During a routine visit to a physical education class, a nurse receives multiple complaints of shortness of breath, coughing, and nausea.
What should be the nurse’s immediate action?
Administer oxygen therapy.
Establish a triage area.
Notify the parents of the students.
Contact the local health department.
The Correct Answer is B
Choice A rationale
Administering oxygen therapy is a specific medical intervention that may not be immediately necessary or appropriate depending on the cause of the symptoms. It would be more appropriate to first establish a triage area to assess the severity of the students’ conditions.
Choice B rationale
Establishing a triage area is the correct immediate action. This allows the nurse to quickly assess the severity of each student’s condition, prioritize care, and determine the appropriate next steps.
Choice C rationale
Notifying the parents of the students might be a subsequent step after assessing the students and determining the cause of the symptoms. However, it should not be the immediate action.
Choice D rationale
Contacting the local health department would be appropriate if there was a suspicion of a public health emergency, such as an outbreak of a communicable disease. However, the immediate action should be to assess the students and provide necessary care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Identifying alternative solutions to address concerns is an important step in any project. However, it is not the first step in developing a mobile meal program for older adults who no longer drive. The first step should be to understand the needs of the target population, which can be achieved through a needs assessment.
Choice B rationale
Determining potential funding sources for the program is indeed a crucial aspect of planning. However, before seeking funding, it is essential to understand what needs to be funded, which comes from performing a needs assessment.
Choice C rationale
Inquiring about the availability of volunteers is a significant part of implementing the program. Volunteers could be responsible for meal preparation, delivery, or other tasks. However, the availability of volunteers does not determine the necessity or structure of the program.
Choice D rationale
Performing a needs assessment is the first step in developing a program. A needs assessment involves determining the extent of the need for a service in a particular population. In this case, it would involve determining how many older adults in the community no longer drive and would benefit from a mobile meal program.
Correct Answer is B
Explanation
Choice A rationale
While manic behavior can be disruptive and may require intervention, it is not typically life- threatening. Therefore, this client would not be the highest priority in a triage situation following a bombing incident.
Choice B rationale
A rigid abdomen with manifestations of shock could indicate serious internal injuries, such as bleeding or organ damage. This client would be a high priority for treatment due to the potential for rapid deterioration and life-threatening complications.
Choice C rationale
Superficial partial thickness burn injuries over 5% of the body, while painful and requiring treatment, are not typically immediately life-threatening. This client would be a lower priority compared to a client with signs of shock and potential internal injuries.
Choice D rationale
A femur fracture with a 2+ pedal pulse indicates that the client has a serious injury, but it is not immediately life-threatening. The presence of a 2+ pedal pulse suggests that circulation to the foot is still intact. This client would be a lower priority compared to a client with signs of shock and potential internal injuries.
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