04.04 Triage
Question 6 of 10 There has been a bombing at the convention center downtown. The nurse is working in the emergency department and has been notified that approximately 58 clients are on the way to the hospital facility. Which clients will be given the highest priority? A. Clients with life-threatening yet survivable injuries B. Actively dying clients C. Clients requiring life support D. All children under 2
ANSWER ✅Clients with life-threatening yet survivable injuries During disaster triage, clients with the most life-threatening but survival injuries are given priority. Actively dying clients A client must have survivable injuries to be given highest priority. Clients requiring life support Life support is not necessarily a survivable condition. These clients would not be given priority over those with survivable, serious conditions. All children under 2 Age is less of a factor than the severity of the injury and the probability of survival from that injury.
Question 9 of 10 After receiving report on four clients the emergency room nurse should see the client with which of the following diagnosis first? A. Liver failure and now has petechiae B. Chronic back pain 8/10 C. Ovarian cyst D. Cellulitis that is now itchy
ANSWER ✅Liver failure and now has petechiae The client with liver failure runs the risk of not producing the proper factors for clotting and having petechiae may indicate that they are bleeding internally. This is a priority. Cellulitis that is now itchy Itching cellulitis is often a sign of healing, which is a good thing. Chronic back pain 8/10 Chronic back pain can be helped but won't completely fix. This client is used to living with back pain, which should not be ignored but can wait as the client at risk for internal bleeding is the priority. Ovarian cyst There isn't much we can do for this, an ovarian cyst will often rupture on its own or require surgical removal. There is nothing immediate we can do for this client. The priority is the client with petechiae and liver failure because of the internal bleeding risk.
Question 8 of 10 A client presents to the emergency department with complaints of chest pain. What is the priority for the nurse? A. Get an EKG B. Get vital signs C. Visually assess the client D. Ask the client if they have had a cough
ANSWER ✅Visually assess the client When a client presents to the emergency department with any complaint, the first thing the nurse does is visually assess the client. This is known as "getting eyes on the client". The client with chest pain may be pale, diaphoretic, and have altered consciousness, or the client with chest pain may be walking, have normal looking skin, and be able to carry on a conversation. How the client looks to the nurse begins the process of clinical judgement regarding which actions are appropriate to take next. Ask the client if they have had a cough This is not a priority for the client with chest pain. Get an EKG The nurse will call for an EKG, but vital signs will be completed before the EKG is done. Get vital signs Vital signs will be started on the client immediately after the nurse visually assesses the client.
Question 4 of 10 A nursing student is asking a nurse about prioritization of client needs. The nurse knows that which of the following client symptoms would need to be seen first? A. Altered mental status with fever B. Headache with photophobia C. 28 week pregnant woman with bilateral leg swelling D. Finger swelling over rings that can't be removed
ANSWER ✅Altered mental status with fever Anyone who is altered and febrile is at potential risk for infection or sepsis, which is very dangerous. This client needs to be seen to assess if the altered mental status is new and the fever must be treated. 28 week pregnant woman with bilateral leg swelling Swelling of the legs is expected in pregnancy. If it was unilateral we might be concerned of a blood clot, but this client has bilateral leg swelling which is a normal finding in pregnancy. Finger swelling over rings that can't be removed This is a concern for circulation, but this client is stable. A client with altered mental status and fever is not stable. The client with finger swelling is the second priority, as the ring will need to be cut off to improve circulation. Headache with photophobia This client is currently stable. The client with altered mental status and fever needs to be assessed first.
A client is brought into the trauma bay after being stabbed in the abdomen with a 12 inch knife. The blade is still present in the client. The client is complaining of severe abdominal pain and is restless. After completing the initial survey, which of the following is the next thing the nurse should do? A. Remove the knife B. Stabilize the knife C. Intubate the client D. Insert a chest tube
ANSWER ✅Stabilize the knife In the trauma bay, we do not remove impaled objects unless to leave them in place would cause further harm. Our priority at this point is to stabilize the object to prevent it from causing any further damage to the client. Insert a chest tube While it may be part of our treatment plan, it is not the priority. Remove the knife Without truly knowing all internal injuries, the removal of an impaled object can cause further damage. This should only be done in a controlled environment like the OR unless not removing it would cause further harm . Intubate the client While the client may be restless, you do not have enough information in this case to warrant intubation and a nurse does not perform intubation.
Question 3 of 10 Which of the following clients should be seen first? A. A client with a foreign body in the throat B. COPD client with O2 saturation of 88% C. Bleeding abdominal stab wound D. Heart attack (STEMI)
ANSWER ✅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. COPD client with O2 saturation of 88% 88% is not an emergent oxygen saturation. This client is stable enough to see last. Heart attack (STEMI) While this is a medical emergency, it is a circulation issue, and airway is prioritized before circulation. Bleeding abdominal stab wound While this is also a medical emergency, it is a circulation issue, which means the client with a foreign body in the throat takes priority over the bleeding stab wound.
Question 5 of 10 There are 4 pediatric clients sitting in the waiting room of the emergency department. A bed becomes available and the triage nurse knows to take back the client with which of the following first? A. A fever of 105 F B. Acute asthma exacerbation; O2 saturation of 100% on room air C. An open fracture; no hemorrhage noted D. Epistaxis
ANSWER ✅A fever of 105 F A fever of 105F is a priority over a currently stable asthma, but the asthma needs to be quickly seen next. The febrile child is at high risk of a seizure with a temp that high. The other clients are stable. Acute asthma exacerbation; O2 saturation of 100% on room air This asthma client is stable. They do need to be seen quickly because of their excellent oxygen saturation, so the fever needs to be taken care of first. If this client had a low oxygen level, they would be the first priority. An open fracture; no hemorrhage noted This client is also stable. The priority is to treat the fever to ensure that is lowered and there is no febrile seizure. Epistaxis This is a nose bleed. This is important to see and ensure blood loss in minimal and stopped, but the priority is to treat the high fever first.
Question 2 of 10 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? A.Epiglottitis B.Dehydration C.Fever D.Fussiness
ANSWER ✅Epiglottitis Epiglottitis is the emergency because you are concerned for losing the airway (ABCs). Fever The fever would be seen second for fear of febrile seizures. Dehydration This client would be seen after the epiglottitis and fever are stabilized. Fussiness Based on the information given, a child with fussiness would be seen last out of the 4 clients. There is nothing to indicate an emergent condition.
Question 7 of 10 There are four clients that the nurse is prioritizing in order of importance. Of the following clients, which client should the nurse see first? A.Failure to thrive and pressure ulcers B. Anxiety disorder and the feeling of an elephant on the chest C. Arm abscess who is fussy D. Right lower quadrant pain with sudden pain relief
ANSWER ✅Right lower quadrant pain with sudden pain relief Complaining of abdominal pain in the lower right quadrant is a sign of appendicitis and sudden pain relief is the sign of a ruptured appendix, which would be an emergency. This is the priority. Arm abscess who is fussy This client is stable. Because we know that the client is fussy, we know the client has an airway, so this is not the priority to be assessed first. Failure to thrive and pressure ulcers This client is stable. The priority is addressing the possible ruptured appendix. Anxiety disorder and the feeling of an elephant on the chest Anxiety disorder is often accompanied with a feeling of being unable to breathe. What makes this client's condition about anxiety rather than breathing is the anxiety disorder. Since the client has this disorder, the nurse will have a high index of suspicion that this client's feeling of an elephant is due to anxiety, not a heart attack or breathing problems.
Question 1 of 10 Four ambulances arrive to the emergency room. The nurses know to see which of the following clients first? A.Fall off bike with arm deformity, bluish fingers B.Traumatic leg amputation, bleeding through gauze C.Fish hook caught in the lower lip D.MVC with neck and back pain and limited ROM
ANSWER ✅Traumatic leg amputation, bleeding through gauze This client has lost a limb and is actively bleeding. The active bleed puts the client at risk for hemorrhagic shock, making this client the priority over the others. Fish hook caught in the lower lip This client is stable and not at risk for loss of life or limb, therefore is not the priority. MVC with neck and back pain and limited ROM It is important that this client is evaluated due to risk for spinal fractures, but stabilization of the neck can be delegated. The client with an actively bleeding amputation takes priority. Fall off bike with arm deformity, bluish fingers This client would need to be seen next AFTER the amputation due to the apparent circulation problems and possible loss of hand or fingers. Loss of LIFE is still higher priority than loss of LIMB, which is why the hemorrhage would take priority.
