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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Equianalgesic dosing compares other opioids to morphine to ensure that equivalent pain relief is achieved.
B. For patients unable to verbalize pain, behavioral indicators such as facial expressions or body movements are the best way to assess pain.
C. Meperidine is not stronger than morphine and has a higher risk of toxicity, especially when given at higher doses or frequent intervals.
D. The patient’s self-report is considered the most accurate and essential tool for assessing pain.
E. Transcutaneous electrical nerve stimulation and heat/cold therapy work by stimulating nonpain sensory fibers, which can help alleviate pain by overriding pain signals.
Correct Answer is A
Explanation
A. Respiratory acidosis is correct because the patient has a low pH (acidosis) and elevated PaCO₂, indicating hypoventilation as the primary cause.
B. Metabolic alkalosis is incorrect because bicarbonate is within the normal range, and there is no metabolic compensation.
C. Respiratory alkalosis is incorrect because alkalosis would present with a high pH and low PaCO₂, the opposite of this scenario.
D. Metabolic acidosis is incorrect because bicarbonate is normal, ruling out a metabolic cause.
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