The nurse is triaging a 65-year-old patient who arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. What category is appropriate?
Non-urgent
Urgent
Emergent
High urgent
The Correct Answer is C
A. Non-urgent patients have stable vital signs, mild symptoms, and conditions that do not pose an immediate threat to life or limb. This patient’s chest pain, diaphoresis, and dizziness indicate a potential acute cardiac event, which is life-threatening and cannot be categorized as non-urgent.
B. Urgent classification applies to patients with conditions that require timely care but are not immediately life-threatening, such as minor infections or moderate pain. The patient’s symptoms suggest myocardial ischemia, which is more serious.
C. Emergent patients have life-threatening conditions requiring immediate intervention to prevent death or severe complications. Diaphoresis, dizziness, and left-sided chest pain in a 65-year-old strongly indicate a possible myocardial infarction or acute coronary syndrome, making immediate triage and intervention essential.
D. High urgent is sometimes used for serious but not immediately life-threatening conditions requiring attention within 1–2 hours. While serious, this patient’s presentation requires immediate evaluation and treatment, placing them in the emergent category.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. An ankle fractureis painful and requires medical attention, but it is not immediately life-threatening. This client can be triaged after patients with more urgent cardiovascular or systemic emergencies.
B. Vomiting and flank pain from a history of kidney stonescan cause dehydration and severe discomfort, but it is not immediately life-threateningunless complications such as obstruction or infection occur.
C. Profound weakness and fever of 103° Findicate a possible infection that requires prompt evaluation, but the client is currently less acutely at risk for sudden deteriorationcompared with someone having possible acute coronary syndrome.
D. Sweating, jaw pain, and pain in the left armare classic signs of acute myocardial infarction (heart attack). This condition is life-threateningand requires immediate triage and intervention. Prompt recognition and rapid treatment can prevent cardiac tissue damage and reduce mortality.
Correct Answer is D
Explanation
A. The Rapid Shallow Breathing Index (RSBI) is calculated as the ratio of respiratory rate to tidal volume (in liters). An RSBI <105 is generally considered favorable for weaning. A value of 85 indicates the patient is breathing efficientlyand may be ready to wean.
B. Negative inspiratory force measures inspiratory muscle strength. Values more negative than -20 to -30 cm H2O are considered adequate. A NIF of -28 cm H2O indicates sufficient inspiratory strengthfor spontaneous breathing.
C. A tidal volume ≥5 mL/kg is generally acceptable for weaning. A value of 6 mL/kg indicates adequate ventilationduring spontaneous breathing trials.
D. A FiO2 >40% to maintain adequate oxygen saturation indicates ongoing oxygenation impairment, suggesting the client may not yet be ready for weaning. Successful weaning usually requires an FiO2 ≤40% and PEEP ≤5 cm H2O to maintain SpO2 ≥90–92%, ensuring the lungs can sustain oxygenation without excessive support.
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