Author Question: A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 ... (Read 117 times)

jhjkgdfhk · **on:** Jun 25, 2018

A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, I had a temperature of 103.9 F (39.9 C) at home. The nurse's first action should be to

a. assess the patient's current vital signs.
b. give acetaminophen (Tylenol) per agency protocol.
c. ask the patient to provide a clean-catch urine for urinalysis.
d. tell the patient that it will 1 to 2 hours before being seen by the doctor.

Question 2

When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate?

a. Do you feel safe in your home?
b. You should not return to your home.
c. Would you like to see a social worker?
d. I need to report my concerns to the police.

xiazhe · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation.

Answer to Question 2

ANS: A
The nurse's initial response should be to further assess the patient's situation. Telling the patient not to return home may be an option once further assessment is done. A social worker may be appropriate once further assessment is completed.