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 B

Explanation

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.

A. autonomy B. nonmaleficence C. justice D. fidelity

Correct Answer is B

Explanation

A. Autonomy refers to respecting the patient’s right to make their own decisions. While important, it is not the ethical principle that guides the nurse's decision to report the situation to Adult Protective Services.
B. Nonmaleficence refers to the duty to do no harm. Reporting the neglect of the client to Adult Protective Services is consistent with preventing further harm and ensuring the client’s safety.
C. Justice refers to fairness and equal treatment. While the nurse is working to protect the client, the situation involves more than just fairness, making nonmaleficence the more applicable principle.
D. Fidelity refers to loyalty and keeping promises, but it does not specifically guide the nurse’s action in this situation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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