Which patient situation will be classified in the emergent triage category?

A minor who is experiencing acute pain in the abdomen and labia after rape

A postmenopausal woman who has bruises on the genitalia

A sexually assaulted patient who has multiple facial fractures

A rape victim who has an active hemorrhage in the abdomen

Answer and Explanation

The Correct Answer is D

A. A minor with acute pain is incorrect because while urgent, it does not pose an immediate life-threatening risk and would likely fall into the urgent category.
B. A postmenopausal woman with bruising is incorrect because bruising alone does not indicate an immediate life-threatening condition and would be categorized as non-urgent.
C. A sexually assaulted patient with multiple facial fractures is incorrect because while serious, it is not immediately life-threatening and would likely be categorized as urgent.
D. A rape victim with active hemorrhage in the abdomen is correct because uncontrolled bleeding is life-threatening and requires immediate intervention, placing this patient in the emergent category.

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Correct Answer is A

Explanation

A. Deep breathing and holding can help relax the patient, reduce pain perception, and enhance the effects of opioid medications.
B. Ambulating may be appropriate but should be done carefully, as it could exacerbate pain or cause dizziness after opioid administration.
C. While distraction like watching TV can help manage pain, it is not as effective as active pain-relieving interventions like deep breathing.
D. Applying ice to the incision site can be helpful for pain management, but deep breathing is more directly beneficial for managing postoperative pain.

A. Adding insulin to the TPN B. Discontinuing the infusion C. Weaning from the TPN over a 6-hour period D. Starting an infusion of 0.9% normal saline

Correct Answer is A

Explanation

A. Insulin can be added to the TPN to control blood sugar levels. TPN often leads to hyperglycemia, and insulin is commonly added to the solution to regulate glucose levels.
B. Discontinuing the infusion would not address the hyperglycemia and would risk nutrient deficiencies.
C. Weaning from TPN may be indicated when discontinuing the nutrition support, but it is not a direct intervention for hyperglycemia.
D. Starting an infusion of 0.9% normal saline would not address the hyperglycemia directly and may not be effective in managing the glucose levels.

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Which patient situation will be classified in the emergent triage category?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client experienced abdominal surgery the previous day and has just received an opioid medication for report of pain. The client is sitting in a chair next to the bed. An additional activity that the nurse uses to relieve pain is:

Correct Answer is A

Explanation

A patient is admitted with severe malnutrition. A central venous catheter is placed in the right subclavian vein and total parenteral nutrition (TPN) is started. What medical interventions may be initiated with the onset of hyperglycemia?

Correct Answer is A

Explanation

Which combinations of drugs have been found to be effective in managing the pain associated with musculoskeletal and soft tissue inflammation?

A patient is admitted with severe malnutrition. A central venous catheter is placed in the right subclavian vein and total parenteral nutrition (TPN) is started. For which complication should the patient be evaluated immediately after insertion of the catheter?

You are explaining the importance of strict intake and output for patients with pulmonary alterations. What is the rationale for careful intake and output for patients with pulmonary alterations?

A patient on mechanical ventilation is receiving total parenteral nutrition (TPN). Which statement is true?

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

Which action is the priority for the forensic nurse examiner (RN-FNE) when caring for a patient who was abducted and gang-raped and is now in serious condition in the emergency department?

A patient is admitted with acute liver failure and encephalopathy. Which dietary restrictions should be maintained for the patient?