Lacharity Chapter 20: Pass with Flying Colors: Verified Instructor Notes Included

Ans: 2, 1, 4, 3 An irritable infant with fever and petechiae should be further assessed for other signs of meningitis. The client with the head wound needs additional history taking and assessment for intracranial pressure. The client with moderate abdominal pain is in discomfort, but her condition is not unstable at this point. For the ankle injury, medical evaluation could be delayed up to 24 to 48 hours if necessary, but the client should receive the appropriate first aid. Focus: Prioritization When a primary survey of a trauma client is conducted, what is considered one of the priority actions? 1. Obtain a complete set of vital sign measurements. 2. Palpate and auscultate the abdomen. 3. Perform a brief neurologic assessment. 4. Check the pulse oximetry reading. Ans: 3 A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Measuring vital signs, assessing the abdomen, and checking pulse oximetry readings are considered part of the secondary survey. Focus: Prioritization A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness. What is the priority action? 1. Initiate continuous electrocardiographic monitoring. 2. Notify the ED physician. 3. Administer oxygen via nasal cannula. 4. Establish IV access. Ans: 3 The priority goal is to increase myocardial oxygenation. The other actions are also appropriate and should be performed immediately after administering oxygen. Focus: Prioritization A client is admitted through the ED for treatment of a strangulated intestinal obstruction with perforation. What in