatory may create resistance and does not promote a collaborative approach to addressing concerns.
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