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 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.
Correct Answer is A
Explanation
Choice A rationale: This is because ceftriaxone is an antibiotic that can be administered by gravity drip without an IV pump, as long as the flow rate is monitored and adjusted manually.
Choice B rationale: Heparin in normal saline, especially for deep vein thrombosis, requires precise control of the infusion rate, making an infusion pump necessary.
Choice C rationale: Regular insulin in normal saline for ketoacidosis should be administered via an IV pump due to the need for precise control of the infusion rate.
Choice D rationale: Magnesium in normal saline for hypomagnesemia may also require careful control of the infusion rate, making an infusion pump preferable.
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