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: The immediate priority during a fire alarm is to ensure the safety of clients and staff. Instructing everyone to stay in the client rooms with doors closed helps contain any potential smoke or fire, providing protection while the situation is assessed.
Choice B rationale: Instructing family members to stay in the waiting area might not be the primary concern during a fire alarm. The focus is on the safety of clients and staff.
Choice C rationale: While determining the nature of the emergency is important, taking immediate actions to ensure safety is the priority. The charge nurse can address the cause once the safety of individuals is secured.
Choice D rationale: Evacuating clients should only be considered if it is determined to be safe to do so. It's crucial to assess the situation and follow established protocols before initiating evacuation.
Correct Answer is D
Explanation
Choice A rationale: Paging a chaplain on call can be a supportive measure, but it might not address the immediate need for communication and coordination with the family.
Choice B rationale: Allowing each family member to ask a question one at a time may not be the most effective approach when dealing with multiple and repetitive questions.
Choice C rationale: Requesting the healthcare provider to speak with the family might be appropriate, but it could take time, and the immediate need is to establish effective communication.
Choice D rationale: Asking the family to identify a specific spokesperson helps streamline communication and ensures that information is conveyed more efficiently. This approach can help manage the situation and address the family's concerns collectively.
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