An emergency room nurse will give first priority to the patent with the most critical need, which is the patient who
Bleeding from a chin laceration
complain of severe chest pain
has a fever of 102 degrees
complains of a productive cough
The Correct Answer is B
A. Bleeding from a chin laceration: This is a significant concern, but it's generally not immediately life-threatening. The bleeding can be controlled, and it's not likely to lead to a rapid decline in the patient's condition.
B. Complain of severe chest pain: This is a critical symptom as it could indicate a heart attack or other serious cardiac issue. Chest pain could be a sign of a lack of blood flow to the heart, which can lead to severe complications if not addressed urgently.
C. Has a fever of 102 degrees: While a fever indicates an infection or inflammation in the body, a fever of 102 degrees Fahrenheit, by itself, is not an immediate life-threatening situation. It suggests an underlying issue that needs medical attention but might not be as urgent as severe chest pain.
D. Complains of a productive cough: While a productive cough (bringing up phlegm or mucus) could indicate a respiratory infection, it's generally not as urgent as severe chest pain. Respiratory issues can become serious, especially in vulnerable populations, but they often progress over a longer timeframe compared to the rapid onset of a heart attack, for example.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The case management system:
Case management involves coordinating comprehensive healthcare services for patients across different settings and healthcare professionals.
This choice doesn't describe the specific style of documentation used in the scenario provided.
B. SOAP Note:
Subjective: Information reported by the patient, like feelings or symptoms.
Objective: Observable and measurable data, such as physical examination findings.
Assessment: The nurse's professional judgment about the patient's condition.
Plan: Interventions and treatments planned for the patient.
In the scenario, the documentation includes subjective information (patient denies itching, happy with improvement), objective data (rash fading, no visible hives), the nurse's assessment (skin integrity improving), and the plan (check rash daily until discharge). This aligns with the structure of a SOAP note.
C. Narrative style:
Narrative charting involves writing out the patient's story in a paragraph form.
While it can contain similar information to a SOAP note, it doesn't follow the structured format of SOAP (Subjective, Objective, Assessment, Plan) and tends to be more detailed and descriptive.
D. Charting by exception:
Charting by exception involves documenting only abnormal findings or significant events.
This method reduces redundant documentation, focusing on deviations from the expected or normal findings.
The scenario provides a mix of both normal (improvement in skin, patient satisfaction) and abnormal (initial rash and hives) findings, so it's not solely charting by exception.
Correct Answer is C
Explanation
A. Psychosocial needs should be met first:
Psychosocial needs are undoubtedly essential aspects of patient care. However, the priority of nursing problems depends on the patient's condition and the urgency of the situation. While psychosocial needs are critical, they might not always be the first priority, especially in acute or life-threatening situations. Safety and physiological needs often take precedence.
B. Problems don't need to be prioritized:
In nursing practice, problems do need to be prioritized. Patients usually have multiple issues that need attention, and prioritization ensures that the most urgent or life-threatening problems are addressed first. Without prioritization, critical issues might be delayed, potentially leading to adverse outcomes.
C. Problems should be ranked according to their importance:
This statement is correct. Prioritizing nursing problems involves ranking them based on their importance and urgency. It ensures that the most critical issues are addressed promptly and effectively, enhancing patient outcomes and safety.
D. Safety is the #1 priority:
This statement is also correct. In nursing, patient safety is paramount. Ensuring the patient's safety is the top priority in all situations. This includes assessing and managing risks, preventing accidents or injuries, and providing a safe environment for both patients and healthcare providers. Safety concerns often take precedence over other nursing problems.
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