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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).

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A rationale: The client post triple coronary bypass with serosanguinous drainage in one chest tube requires attention but is not the highest priority based on the information provided.

Choice B rationale: The client with diabetic ketoacidosis and a blood glucose level of 195 mg/dl (10.8 mmol/L) needs immediate attention due to the elevated glucose level but the client with a pneumothorax and low oxygen saturation takes precedence.

Choice C rationale: The client with an Ileal conduit and scant blood in the drainage pouch is a concern but not as urgent as the client with diabetic ketoacidosis.

Choice D rationale: The client with a pneumothorax has a life-threatening condition that requires immediate attention. A pulse oximeter reading of 90% indicates hypoxia, which can lead to organ damage and death.

A. Perform urinary catheter irrigations with normal saline. B. Initiate teaching for client care after discharge. C. Begin Initial sterile wound care for surgical clients. D. Receive a postoperative client and conduct the assessment.

Correct Answer is A

Explanation

Choice A rationale: The nurse can delegate urinary catheter irrigations to the PN, as this is a skill that can be performed by a licensed nurse under the supervision of a registered nurse (RN).

Choice B rationale: Initiating teaching for client care after discharge is within the scope of a registered nurse and may not be delegated to a practical nurse.

Choice C rationale: Beginning initial sterile wound care for surgical clients may fall under the scope of a registered nurse or other licensed staff, not necessarily a practical nurse.

Choice D rationale: Receiving a postoperative client and conducting the assessment also requires the RN's critical thinking and clinical skills.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? Reference Range: Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Correct Answer is D

Explanation

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?

Correct Answer is A

Explanation

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