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 ["A","C","D","E"]
Explanation
A. Reinforces application of the nursing process: True. The Problem-Oriented Medical Record (POMR) is designed to organize patient data based on specific problems, which aligns well with the nursing process. It emphasizes problem-solving and critical thinking in the context of patient care.
B. Formats documentation into chronological order: This is not entirely accurate for POMR. POMR organizes data by problems, not necessarily in strict chronological order. Information is clustered around specific problems, making it easier to identify relevant data quickly.
C. Promotes the problem-solving approach: Yes, this is correct. POMR emphasizes identifying and solving individual patient problems, encouraging a systematic and problem-oriented approach to patient care.
D. Makes tracking trends in patient care easy: This can be true, especially when it comes to tracking the progress of specific problems over time. POMR allows healthcare providers to see the evolution of each problem, making it easier to track trends related to individual issues.
E. Allows for easy auditing of patient records to evaluate staff performance: POMR does facilitate easier auditing since each problem is documented separately, allowing for clear assessment of how each problem is being managed. This can be valuable for evaluating staff performance.
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