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 ["0.2"]
Explanation
Step 1 is 2 mg ÷ (10 mg/mL) = 0.2 mL. The nurse should administer 0.2 mL per dose.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Always doing your best is a core tenet of effective leadership, as it promotes a standard of excellence and continuous improvement. This principle emphasizes the importance of giving maximum effort in all tasks, which fosters a culture of high performance and dedication within a team. By consistently striving for one's best, a leader sets a powerful example that inspires team members to also invest their full capabilities, thereby enhancing overall productivity and quality of work. This commitment to personal excellence is a foundation for professional growth and team success.
Choice B rationale
Be trustful of the intangible is not a recognized principle within "The Four Agreements.”. The agreements are grounded in tangible, actionable principles that can be directly applied to one's thoughts and actions, focusing on interpersonal communication and self-perception. The "Four Agreements" are practical guidelines for personal conduct, not abstract or spiritual concepts. This choice introduces a non-scientific or non-recognized element that does not align with the foundational philosophy of the specified framework, which is rooted in concrete behavioral changes.
Choice C rationale
Being impeccable with your word involves speaking with integrity, saying only what you mean, and avoiding using language against yourself or others. This principle is fundamental to fostering trust and clarity in communication. By upholding this standard, a leader ensures that their promises are reliable, their feedback is constructive, and their intentions are transparent. This consistency builds a strong foundation of respect and credibility within a team, minimizing misunderstandings and promoting a healthy, honest work environment.
Choice D rationale
Avoiding assumptions is crucial for effective leadership as it prevents misunderstandings and promotes clear communication. This principle encourages leaders to ask questions and seek clarification rather than jumping to conclusions about the motives or actions of others. By refraining from making assumptions, a leader can approach situations with an open mind, which allows for more objective problem-solving and fairer evaluations. This practice fosters a more trusting and collaborative team dynamic by ensuring all parties feel heard and understood.
Choice E rationale
Not taking anything personally is a key agreement because it helps leaders maintain emotional resilience and objectivity. This principle teaches that the actions and words of others are a reflection of their own reality, not a direct attack on you. By separating one's self-worth from external opinions or events, a leader can remain calm under pressure, provide unbiased feedback, and make sound decisions without being swayed by personal feelings. This detachment is essential for effective conflict resolution and stable leadership
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