Which patient finding supports the nurse's decision to place a patient in the urgent triage category?
Blood pressure: 130/90 mm Hg
Respirations: 6 breaths/min
Body temperature 104°F (40°C)
Heart rate: 70 beats/min
The Correct Answer is B
A. A blood pressure of 130/90 mm Hg is slightly elevated but not immediately life-threatening and is not typically an urgent triage concern.
B. Respirations of 6 breaths/min indicate severe respiratory distress and inadequate ventilation, which is a critical finding that requires immediate attention. This finding justifies placing the patient in the urgent triage category.
C. Body temperature of 104°F (40°C) may indicate infection or other serious conditions, but it is not as immediately life-threatening as significantly impaired respiratory function.
D. Heart rate of 70 beats/min is normal and does not indicate an urgent need for care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encouraging denial of illness is incorrect as denial is not a healthy coping mechanism and may hinder treatment adherence.
B. Encouraging the patient to let staff have total control is incorrect because patient autonomy and involvement in care decisions enhance coping and emotional well-being.
C. Fostering trust in the interprofessional health care team is correct as it helps the patient feel supported and engaged in their care, reducing anxiety and promoting better coping strategies.
D. Telling the patient that everything will be all right is incorrect because it is a false reassurance that does not validate the patient's feelings or situation.
Correct Answer is ["A","B","C","E"]
Explanation
A. Ability to meet life's challenges is correct because psychosocial and spiritual interventions provide coping mechanisms and resilience.
B. Hope is correct as these interventions help instill optimism and a sense of purpose.
C. Will to survive is correct since emotional and spiritual support can enhance motivation and perseverance.
D. Fear is incorrect because these interventions are intended to reduce fear rather than cause it.
E. Energy is correct because improving mental well-being can contribute to increased vitality and motivation.
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