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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Acute pain is typically not associated with nervous system damage and should not last indefinitely.
B. Acute pain typically does not persist for more than 6 months; it is expected to subside after the healing process is complete.
C. While acute pain can result from joint injuries, it generally does not last as long as 9 months.
D. Acute pain is temporary, typically resolving as the underlying injury or condition heals, and should not last more than 6 months.

A. Evaluating the patient's level of consciousness (LOC) using the Glasgow Coma Scale B. Informing the patient that the RN-FNE cannot act on a patient's behalf C. Monitoring vital signs, especially blood pressure and pulse D. Assessing the patient's airway

Correct Answer is D

Explanation

A. Evaluating the patient's level of consciousness using the Glasgow Coma Scale is important, but it is secondary to ensuring that the airway is open and that breathing is maintained.
B. Informing the patient that the RN-FNE cannot act on the patient's behalf is unnecessary at this point; the priority is immediate medical intervention.
C. Monitoring vital signs, such as blood pressure and pulse, is crucial but secondary to addressing immediate life-threatening conditions like airway compromise.
D. Assessing the patient's airway is the priority because airway compromise is the most critical issue in emergency care. The RN-FNE must stabilize the patient's airway first before proceeding with other assessments.

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Which patient finding supports the nurse's decision to place a patient in the urgent triage category?

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