The triage nurse has four clients arrive in the emergency department at the same time. List the order in which the RN will assess these clients from first priority to last priority.

A 50-year-old female with moderate abdominal pain and occasional vomiting

A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity.

An ambulatory dazed 25-year-old male with a bandaged head wound.

4. An irritable 3-day old with a fever, petechiae, and nuchal rigidity.

1,2,3,4

2,1,3,4

4,3,1,2

3,4,2,1

Answer and Explanation

The Correct Answer is C

Rationale:

A. 1, 2, 3, 4 – This order fails to prioritize life-threatening conditions. A neonate with fever, petechiae, and nuchal rigidity is at high risk for meningitis or sepsis and must be assessed first.

B. 2, 1, 3, 4 – A twisted ankle with intact circulation and no deformity is a low-priority, non-emergent condition and should not be assessed early.

C. 4, 3, 1, 2 – The 3-day-old infant with fever, petechiae, and nuchal rigidity is the highest priority due to the risk of bacterial meningitis or sepsis, which are life-threatening emergencies, especially in neonates.
The 25-year-old male with a head injury and altered mental status (dazed) is next, as this suggests a potential concussion or intracranial injury, which can rapidly deteriorate.
The 50-year-old female with moderate abdominal pain and occasional vomiting is stable and does not show signs of shock or acute abdomen, making her a lower priority.
The 35-year-old jogger with a twisted ankle, intact pedal pulse, and no deformity has a minor musculoskeletal injury and is the lowest priority.

D. 3, 4, 2, 1 – Although head injury is serious, the neonate with fever and petechiae must be assessed first because of the immediate risk of sepsis and meningitis.

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Correct Answer is ["C","D"]

Explanation

Rationale:
A. A temperature of 99.9°F (37.7°C) does not meet the SIRS criterion, which requires a temperature greater than 100.4°F (38°C) or less than 96.8°F (36°C). Mild elevations below this threshold are insufficient to indicate systemic inflammation.

B. A heart rate of 85 beats/min is within the normal adult range. SIRS requires tachycardia >90 beats/min, so this finding does not meet the diagnostic criteria for SIRS.

C. A respiratory rate of 24 breaths/min meets the SIRS criterion of tachypnea >20 breaths/min. Tachypnea is an early physiological response to systemic inflammation, reflecting increased oxygen demand and compensatory mechanisms to maintain tissue perfusion.

D. A WBC count of 15,000 cells/mm³ indicates leukocytosis, which fulfills the SIRS criterion of WBC >12,000/mm³. Elevated WBC reflects activation of the immune system and systemic inflammation, a hallmark of SIRS.

A. To prevent the formation of infarcts of emboli B. To limit stroke volume and cardiac output C. To prevent pulmonary and peripheral edema D. To maintain adequate mean arterial pressure

Correct Answer is D

Explanation

Rationale:
A. Preventing infarcts or emboli is not the primary purpose of vasoactive medications. While some anticoagulants may reduce clot formation, vasoactive drugs are focused on hemodynamic support, not clot prevention.

B. Limiting stroke volume and cardiac output is counterproductive in shock. Shock occurs due to inadequate tissue perfusion, and decreasing cardiac output would worsen hypoperfusion and organ dysfunction.

C. Preventing pulmonary and peripheral edema is a secondary concern. While careful fluid management and some medications can reduce edema, vasoactive agents do not primarily target fluid accumulation.

D. The primary goal of vasoactive medications (such as dopamine, norepinephrine, or phenylephrine) is to maintain adequate mean arterial pressure (MAP) to ensure perfusion of vital organs. In shock, blood pressure may fall due to hypovolemia, vasodilation, or cardiac dysfunction. Vasoactive drugs constrict blood vessels and/or increase cardiac output, supporting MAP and improving tissue oxygen delivery. Maintaining an adequate MAP (usually ≥65 mm Hg) is crucial to prevent organ ischemia and progression to multi-organ failure.

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Naxlex Comprehensive Predictor Exams

Which of the following clinical manifestations are suggestive of the systemic inflammatory response syndrome (SIRS)? Select all that apply.

Correct Answer is ["C","D"]

Explanation

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment?

Correct Answer is D

Explanation

Administering Dopamine (Inotropin) at 2 mcg/kg/minute results in:

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