A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?

Correct Answer: C

Rationale: The correct answer is C because a middle adult male who is diaphoretic and reports epigastric pain may be experiencing a heart attack or another serious cardiac issue, requiring immediate provider care. Diaphoresis and epigastric pain are classic symptoms of a heart problem, making it a priority to rule out life-threatening conditions. Explanation for why the other choices are incorrect: A: While the adolescent female with belligerence and slurred speech may need attention, her symptoms are not immediately life-threatening. B: The toddler with a laceration on the forehead needs prompt care but is not in immediate danger. D: The young adult with a sunburn, although painful, does not require immediate provider care compared to a potential cardiac emergency presented by choice C.

Correct Answer: B

Rationale: The correct answer is B (Weight and height) because BMI (Body Mass Index) is calculated using weight and height measurements. The formula for BMI is weight (in kilograms) divided by height squared (in meters). This calculation gives an indication of a person's overall body fat and helps assess the risk of health problems related to weight. Choice A (Height and bp) is incorrect because blood pressure (bp) is not used in calculating BMI. Choice C (Face and vital signs) is also incorrect as these factors are not relevant to determining BMI. Choice D is incomplete. In summary, weight and height are the key components needed to compute BMI accurately.

Correct Answer: A

Rationale: The presence of fluid in a bulla on the leg indicates a blister, commonly caused by friction or burns. The fluid acts as a protective cushion for the underlying skin. Pus, on the other hand, is a sign of infection and inflammation, not typically found in a bulla. Therefore, option A is correct as it aligns with the typical presentation and pathophysiology of a bulla. Options B, C, and D are incorrect as pus is not a characteristic feature of a bulla and the other choices are incomplete or irrelevant.

Correct Answer: B

Rationale: The correct answer is B, Prevention of bedsores. Maintaining skin integrity is crucial to prevent pressure ulcers (bedsores). Pressure ulcers develop when there is prolonged pressure on the skin, leading to tissue damage. Preventing bedsores involves frequent repositioning, using supportive surfaces, and keeping the skin clean and dry. Avoiding infection (choice A) is important but is just one aspect of maintaining skin integrity. Choice C and D are incomplete, making them incorrect options. In summary, preventing bedsores directly aligns with the primary goal of maintaining skin integrity by ensuring the skin remains healthy and intact.

Correct Answer: B

Rationale: The correct answer is B: Knock. Before entering a patient's room, it is crucial to knock to respect the patient's privacy and give them a chance to prepare for your entry. This action demonstrates courtesy, professionalism, and consideration for the patient's personal space. It also helps prevent any potential embarrassment or discomfort for the patient. Choice A (Greet) should come after knocking to establish communication. Choice C (Twist the knob) is incorrect as it is a physical action that should be done after knocking to open the door. Choice D is incomplete.