Recall that notes made in a clients record must be objective Eliminate the

Recall that notes made in a clients record must be

This preview shows page 76 - 78 out of 100 pages.

Focus on the data in the question. Recall that notes made in a client’s record must be objective. Eliminate the options that are comparable or alike in that they indicate that an incorrect dose of medication was administered. Next note that the correct option clearly and accurately describes the incident in an objective manner. Review documentation of a medication error or other incident if you had difficulty with this question. References: Huber, D. (2010 ). Leadership and nursing care management (4th ed., pp. 557, 558). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 704, 705). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Ethical/Legal Awarded 0.0 points out of 1.0 possible points. 77.77.ID: 283672737 A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All victims are alert. Which of these clients does the nurse assign to the emergent category? Select all that apply. A victim with respiratory distress Correct A victim with a fractured humerus A victim with partial amputation of the foot Correct A victim with a forehead laceration that is not bleeding A victim with multiple nonbleeding bruises of the arms and legs Incorrect Rationale: One rating system commonly used in the ED consists of three tiers — emergent, urgent, and nonurgent — with the categories sometimes identified with color coding or numbers. The emergent classification (a.k.a. red or priority 1) is given to clients with life- threatening injuries (here, the clients with respiratory distress [airway] and partial amputation of the foot [bleeding/circulation]) who require immediate attention and continuous evaluation but have a high chance of survival once their conditions have been stabilized. The urgent (a.k.a. yellow or priority 2) classification is given to clients whose injuries and complications are not life threatening (here, the client with the fractured humerus), provided that they are treated within 1 to 2 hours; such clients require evaluation every 30 to 60 minutes thereafter. The nonurgent
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(a.k.a. green or priority 3) classification is given to clients with local injuries (here, the clients with the forehead laceration and bruises of the arms and legs) who do not have immediate complications and can wait several hours for medical treatment; these clients require evaluation every 1 to 2 hours thereafter. Test-Taking Strategy: Use the ABCs — airway, breathing, and circulation — which will easily direct you to the correct options. Respiratory distress involves the airway, and the victim with amputation is at risk for bleeding (i.e., circulation). Review the triage system and priorities of care if you had difficulty with this question.
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