Four patients arrive at the emergency department at the same time. Which patient will the nurse see first?
An infant with temperature of 102.2° F and diarrhea for 3 days
A teenager with a sprained ankle and excessive edema
A middle-aged adult with abdominal pain who is moaning and holding her stomach
An older adult with nausea and vomiting for 3 days with blood pressure 112/60
The Correct Answer is A
A. An infant with temperature of 102.2° F and diarrhea for 3 days: Infants are vulnerable to dehydration and fluid imbalances, which can quickly become life-threatening. A fever of 102.2°F combined with diarrhea for three days raises concern for potential severe dehydration, infection, or sepsis, which requires immediate attention.
B. A teenager with a sprained ankle and excessive edema: While the teenager’s condition is painful, a sprained ankle and excessive edema are generally not life-threatening. This condition can be treated after more urgent cases are addressed.
C. A middle-aged adult with abdominal pain who is moaning and holding her stomach: While abdominal pain may indicate a serious condition, the patient's symptoms don't necessarily suggest an immediate life-threatening situation, particularly if vital signs are stable.
D. An older adult with nausea and vomiting for 3 days with blood pressure 112/60: The blood pressure is within normal limits and while nausea and vomiting for three days are concerning, this patient’s condition is not immediately life-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Slices of smoked ham with potato salad: Smoked ham is high in sodium, hence inappropriate for someone on a restricted sodium diet. Potato salad, depending on preparation, can also be high in sodium due to added salt or processed ingredients.
B. Bowl of tomato soup with a grilled cheese sandwich: Both tomato soup and a grilled cheese sandwich often contain high amounts of sodium, especially if made with canned soup or processed cheese. This would not be suitable for a restricted sodium diet.
C. Salami and cheese on whole wheat crackers: Both salami and cheese are high in sodium, making this a poor choice for someone following a restricted sodium diet.
D. Grilled chicken breast with glazed carrots: Grilled chicken breast is a lean protein with minimal sodium, and glazed carrots, if prepared without added salt or high-sodium ingredients, can be a suitable option. This meal aligns with a restricted sodium diet.
Correct Answer is C
Explanation
A. Assess the patients for edema in extremities: While assessing for edema can be helpful in heart failure patients, it may not be the most effective method to monitor fluid volume status in patients at risk for dehydration, as edema may not be present in early dehydration.
B. Ask the patients to record their intake and output: Recording intake and output is important for monitoring fluid balance, but it is not as reliable as daily weight measurements. Patients may not be accurate in recording intake and output, especially in acute settings.
C. Weigh the patients every morning before breakfast: Weighing patients at the same time every day provides the most accurate and reliable measure of fluid volume status. A sudden weight gain or loss can indicate fluid retention in heart failure or dehydration, making this the most effective intervention for monitoring fluid status in both conditions.
D. Measure the patients' blood pressures every 4 hours: Blood pressure monitoring can provide some insight into fluid status, but it is not as directly indicative of fluid volume as daily weights. BP changes may not be as sensitive to small fluctuations in fluid volume.
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