A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse?
Chest discomfort one hour after consuming a large, spicy meal.
Low-grade fever, headache, and malaise for the past 72 hours.
Unable to bear weight on the left foot, with swelling and bruising.
One inch (2.5 cm) bleeding laceration on the chin of a crying 5-year-old.
The Correct Answer is A
Triage in the emergency department utilizes the Emergency Severity Index to prioritize clients based on clinical urgency and resource needs. Nurses must identify life-threatening conditions such as myocardial infarction or airway compromise immediately. Chest pain is always treated as a potential cardiac event until diagnostic tests like an electrocardiogram or troponin levels prove otherwise.
Rationale:
A. Chest discomfort is the highest priority because it can indicate an acute myocardial infarction. Even when associated with spicy food, the nurse must exclude ischemic heart disease before considering gastrointestinal causes. Immediate intervention is required to prevent permanent cardiac muscle damage or sudden cardiac arrest.
B. These symptoms suggest a viral prodrome or a minor infectious process that has been present for 72 hours. While the client requires assessment, their condition is hemodynamically stable and does not pose an immediate threat to life. They can safely wait for evaluation after higher-priority clients are stabilized.
C. An inability to bear weight with localized edema and ecchymosis indicates a potential musculoskeletal injury or fracture. While painful, this condition is usually neurovascularly intact and localized to the extremity. It does not take precedence over a client with potential cardiac or systemic instability.
D. A small laceration on a pediatric client is distressing but represents a minor trauma with controlled hemorrhage. The child is crying, which indicates a patent airway and adequate cerebral perfusion. This client is classified as stable and will be treated after more urgent physiological threats are addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.6"]
Explanation
Pediatric medication administration requires extreme precision because dosage is typically calculated based on the child's weight (mg/kg) rather than a standard adult dose. Because children have different metabolic rates and smaller volumes of distribution, even minor errors in calculation or rounding can lead to sub-therapeutic levels or toxicity.
Rationale:
Step 1: Calculate total daily dose
Total daily dose (mg/day) = Weight × Dose per kg/day
= 6.5 × 0.5
= 3.25 mg/day
Step 2: Determine dose per administration
Medication is given every 12 hours = 2 doses/day
Dose per dose = 3.25 ÷ 2
= 1.625 mg
Step 3: Round to the nearest tenth
≈ 1.6 mg
Correct Answer is D
Explanation
Sickle cell anemia involves the production of abnormal hemoglobin S, causing crescent-shaped erythrocytes that obstruct microvascular flow. This vaso-occlusive crisis leads to severe tissue ischemia, infarction, and excruciating bone pain. Effective management requires prophylactic analgesia and aggressive hydration to maintain perfusion and prevent chronic organ damage from repetitive sickling episodes.
Rationale:
A. While warmth can promote vasodilation, it is not a substitute for pharmacological intervention during a crisis. Relying on non-pharmacological methods alone fails to address the underlying ischemia. Over-reliance on alternative therapy can lead to uncontrolled pain and increased physiological stress for the child.
B. Rest is necessary to reduce metabolic oxygen demand, but it does not treat the physiological cause of the pain. Without analgesic administration, the child remains at risk for complications like acute chest syndrome. Proper pain management must be the priority to ensure the child can eventually mobilize.
C. Distraction techniques like television are supplementary and cannot manage the high-intensity pain associated with sickling. Educational efforts must clarify that therapeutic opioids used for organic pain rarely result in addiction. Maintaining consistent blood levels of medication is essential for pediatric sickle cell patients.
D. Administering analgesics around the clock ensures a steady state of medication, preventing pain from becoming unbearable. This approach is superior to as-needed dosing because it targets the continuous ischemia present during a crisis. Preventing the peak-and-trough effect of pain minimizes the total dose required for relief.
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