TRIAGE – 35 items
1. A 35-year old woman has just been brought into the ED by the police after having been successfully assaulted. The patient is alert. Initial assessment reveals bruises and abrasions on her face, breasts, arms, and hands. She makes minimal eye contact with the nurse and speaks only when asked a question. What is the most appropriate action for the emergency nurse to take?A. Escort the patient to the bathroom for a shower and contact a social worker.
B. Notify the emergency physician that a vaginal examination must be done immediately.
C.
Accompany the victim in a private treatment area and explain the sexual assault examination process.D. Once the patient is in the treatment area, let her be alone to compose her
thoughts about the incident so that an accurate police report can be filed.
Rationale:C. Remaining with the patient throughout the sexual assault examination process permits a trust relationship to develop between the nurse and the patient. Minimizing the interactions with various staff members will reduce the patient’s anxiety about the process.
A. The patient should not shower or change her clothes until the sexual assault examination is completed. The shower could destroy potential valuable evidences.
B. Timeliness of the examination is unimportant. This is not the first action to be taken by the emergency nurse. Evidence collection may occur up to 72 hours after the assault.
D. The patient should be afforded a comforting, compassionate environment of care that is provided by the emergency nurse. The patient should not be left alone except by her own request.
2. A 40- year old male involved in a house fire presents, conscious, to the ED with dyspnea, sooty sputum and a brassy cough. He is receiving 100% oxygen via nonrebreather reservoir mask. The ED nurse should FIRST:A. Check for burn percentage
B. Prepare for intubation
C. Assess airway and breathingD. Start fluid resuscitation
Rationale:C. Assessing airway and breathing is the priority. Dyspnea, sooty sputum and brassy cough are signs of an inhalation injury. A patient with inhalation injury is at risk for edema and obstruction of the airway.
A. Checking for burn percentage is important, especially for calculating fluid resuscitation formula, but the highest priority are airway patency and ventilatory status.
C. Intubation equipment should be readily available, but assessing airway and breathing is always the initial response.
D. Fluid resuscitation maybe important part of the patient’s management, but the first response is always to assess the airway and breathing.
3. Which of these children is at highest risk for foreign body aspiration?A. A 7-year-old with gastroenteritis
B. A 4-year-old with rhinitis
C. A 2-year-old with a history of chicken pox (varicella) exposure
D. A 6-year-old with a history of cerebral palsyRationale:D. A 6-year-old with cerebral palsy is at greater than normal risk for aspiration because the medical condition causes a decrease in or loss of protective reflexes.
A. A 7-year-old male with a history of gastroenteritis is older than the age group in which aspiration of a foreign body is common.
B. Rhinitis is an inflammation of the nasal mucosa. It does not involve loss of the protective reflexes and is not associated with foreign body aspiration.
C. Exposure to chickenpox, which causes a rash that ends with lesions that are crusted over, would cause no loss of protective reflexes and not associated with foreign body aspiration.
A 24-year old sanitation worker presents to the ED holding 3 amputated fingers in a soiled cloth. The patient is awake, alert, and oriented, but appears to be anxious and upset. Upon examination of the affected hand, you note that the first, second, and third finger are missing. The hand is swollen, ecchymotic, and bleeding profusely from the stumps.
4.
The nurse should FIRST:A. Apply direct pressure to the stump to control bleeding
B. Administer an oral antibiotic.
C. Reapproximate the amputated digits and hold them in place with a pressure dressing.
D. Place the amputated digits in a sterile water.
Rationale:A. Direct pressure should be applied to control bleeding without causing further tissue damage. A pressure dressing may be used.
B. Antibiotics will be included in the plan of care, but more likely intravenous antibiotics than the oral kind. The patient should receive nothing by mouth and be prepared for reimplantation surgery.
C. Amputated body parts should be wrapped in sterile gauze, moistened with saline, and placed in a plastic bag, which should be placed in an airtight container on ice. Attempting to reapproximate the stumps could cause additional injury.
D. The amputated digits should not be immersed directly in any solution.
5. The full emergency operations cycle includes:A. Planning, education, drills, and evaluation.
B. Scene management, hospital management, and city management.
C. Meetings, assembling reference notebooks, and construction of facilities.
D. Training exercises and critiquing.
Rationale:A. Planning, education, drills, and evaluation make up the emergency operations preparation cycle, starting at any point and completing the full cycle.
B. Scene management, hospital management, and city management are components of communitywide emergency operations planning.
C. Meetings, assembling, reference notebooks, and constructions of facilities are some of the tasks that may be required for emergency operations planning.
D. Training exercises and critiquing are components of the education portion of the emergency operations preparation cycle.
6. A passenger train has derailed. First responders indicate that at least 56 people have been injured. A nurse has gone in the ambulance to assist with care at the scene. Which of the following patients is the highest priority for treatment and transport (“red category”)?A. A 75-year-old with a femur, tibia, and fibula fractures; pale, moist skin and pelvic tenderness and mobility on palpation.
B. A 45-year-old with metal rod impaled in the right forearm. The arm is neurovascularly intact. The patient is ambulatory.
C. A 63-year-old with second degree and third degree burns over 95% of the body surface areas. The patient is unconscious and has a thready pulse.
D. A 25-year-old with pain in the left lateral lower chest and a 5-inch laceration in the left forearm. The wound spurts blood when uncovered. The patient is controlling the bleeding by applying pressure with a bandana. Skin is pink and dry.
Rationale:A. An unstable pelvic fracture with signs of shock warrants immediate intervention to decrease the chances of death. The patient is the first priority.
B. A stable patient with an arm injury and neurovascular intactness is not first priority. The patient is currently minor (“green category”), but should be monitored for deterioration to delayed (“yellow”) or (“red”) categories.
C. An unconscious burn patient with burn more that 80%-90% of the body and a thready pulse is considered terminal (“black” category). This patient is the lowest priority.
D. A stable patient with a controlled arterial bleed and left lateral lower chest pain is currently delayed (“yellow” category). Part of the concern is the potential injuries in the left lower chest and left upper abdomen.
7. A 17-year-old female presents to the ED with a chief complaint of left-sided pelvic pain. The patient states that the pain started 3 hours ago and has become constant, sharp and very severe. Her last menstrual period was approximately 6 weeks ago. But she has been spotting for several days. The patient states that she is sexually active. Initial vital signs are BP 120/70 mmHg, pulse 128/min, respiration 22/min, and temperature 100 degrees F( 37.8 degrees C). You suspect ectopic pregnancy. . What is the appropriate triage category for this patient?A. Urgent
B. Emergent
C. Nonurgent
D. Referral to fast track
Rationale:B. A suspected ectopic pregnancy in a patient with severe pain and tachycardia is an emergent situation. Spontaneous tubal rupture may occur, with resultant intraperitoneal hemorrhage and shock. Ectopic pregnancy is the leading cause of maternal death in the first trimester of pregnancy and the second cause of maternal mortality overall.
A. “Urgent” is not an appropriate triage category for this patient. A delay in the diagnosis and definitive care would increase the risk of morbidity and mortality.
C.”Nonurgent” is not an appropriate triage category for this patient. A delay in the diagnosis and definitive care would increase the risk of morbidity and mortality.
D. The patient should not be referred to the fast track. A delay in the diagnosis and definitive care would increase the risk of morbidity and mortality.
PEDIA 8. You are giving discharge instructions the parents of a newborn. The parents brought the baby to your ED “to be checked out” because the family was involved in a motor vehicle crash. The baby who was secured in an infant seat that his mother was holding appears to be uninjured. Mom was the uninjured front seat passenger. You tell the parents that babies should be:A. Placed in a rear-facing seat until they weigh 10lbs. (13.6 kg)
B. Placed in a forward- facing seat in the rear seat of the car until they weigh 30lbs (13.6 kg)
C. Placed in the rear-facing seat in the rear seat of the car until they weigh 20lbs (9.0kg).
D. In the rear-facing seat unless they are in the back seat.
Rationale:C. From birth to at least 20lbsand at least 1 year of age, children riding in cars should be faced in the rear facing –seats.
A. Incorrect
B. Incorrect
D. Incorrect
PSYCHE 9. What is the first step in crisis intervention?A. Assist the person in gaining an intellectual understanding of the problem.
B. Explore coping mechanisms
C. Include support systems to review the client.
D. Assess the precipitating events and its impact on the person.
Rationale:D. Assessing the actual event, the patient’s perception of the event, and the impact on the patient’s ability to solve problems is the first step in crisis intervention.
A. Assisting the patient in gaining an understanding of the problem is the second step in crisis intervention.
B. Exploring available coping mechanisms is the third step in crisis intervention.
C. Including support system is the fourth step in crisis intervention.
10. Depressed patient’s with suicidal ideation who are being evaluated are at greater risk for committing suicide:A. During the winter months
B. Before starting antidepressants
C. After the depression lifts
D. When they are agitated and unfocused
Rationale:C. After the depression lifts, the patient with suicidal ideation often is able to carry out the plans made while depressed but that s/he was unable to carry out.
A. The suicide rate increases during the spring as the amount of daylight increases.
B. After taking antidepressants for a few weeks, a depressed patient may have the energy to commit suicide that s/he did not have before starting the treatment.
D. A depressed patient who has made the decision to commit suicide may appear serene and goal directed.
11. A 54-year-old patient is transferred to the ED from the accident scene after his right arm and forearm were crushed in a cardboard bailing machine. There is severe tissue damage with unknown bony involvement to the right arm and forearm. The patient fainted briefly after the accident but is currently awake, alert and oriented. Vital signs are BP 156/98 mmHg, HR 112/min, and respirations 24/min. the patient is moaning in extreme pain. EMS personnel established an IV of Ringer’s lactate and administered IV Meperidine ( Demerol).
11. Upon the patient’s arrival in the ED, the ED nurse should FIRST:A. Establish second large- bore IV
B. Prepare the patient for immediate surgery
C. Perform primary and secondary surveys
D. Administer more pain medications
Rationale:C. The first duty of the primary nurse is to make primary and secondary surveys on the patient. This is done to establish a baseline and comparative assessment with the EMS findings and determine if there are any other life-threatening injuries present.
A. All patients with significant injury need a second large-bore IV; however initiating it should not be the nurse first action.
B. Eventually this patient needs surgery, but it is not the priority. The neurovascular assessment and the physicians plan will determine when the patient will have surgery.
D. Pain medication is important but can be administered only with a physicians order and after an initial assessment has been done.
12. A victim of an assault with a bat presents to the ED with blunt trauma to the head and neck. The primary intervention to the patient would be to do:A. Start an IV, draw trauma bloods, and infuse normal saline
B. Position airway, place on oxygen, and prepare for possible intubation.
C. Assess mental status, place on cardiac monitor, and check vital signs.
D. Place on cervical collar, administer pain meds and supplemental oxygen.
Rationale:A. Starting an IV, drawing trauma bloods, and infusing normal saline should be all done to evaluate the patient’s circulation, but the priority is to establish airway, followed by an assessment of the breathing status
B. In treating trauma, remember the ABC’s. In this case, airway needs are the priority because there is high risk for obstruction or aspiration. Therefore, the patient should be positioned to ensure a patent airway, place on high flow oxygen, and prepared for possible emergency intubation.
C. Assessing mental status, placing the patient in cardiac monitor and checking vital signs are important assessments and interventions, but the airway should be maintained first, followed by assessing the patients breathing and circulatory status.
D. Placing the patient in a cervical collar is priority because cervical spine immobilization is part of airway maintenance. Once the airway is maintained, the patient’s breathing is assessed and supplemental oxygen is administered. Administration of pain medication is not the initial priority but needs to be addressed after the patient’s primary needs have been met and condition stabilized.
A 17 year-old high school student was brought to the ED by her parents, who state that she has been crying incessantly and has been withdrawn and unable to sleep since breaking up with her boyfriend 3 weeks ago. Parents express concern to the triage nurse by stating that they feel their daughter will harm herself if she is not admitted to the hospital for observation. Triage assessment reveals a tearful young female who is wringing her hands constantly. There is no evidence of physical injury and the patient denies ingestion of harmful substances or medications. Vital signs are BP 90/60mmHg, HR 126/min, and RR 22/min. During her stay in the ED, this patient becomes agitated and hostile towards her parents and the staff?
13. Which of the following would be the most appropriate action for the ED to take?A. Call a security and have the patient restrained immediately.
B. Notify the consulting psychiatrist to obtain an order for a sedative.
C. Ensure the safety of the patient by minimizing environmental stimuli and politely request that the parents wait outside in a nearby location.
D. Speak quietly to the patient in calm, compassionate manner for the purpose of defining the source of her agitation.
Rationale:D. If triggers for increased agitation are identified, the emergency nurse should be able to manipulate the patient’s environment of care to minimize their incidence.
A. Intervention that is less likely to limit the patient’s freedom should be tried prior to any restrictive devices.
B. Although this patient would be referred to a mental health consultation, obtaining an order for chemical sedation is inappropriate this time.
C. Assurance of patient and family safety is paramount to all care interactions. However, this patient is calling attention for human interaction and assistance.
14. A passenger train has derailed. First responders indicate that at least 56 people have been injured. A nurse has gone in the ambulance to assist with care at the scene. Which of the following patients is the LOWEST priority for treatment and transport (“black category”)?A. A 75-year-old with a femur, tibia, and fibula fractures; pale, moist skin and pelvic tenderness and mobility on palpation.
B. A 45-year-old with metal rod impaled in the right forearm. The arm is neurovascularly intact. The patient is ambulatory.
C. A 63-year-old with second degree and third degree burns over 95% of the body surface areas. The patient is unconscious and has a thready pulse.
D. A 25-year-old with pain in the left lateral lower chest and a 5-inch laceration in the left forearm. The wound spurts blood when uncovered. The patient is controlling the bleeding by applying pressure with a bandana. Skin is pink and dry.
Rationale:C. An unconscious burn patient with burn more that 80%-90% of the body and a thready pulse is considered terminal (“black” category). This patient is the lowest priority.
A. An unstable pelvic fracture with signs of shock warrants immediate intervention to decrease the chances of death. The patient is the first priority.
B. A 45-year-old with metal rod impaled in the right forearm. The arm is neurovascularly intact. The patient is ambulatory.
is currently delayed (“yellow” category). Part of the concern is the potential injuries in the left lower chest and left upper abdomen.
D. A stable patient with a controlled arterial bleed and left lateral lower chest pain is currently delayed (“yellow” category). Part of the concern is the potential injuries in the left lower chest and left upper abdomen.
15. Your ED received four patients from a motor vehicle crash. Which patient needs to be stabilized and transferred to a Level I facility first?A. A 16-year old female; driver; no seat belt. Injuries to right arm and leg, with abdominal trauma. Vital signs stable.
B. An 18-year old female; front seta passenger. Multiple facial lacerations and fractures, positive loss of consciousness. Decreasing oxygen saturation and positive chest trauma.
C. A 17-year old female; rear seat passenger, no seat belt. She is 22 weeks pregnant, with abdominal trauma, low BP, tachycardia and respiratory distress.
D. A 15-year old female; rear seat passenger with seat belt. Injuries to right leg and chest. Vital signs stable.
Rationale:C. The 17-year old female who is pregnant is at high risk for uterine rupture, which would endanger not only her life but the fetus as well.
A. This patient will need close monitoring and further evaluation.
B. This patient would need intubation and probable transfer to Level 1 facility.
D. This patient can be evaluated, monitored, and treated at the local ED.
A. A stye is a nonurgent problem.
A. A stye is a nonurgent problem.
A. A stye is a nonurgent problem.
16. Which of the following patients represents the highest triage acuity level?A. 12 year old reporting a “stye on the left eye”
B. A 34 year old with “pepper spray to both eyes”.
C. A 22-year-old who is “unable to remove my contact lens”
D. A 4-year –old with “itchy, sticky eyes”
Rationale:A. A stye is a nonurgent problem.
B. Pepper burn is a chemical burn. Chemical burns are the most urgent of all ocular emergencies.
C. Contact lens removal is not a priority over a patient with a chemical burn.
D. Itchy, sticky eyes consistent with conjunctivitis are nonurgent conditions.
17. You are a camp nurse providing emergency care to a group on an outing. Which of the following campers you suspect to have the highest likelihood of experiencing frostbite?A. An 18-year-old female who jogs frequently.
B. A 25-year-old black male who smokes less than 1 pack per day.
C. A 45-year-old female who has the history of recent cataract surgery.
D. A 16-yaer-old male with asthma and a cold.
Rationale:B. Factors affecting the severity of frostbite include skin color. Dark-skinned people are most prone to frostbite injury, poor peripheral vascular status, anxiety and exhaustion.
A. This patient does not have any of the proven factors that increase the risk of frostbite.
C. Recent cataract surgery would not make this individual more prone to frostbite.
D. Asthma and cold would not increase the individual’s risk for frostbite.
Tricky Triage 18. A patient is in a withdrawn catatonic state and exhibits waxy flexibility. During the initial phase of hospitalization for this client, the nurse’s first priority is to:1. Watch for edema and cyanosis of the extremity
2. Encourage patient to discus events that led to the catatonic state
3. Provide a warm, nurturing relationship, with therapeutic use of touch
4. Identify the predisposing factors of the illness
Rationale:1. Circulation may be severely impaired in a patient with waxy flexibility who tends to remain motionless for hours unless moved.
Triage 19. The nurse can anticipate that the person most likely to be at risk for depression is:1. An elderly person with previous history of depressive episodes
2. A middle-aged man who is a moderate alcohol drinker
3. A housewife with 3 school-age children
4. A nursing student at exam time
Rationale:1. Is correct because depressive episodes are often recurrent . answers 2, 3 and 4may or may not experience depression. Answers 2 and 4 are likely to experience anxiety
Triage 20. In admitting a patient with Alzheimer’s disease to the unit, which placement variable would have the highest priority?1. Place the patient with a roommate
2. Place the patient without a roommate
3. Place the patient close to the nurse’s station
4. Place the patient at a distance to the nurse’s station
Rationale:3. Nursing observation is easier if the patient is near to the nurses station. Therefore, answer 4 is incorrect. A roommate may or may not be all right, but facilitating nursing observations is the highest priority for a patient with memory problems and confusion who is a safety risk for wandering off the unit.
Triage 21. A hospitalized patient with Alzheimer’s disease is often found wandering in the streets. What measure(s) should be taken in the unit to prevent the patient from wandering off?1. Place the patient in a day time restraints
2. Place the patient in a night time restraints
3. Provide a security guard at the door
4. Use electronic surveillance devices
Rationale:4. This answer is concerned with accident prevention and is a means of observation of the patient. Answers 1 and 2 are incorrect because the use of restraints is inappropriate and not justified. Having a security guard is not realistic.
Triage 22. Which nursing assessment would identify the earliest indication of increasing intracranial pressure?1. Temperature over 1020F
2. Change in level of consciousness
3. Widening pulse pressure
4. Unequal pupils
Rationale:2. As cerebral hypoxia develops, the patient becomes restless and drowsy well before any of the characteristic signs and symptoms of increasing intracranial pressure is present. Answers 1, 3, and 4 are all consistent with increase ICP but occur much later, after there has been significant cerebral herniation and distortion of the brain.
Triage: 23. Which client would be the highest risk for injury?1. A 3-month-old in an infant seat sitting on a coffee table.
2. A 2-month-old playing in the living room unattended by an adult.
3. A 21/2 yea-old with a tracheostomy playing outside in the backyard
4. A 7-year-old who goes to after school care in a 38-year-old home
Rationale:3.This age of child puts everything in their mouth, so they could put an object in the tracheostomy
Triage 24. Before administering oxygen therapy, the nurse would:1. Review the patient’s history for indications of COPD
2. Observe patient’s respiratory pattern
3. Draw arterial blood gases
4. Auscultate bilateral breath sounds
Rationale:1. The risk to the patient with COPD if the O2 flow rate is too high. The patient with COPD has a hypoxic respiratory drive. If the liter flow is above 2 L, there is a risk for respiratory depression. Answers 2,3, and 4 are important nursing actions to determine the effectiveness of oxygen therapy.
MS Skin/Triage 25. Which action is the highest priority for a teenager admitted with burns to 50% of the body?1. Counseling regarding problems of body image
2. Maintaining respiratory isolation
3. Maintain aseptic technique during procedures
4. Encourage peers to visit on a regular basis.
Rationale:3.Safety is the priority for the client who is at risk for infection. Option 1, may be necessary at some point, but safety issues come first. Option 2, is incorrect because the appropriate isolation technique should be protective-not respiratory-isolation. Option 4, is important for an adolescent but is not a priority over safety.
26. The priority nursing intervention to a suicidal patient in the ED include:A. placing the patient in a private area
B. Talking to the patient about any suicidal plans
C. Implementing a “no suicide” safety contract
D. Praising the patients positive attributes
Rationale:B. Talking about the patients suicide plans-including the means, location, and time-is a necessary part of a lethality assessment. Such a discussion does not introduce the idea to commit suicide.
A. A form of supervision, either one-one or uninterrupted observation, is necessary for a suicidal patient in the ED until a physician’s order has removed the need for such observation.
C. A no-suicide or safety contract is an appropriate intervention for a psychiatric patients or outpatients. In the Ed, however, a more appropriate action would be to determine the patient’s suicide plans and to place the patient on one-one or constant visual supervision.
D. Artificial praises is usually recognized as such by the patient and often lowers the patients already low self-esteem.
A 17-year-old female presents to the ED with a chief complaint of left-sided pelvic pain. The patient states that the pain started 3 hours ago and has become constant, sharp and very severe. Her last menstrual period was approximately 6 weeks ago. But she has been spotting for several days. The patient states that she is sexually active. Initial vital signs are BP 120/70 mmHg, pulse 128/min, respiration 22/min, and temperature 100 degrees F( 37.8 degrees C). You suspect ectopic pregnancy.
27. What is the appropriate triage category for this patient?A. Urgent
B. Emergent
C. Nonurgent
D. Referral to fast track
Rationale:B. A suspected ectopic pregnancy in a patient with severe pain and tachycardia is an emergent situation. Spontaneous tubal rupture may occur, with resultant intraperitoneal hemorrhage and shock. Ectopic pregnancy is the leading cause of maternal death in the first trimester of pregnancy and the second cause of maternal mortality overall.
A. “Urgent” is not an appropriate triage category for this patient. A delay in the diagnosis and definitive care would increase the risk of morbidity and mortality.
C.”Nonurgent” is not an appropriate triage category for this patient. A delay in the diagnosis and definitive care would increase the risk of morbidity and mortality.
D. The patient should not be referred to the fast track. A delay in the diagnosis and definitive care would increase the risk of morbidity and mortality.
28. Parents bring their 5-day-old infant to the ED for “poor feeding”. Mom reports the baby was feeding well until yesterday evening. Your triage exam reveals a term infant who is pale, slightly mottled, and listless, with poor muscle tone. Vital signs are HR 160 beat/min, respirations 44 breaths/min, with mild retractions, and temperature 100.8 degrees F (38.2 degrees C). Capillary refill time is 3 seconds centrally and 4 seconds peripherally. Based on your assessment you would do next:A. Send the family to the registration desk
B. Triage the infant as emergent and send the infant directly to the treatment area.
C. Placed mother and baby behind the curtain at triage so you can see if the infant will breastfeed.
D. Triage the infant as urgent and send the family to the waiting room.
Rationale:B. A sick/symptomatic neonate is classified as “emergent” and is sent immediately to the treatment room.
A. A sick/symptomatic neonate is classified as “emergent” and is sent immediately to the treatment room.
C. Incorrect answer
D. Incorrect answer
29. The patient in the hospital becomes confused and disoriented. She pulls leaves form a lily-of-the-valley plant and eats several of them. The floor nurse brings the patient to the ED for treatment. As the triage nurse, you would choose which of the following category:A. Emergent
B. Urgent
C. Nonurgent
D. Refer back to medical floor
Rationale:A. Because lily-of-the-valley ingestion may cause decrease cardiac excitability and hyperkalemia, this patient should receive immediate treatment. Extreme bradycardia may be noted.
B. As noted, the patient should be triage as emergent.
C. Same as above.
D. Same as above.
30. Six patients report for treatment in 5 minutes. The triage nurse calls for additional help at triage because:A. The primary assessment of the patients should occur within the first 2 to 5 minutes of arrival at the ED.
B. Comprehensive triage takes 10 to 15 minutes per patient.
C. All of the patient care areas in the triage are full.
D. Patients satisfaction will be diminished if patient waits too long at triage.
Rationale:A. The primary assessment of the patient should occur within 2 to 5 minutes of his or her arrival at the ED to determine whether the condition is life threatening.
B. Although this statement is true, primary assessment takes precedence.
C. Not a triage priority.
D. Although this statement is true, patient’s satisfaction is not a priority.
31.An off-duty ED nurse stops at a motor vehicle crash (MVC). The nurse’s first priority in rendering aid is:A. Stabilization of the patient’s cervical, spine with simultaneous airway control
B. Breathing assessment and assistance
C. Circulatory assessment and assistance
D. His/her own safety
Rationale:D. Securing the scene is the first priority in all prehospital situations. After the caregiver has determined that the scene is safe, patient care may begin.
A. Cervical spine stabilization and airway control are important, but occur after the scene has been secured.
B. Breathing follows scene security, cervical spine stabilization, and airway control.
C. Circulation follows scene security, cervical spine stabilization, airway control, and breathing assessment and intervention.
Triage CD/ Pedia: (1 item)
32. A 6-year-old boy is brought to the triage desk by his aunt. He has had fever and coughs for 3 days and now has a red rash. The aunt does not know other details of the child’s health history. Your first action as triage nurse should be to:A. Contact the child’s parents for permission to treat
B. Institute isolation precaution with the child immediately
C. Obtain vital signs and examine the rash
D. Ask the aunt to wait her turn, since several other patients are waiting.
Rationale:B. Measles (Rubeola) should be considered when there is a history of fever and cough followed by the appearance of red rash. There are many causes of fever and rash in children; however, given the lack of immunization history and the extremely contagious nature of rubeola, safe practice necessitates immediate isolation precautions to prevent potential spreads
Triage: MS/ENDO (1 item)
33. Which nursing diagnosis describes the most life-threatening problem in a patient with hyperglycemic, hyperosmolar, nonketotic coma (HHNC)?A. Fluid volume deficit
B. Fluid volume Excess
C. Impaired gas exchange
D.Altered cerebral tissue perfusion
Rationale:A. Patients with HHNC have blood glucose level greater than 800mg/dl, causing osmotic diuresis and profound dehydration. Patients with this illness are often elderly and already have decreased cardiac and renal function.
B. HHNC patients are fluid volume depleted, not overloaded. However they need to be closely monitored for fluid volume excess during the treatment.
C. This illness is primarily a vascular volume problem. Unless the patient has underlying pulmonary disease or anemia, gas exchange will probably be adequate. Patients are at risk, however, for ineffective airway clearance.
D. Altered cerebral tissue perfusion is a problem, but not immediately life-threatening unless the airway is obstructed. Once volume replacement has occurred, the patients level of consciousness should normalize. During treatment, patients may develop cerebral edema because the blood brain barrier does not allow rapid exchange of fluids, solutes and medications.
Triage; MS/Cardio (1 item)
34. A 55-year-old female enters the ED complaining of severe chest pain that lasted for 5 hours. She starts to complain of respiratory distress and is cool, pale and diaphoretic. Her respiratory rate is 22/min, and respirations appear to be slightly labored. Which of the following takes priority in your care for this patient?A. Administration of 100% oxygen via non-rebreather mask and reassessing respiratory status.
B. Obtaining 12-lead electrocardiogram
C. Establishing an IV of 0.9% normal saline solution and administering a 500-ml fluid bolus.
D. Performing endotracheal intubation
Rationale:A. Administration of 100%oxygen via non-rebreather mask can increase oxygen delivery to the cells and reduce the workload of the heart. Reassessment is important to determine the adequacy of the treatment.
B. Obtaining 12-lead electrocardiogram, although a priority, does not take priority over increasing oxygen delivery.
C. Establishing an IV of 0.9% normal saline solution is important so that medications can be delivered, but because the patient is currently in respiratory distress, clearing the airway takes precedence over establishing an IV.
D. Performing endotracheal intubation would be overly aggressive in treating this patient’s respiratory problem.
Triage/ SKIN (1 item)
35. Which of the following dressings should be applied to the patient with burns over 40% of the body surface area (BSA) before transfer to a regional burn center?A. Silver sulfadiazine (Silvadene) dressings
B. Mafenide ( Sulfamylon) dressings
C. Sterile, saline soaked dressings
D. Dry, sterile dressings
Rationale:D. Major burns should be covered with dry sterile dressing before transport. These dressings protect the damaged tissue without increasing the risk of hypothermia.
A. Silvadene dressings are appropriate once the burn has been fully evaluated. Application before transfer may delay the transfer and definitive treatment once the patient arrives at the burn center because these dressings must be removed before the burns can be adequately assessed.
B. Application of topical ointments would delay transfer to the regional burn center and assessment once the patient arrives here.
C. A patient with burns is at risk for infection and hypothermia. Wet dressings increase the likelihood of both.
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