While performing triage in the ED, the nurse determines which patient should be seen first.
A patient with type 1 diabetes in ketoacidosis; BP 100/60 mm Hg, HR 100 beats/min, RR 32.
A patient with a respiratory infection with a cough productive of greenish sputum; BP 128/86 mm Hg, HR 88, RR 25.
A patient with a deformed leg indicating a fractured tibia; BP 110/60 mm Hg, HR 86, RR 18.
A patient with burns on the face and chest; BP 120/80 mm Hg, HR 92, RR 24.
The Correct Answer is A
Choice A rationale
This patient is in diabetic ketoacidosis (DKA), a life-threatening condition. The respiratory rate of 32 is consistent with Kussmaul respirations, a compensatory mechanism to blow off excess carbon dioxide and correct the metabolic acidosis. The low blood pressure and high heart rate indicate hypovolemia and a compensatory response to shock. This patient is at high risk for cardiovascular collapse and requires immediate intervention.
Choice B rationale
The patient with a respiratory infection and productive cough is stable. The vital signs are within a range that indicates a non-emergent state, and while a respiratory rate of 25 is elevated, it is not as critical as the patient in DKA. This patient is a priority but can wait for treatment after more critical patients are stabilized.
Choice C rationale
The patient with a fractured tibia has a severe injury, but the vital signs are stable. The respiratory rate of 18 and heart rate of 86 are within normal limits (RR: 12-20, HR: 60-100). This indicates that there is no immediate threat to life. While the patient is in pain and needs treatment, they are not a high priority for triage and can be seen after more unstable patients.
Choice D rationale
Burns to the face and chest can lead to airway compromise, but the vital signs are stable and do not indicate immediate distress. The patient's respiratory rate of 24 is elevated but not critical, and the blood pressure and heart rate are within a stable range. Airway patency is the primary concern, but without signs of impending collapse, this patient is not the highest priority compared to the DKA patient
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Removing the stinger by scraping it off with a knife blade is the recommended method. Unlike pulling with tweezers, which can squeeze the venom sac and inject more venom, a scraping motion minimizes this risk. The stinger of a honeybee is barbed and remains in the skin, attached to the venom sac. Removing it quickly and correctly is crucial to prevent further venom from being released into the body. This technique ensures that the venom sac is not compressed, thus reducing the total amount of venom injected.
Choice B rationale
Sucking the wound is not recommended for a bee sting. This action is ineffective in removing venom and can introduce bacteria from the mouth into the wound, increasing the risk of infection. The venom quickly disperses into the surrounding tissues, making it impossible to remove by suction. Furthermore, this practice has no proven scientific benefit and can lead to secondary complications. The focus should be on proper stinger removal and symptom management, not on unproven methods.
Choice C rationale
Applying a tourniquet is not indicated for a bee sting. A tourniquet can cause severe tissue damage and even necrosis by cutting off blood circulation to the affected limb. Bee sting reactions are typically localized unless the client is severely allergic, in which case a tourniquet would be dangerous and ineffective. The systemic spread of venom is not something that can be stopped by constricting blood flow. This method is dangerous and should only be used in specific, life-threatening arterial bleeding situations.
Choice D rationale
Applying a cold pack is an appropriate first aid measure for a bee sting. The cold temperature helps to constrict blood vessels, which reduces the absorption of venom into the surrounding tissues. This action can also help to numb the area, providing pain relief and reducing swelling. Applying a cold compress for 10-15 minutes can significantly alleviate the localized pain, redness, and swelling that commonly occur after a bee sting, making it a simple yet effective component of immediate care. *.
Correct Answer is D
Explanation
Choice A rationale
Clinical skills and expertise are fundamental to a nurse's professional competence and are essential for providing direct patient care. While they form the basis of a nurse's practice, they do not inherently encompass the broader political aspects of the profession, which involve navigating organizational and systemic dynamics beyond the bedside.
Choice B rationale
Collaboration and teamwork are crucial for effective patient care delivery within a healthcare team. While these skills are necessary for professional success, they are a component of interprofessional practice, not the core definition of politics in nursing, which involves understanding and influencing institutional power structures and policy.
Choice C rationale
Patient care and advocacy are core functions of the nursing profession. Advocacy is a political act, but patient care itself is the direct application of clinical knowledge. The broader concept of politics in nursing extends beyond individual patient advocacy to influencing policies that affect entire populations or the nursing profession as a whole.
Choice D rationale
Politics in nursing involves the strategic use of relationships and influence to impact decision-making at various levels, from the unit to the national stage. It encompasses advocating for policies, securing resources, and influencing power structures to improve patient outcomes, enhance professional practice, and shape healthcare systems. *.
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