A nurse working in an emergency department is performing triage. To which of the following clients should the nurse assign priority?

A client who reports night sweats and fever for the last week

A client who has compound fractures of the tibia and humerus

A client who reports severe vomiting and diarrhea

A client who has soot markings around each naris following a house fire

Answer and Explanation

The Correct Answer is D

a. A client who reports night sweats and fever for the last week:

Night sweats and fever can be indicative of various underlying conditions, including infections. While these symptoms may require medical attention, they do not necessarily indicate an immediately life-threatening condition compared to other options.

b. A client who has compound fractures of the tibia and humerus:

Compound fractures involve broken bones that penetrate through the skin, leading to a risk of severe bleeding, infection, and other complications. This client's injuries are significant and require immediate attention to prevent further complications and provide pain management and stabilization.

c. A client who reports severe vomiting and diarrhea:

Severe vomiting and diarrhea can lead to dehydration, electrolyte imbalances, and other complications, especially if prolonged or accompanied by other symptoms such as fever. While this client requires prompt assessment and treatment, the urgency may not be as high as for other conditions.

d. A client who has soot markings around each naris following a house fire:

Soot markings around the nares (nostrils) suggest inhalation injury, which can lead to airway compromise, respiratory distress, and other serious complications. This client requires immediate assessment and intervention to ensure airway patency, oxygenation, and respiratory support.

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Correct Answer is C

Explanation

a. Establishing communication between providers:

Telehealth can facilitate communication between healthcare providers, allowing them to consult, collaborate, and share information about patient care remotely. This includes discussing patient cases, sharing test results, and coordinating treatment plans.

b. Developing client treatment protocols:

While telehealth may involve the use of protocols and guidelines to guide care delivery, its primary objective is to provide healthcare services remotely rather than developing treatment protocols specifically.Treatment protocols are typically established during a comprehensive assessment, which telehealth can be a part of, but it's not the sole purpose of a client call

c. Assessing client needs:

This is a core objective of telehealth. It allows healthcare professionals to evaluate the client's current health status, gather relevant information, and determine the necessary next steps in their care remotely.

d. Providing medication reconciliation:

Telehealth can facilitate medication reconciliation by allowing healthcare providers to review a patient's medication list remotely, update medication records, and reconcile any discrepancies during virtual appointments.

A. Complete an incident report about the breach of client confidentiality B. Reassign the AP to other clients on the unit C. Instruct the AP to discontinue the conversation D. Notify the client’s provider about the incident

Correct Answer is C

Explanation

a. Complete an incident report about the breach of client confidentiality:

While documenting the incident is important, completing an incident report alone may not address the immediate need to stop the breach of confidentiality.

b. Reassign the AP to other clients on the unit:

Reassignment may be considered after addressing the immediate issue, but it doesn't directly address the inappropriate conversation.

c. Instruct the AP to discontinue the conversation:

This is the correct immediate action. The nurse should intervene and instruct the assistive personnel to stop discussing the client's care in a non-secure location like the cafeteria.

d. Notify the client’s provider about the incident:

While notifying the client's provider may be necessary in certain situations, the immediate concern is to stop the breach of confidentiality and address the inappropriate conversation.

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A nurse working in an emergency department is performing triage. To which of the following clients should the nurse assign priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an ambulatory care setting is orienting a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth?

Correct Answer is C

Explanation

A nurse overhears two assistive personnel discussing a client’s care in the cafeteria. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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