TRIAGE

Which of the following clients should be seen first? - bleeding abdominal stab wound - heart attack (STEMI) - COPD client with O2 saturation of 88% - a client with a foreign body in the throat

- A client with a foreign body in the throat This client has a compromised airway. When we follow the ABCs, airway trumps breathing and circulation. A foriegn body in the throat is the most emergent.

A nurse is triaging clients at a disaster scene. Which of the following clients would be given a red tag? - A client with a spinal cord injury and slow, irregular respirations - A client with a broken arm who can walk to the triage tent. - A client with a deep laceration of the head and requires stitches. - A client with a chest wound and respiratory rate of 38/minute.

- A client with a chest wound and respiratory rate of 38/minute. This is correct. Red tags are given to severe injuries with potential for survival with treatment, including RR greater than 30, inability to follow simple commands, and slow or absent capillary refill

A nurse is working in the emergency room when the hospital is notified of a nearby plane crash. Most of the victims will be transported to the hospital. The nurse is working as part of the triage team. Which clients would be the highest priority? Select all that apply. - A person who has been impaled in the abdomen by a piece of metal - person with breathing difficulties and an oxygen saturation of 89 percent - a woman with a 2nd degree burn on 5 percent of her arm - a man complaining of chest pain

- A person who has been impaled in the abdomen by a piece of metal Clients with major trauma, chest pain, and breathing difficulties all take priority over other injuries. - A person with breathing difficulties and an oxygen saturation of 89 percent The principles of triage require that the nurse understand which clients need to be treated first and which ones can wait. The nurse should know that those with life-threatening injuries that can still be treated take priority over those who are injured but that is not in life-threatening situations. Clients with major trauma, chest pain, and breathing difficulties all take priority over other injuries. - A man complaining of chest pain Clients with major trauma, chest pain, and breathing difficulties all take priority over other injuries.

A nurse is working in a pediatric emergency room and has 4 clients that need assessment. The nurse would be accurate in seeing which client first? - epiglottis - fever - dehydration - fussiness

- Epiglottitis Epiglottitis is the emergency because you are concerned for losing the airway (ABCs).

The nurse knows that common mechanisms of injury involved in penetrating trauma include all of the following except which of the following? - gunshot wounds - motor we hike collisions - stabbing - impalements

- Motor vehicle collisions This is a common mechanism of injury in blunt force trauma, not penetrating trauma

The triage nurse has one bed available in the ED. Which of the following clients waiting to be seen is the priority? - roller skating injury with obvious deformity of the left leg and normal vital signs - nausea/vomiting/diarrhea for 1 week with sinus tachycardia - fall on coumadin who is alert and oriented x4 - dizziness for past 3 hours and normal sinus rhythm on EKG

- Fall on coumadin who is alert and oriented x4 The major concern is a client with a fall on coumadin. The concern is for a hemorrhagic stroke or subdural hematoma. Even though the client is not experiencing any neurological deficits at this time, the sooner this client is assessed and tests are done, the better the outcome.

The nurse in the trauma bay is concerned that a client is suffering from a stomach injury related to a gun shot wound. Which of the following signs and symptoms is the nurse observing? - Pain in the epigastrium or upper left quadrant - Pain in the left shoulder - Right upper quadrant spasms and guarding - A palpable abdominal mass

- Pain in the epigastrium or upper left quadrant These are classic symptoms associated with stomach trauma.

Four clients arrive to the emergency room triage with the following conditions. Which client should be seen first? - pelvic pain that started after gymnastics practice - vaginal bleeding on and off for a month - leg abscess - burning upon urination

- Vaginal bleeding on and off for a month This client needs to be seen first, because there is a risk for hypovolemia due to hemorrhage. The hemoglobin needs to be checked. All other clients are stable.

A mass casualty event sent 50 clients to the emergency room for care. Which of the following client conditions is correctly matched with the appropriate triage priority level? Select all that apply. - Priority 1: An unresponsive penetrating head wound client - Priority 2: A client with 30% body 2nd and 3rd degree burns - Priority 1: A client with a sucking upper chest wound - Priority 3: A client with a simple closed radius arm fracture - Priority 3: A client with severe anxiety about the event

- Priority 1: A client with a sucking upper chest wound The principles of triage require that the nurse assess clients and categorize them according to who needs care right away, who can wait, and who will not receive care. Priority 1 care involves life threatening but survivable injuries, such as a sucking chest wound or a client with burns on 30 percent of the body. Priority 2 describes significant injuries that can wait, such as someone in severe pain, or with a compound fracture. Priority 3 involves minor injuries or mental health issues, and priority 4 describes extensive injuries with little to no chance of survival. - Priority 3: A client with a simple closed radius arm fracture Priority 3 involves minor injuries or mental health issues. - Priority 3: A client with severe anxiety about the event Priority 3 involves minor injuries or mental health issues.

A nurse is working in an emergency department to conduct triage for several clients who have arrived at once. Which of the following vital sign results seen in some adult clients would be considered abnormal? Select all that apply. - Respiratory rate 32/minute - Diastolic blood pressure of 80 mm Hg - Systolic blood pressure of 110 mm Hg - Heart rate of 112 bpm - Temperature 99.9F (37.7C) rectally

- Respiratory rate 32/minute Part of triaging clients is understanding the meaning of vital sign results and the range of limits of what is considered normal. Normal vital signs vary between age groups, with younger clients typically having higher respiratory and heart rates but lower blood pressure compared to adults. The nurse must understand both what is abnormal and how to respond. - Heart rate of 112 bpm Part of triaging clients is understanding the meaning of vital sign results and the range of limits of what is considered normal. Normal vital signs vary between age groups, with younger clients typically having higher respiratory and heart rates but lower blood pressure compared to adults. The nurse must understand both what is abnormal and how to respond.

The triage nurse is working in the emergency department. Which of the following clients would the nurse classify as priority 2, or urgent? Select all that apply. - facial weakness - chest pain - wrist fracture - fever of 103.2 - SBP 168/95

- Wrist fracture A fracture is considered an urgent, or priority 2 situation. These clients can wait 1-2 hours for care, because their situation is not immediately life-threatening. Trauma, strokes, and heart attacks are emergent, or priority 1, and will be seen before a priority 2 client. - Fever of 103.2 A fever is considered a priority 2, because it is not immediately life-threatening. - SBP 168/95 This level of hypertension is considered a priority 2, as it is an urgent need but not an emergent need.

A client presents to the emergency department after being struck in the head with a baseball bat. The client complains of headaches and pain in the deltoid region. The triage nurse knows to perform which of the following first? - determine if there was a loss of consciousness - apply ice to the area of injury - apply c-spine immobilization - obtain a full set of vital signs

- apply c-spine immobilization the mechanism of injury suggests possible c-spine involvement as well as the referred pain to the deltoid area