Nokea
A triage nurse is assessing a patient who complains of 6/10 abdominal pain and states, 'I had a temperature of 40.3°C (104.5°F) last night.' Which of the following triage categories should the nurse assign?
- A. Emergent
- B. Urgent
- C. Nonurgent
- D. Expectant
Correct Answer: B
Rationale: A temperature of 40.3°C and 6/10 abdominal pain suggest a potentially serious condition requiring prompt evaluation (urgent), but not immediate life-threatening intervention (emergent). Nonurgent indicates minor issues, and expectant is for unsalvageable patients.
You may also like to solve these questions
The nurse is rewarming a patient who arrived in the emergency department (ED) with a temperature of 29°C (84.2°F) and no audible heart sounds. Which of the following temperatures should the nurse rewarm the patient to, prior to a pronouncement of death?
- A. 30°C (86.0°F)
- B. 32°C (89.6°F)
- C. 34°C (93.2°F)
- D. 36°C (96.8°F)
Correct Answer: B
Rationale: Patients with severe hypothermia must be rewarmed to at least 32°C (89.6°F) before pronouncing death, as hypothermia can mimic death by suppressing vital signs, and ventricular fibrillation is a common cause of apparent death.
An unresponsive older-adult patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 41.2°C (106.1°F), blood pressure (BP) 86/52, and pulse 102. Which of the following actions should the nurse implement initially?
- A. Administer an Aspirin suppository
- B. Start O2 at 6 L/minute with a nasal cannula
- C. Apply a cooling blanket to the patient
- D. Infuse Lactated Ringer's solution at 1000 mL/hour
Correct Answer: C
Rationale: Applying a cooling blanket is the priority to rapidly lower the core temperature in heat stroke, which is life-threatening at 41.2°C. Aspirin is ineffective, high-flow oxygen via non-rebreather is preferred, and rapid fluid infusion risks pulmonary edema in older adults.
The nurse is caring for a patient with hypotension and temperature elevation after doing yard work on a hot day and is being treated in the emergency department. After the nurse has completed discharge teaching, which of the following patient statements indicates that the teaching has been effective?
- A. I will take salt tablets when I work outdoors in the summer
- B. I should take acetaminophen if I start to feel too warm
- C. I should have sports drinks when exercising outside in hot weather
- D. I will get into a cool environment if I notice that I am feeling confused
Correct Answer: C
Rationale: Sports drinks replace fluids and electrolytes lost during heat exposure, preventing heat-related illnesses. Salt tablets risk gastric irritation, antipyretics like acetaminophen are ineffective for heat-induced hyperthermia, and confusion indicates severe heat stroke requiring immediate medical intervention.
The nurse is preparing to rewarm a patient with hypothermia. Which of the following actions should the nurse implement?
- A. Attach a cardiac monitor
- B. Insert a urinary catheter
- C. Assist with endotracheal intubation
- D. Prepare sympathomimetic drugs for emergency administration
Correct Answer: A
Rationale: Rewarming can cause dysrhythmias in hypothermic patients, so cardiac monitoring is essential to detect and treat these complications. Urinary catheterization and intubation are not routinely required, and sympathomimetics increase dysrhythmia risk.
A patient's family members are in the patient room when the patient has a cardiac arrest and emergency personnel start resuscitation measures. Which of the following actions should the nurse take first?
- A. Have the family wait outside the patient room with a designated staff member to provide emotional support
- B. Keep the family in the room and assign a member of the team to explain the care given and answer questions
- C. Ask the family members about whether they would prefer to remain in the patient room or wait outside the room
- D. Advise the family members that patients are comforted by having family members present during resuscitation efforts
Correct Answer: C
Rationale: Assessing family preferences first respects their emotional needs and informs subsequent actions. Some families benefit from staying, while others prefer to leave, and this decision guides whether to provide support in or out of the room.