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. Excessive fluid losses may lead to dehydration, but this is not typically a primary concern for patients with pulmonary alterations unless there is significant vomiting, diarrhea, or blood loss.
B. Hemodilution is not a common concern in patients with pulmonary alterations. Hypernatremia typically occurs with fluid loss or inadequate fluid intake, but it is not a direct concern related to pulmonary issues.
C. Fluid volume excess can lead to right-sided heart failure in patients with pulmonary alterations. If fluid accumulates, it can worsen pulmonary symptoms and increase the workload on the heart, potentially leading to right-sided heart failure.
D. Fluid retention with tachypnea is not typically a direct cause of fluid retention. While tachypnea is associated with respiratory distress, fluid retention is more closely linked to heart failure or kidney dysfunction.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Blank 1
Prepare for defibrillation: The client is unresponsive and has ventricular tachycardia. This indicates a life-threatening arrhythmia. If a patient with VTach is pulseless, the treatment is defibrillation.
Blank 2
Vtach (Ventricular tachycardia): The ECG tracing shows a rapid, wide-complex tachycardia, which is the hallmark of ventricular tachycardia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.