Difficulty: Medium
Average Score: 63%
Simulated
Passage / Scenario
The nurse in the emergency department (ED) is caring for a 62-year-old male client.Item 1 of 6
Triage Note
1700:
ÔÇó The client was brought to the ED after collapsing on a tennis court.
ÔÇó Vital signs: BP 94/57, T 105┬░ F (40.5┬░ C), P 115, RR 26, Pulse oximetry 95% on room air. ÔÇó The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Which of the following assessment findings from the triage note require immediate follow-up? Select all that apply.
Correct answer
A,B,C,F,G
Rationale
Blood pressure (94/57) indicates hypotension, temperature (105├é┬░F) suggests hyperthermia, pulse (115) and respirations (26) indicate tachycardia and tachypnea, neurological findings (lethargy, confusion) suggest altered mental status, and thready pulses indicate poor perfusion├óÔé¼ÔÇØall requiring immediate follow-up. Pulse oximetry (95%) and clear lung sounds are stable.