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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Orders for diagnostic and therapeutic procedures such as laboratory tests or x-rays:
This refers to medical orders, which are instructions given by a physician for diagnostic tests or treatments. These orders are not part of the nursing care plan. Nurses execute these orders but do not create them.
B. Laboratory and x-ray reports, pathology reports, and the medication record:
These are patient records and reports. While nurses use this information to inform their care, the reports themselves are not the nursing care plan. Nurses analyze these reports to make informed decisions regarding patient care.
C. Nursing orders for individualized interventions to assist the patient to meet expected outcomes:
This is the correct choice. Nursing care plans involve identifying the patient's nursing diagnoses (health issues that nurses can address), setting specific and measurable outcomes, planning interventions tailored to the patient's needs, and evaluating the outcomes. It's a holistic approach designed to address the patient's unique health challenges.
D. The physician's history and physical examination, as well as medical diagnoses:
This refers to the medical diagnosis and assessment, which are critical for understanding the patient's overall health. While nurses consider this information, the nursing care plan specifically focuses on nursing interventions and care strategies, making it distinct from the medical diagnosis.
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.
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