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 ["D"]
Explanation
- Choice A Rationale: This choice is not optimal because the PN has the skills necessary to assist with the thoracentesis, a procedure that requires clinical judgment and skill, which the UAP does not possess. The RN is also needed to obtain the report from the ED due to the complexity of unstable angina, which requires advanced knowledge and assessment skills.
- Choice B Rationale: This option incorrectly assigns the UAP to prepare the room, which is within their scope, but fails to utilize the PN's skills effectively. The PN should be involved in more complex tasks such as assisting with procedures or obtaining detailed reports, rather than the UAP.
- Choice C Rationale: This choice is inappropriate because it assigns the UAP to assist with the thoracentesis, a task they are not trained for and is outside their scope of practice. The RN should be involved in the more complex care of obtaining the report, and the PN should assist with the thoracentesis.
- Choice D Rationale: This is the correct choice because it utilizes all staff members according to their scope of practice and skills. The PN assists with the thoracentesis, a task they are qualified for, the RN obtains the report on the new admission, which requires advanced knowledge, and the UAP prepares the room, a task that fits their role.
- Choice E Rationale: As there is no Choice E provided in the question, no rationale can be given for this option. It is important to follow the instructions and options given in the scenario to provide accurate and relevant information.
Correct Answer is B
Explanation
Choice A rationale: Recording the client's pulse volume distal to the IV site is a nursing responsibility as it involves an assessment of circulation.
Choice B rationale: Reapplying cold compresses is a task that UAP can perform to help minimize swelling and discomfort at the extravasation site.
Choice C rationale: Disposing of the IV tubing after the infusion is discontinued is a nursing responsibility to ensure proper disposal and prevent contamination.
Choice D rationale: Teaching the client about the need to keep the extremity elevated involves patient education and is within the scope of nursing practice.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today