NUR 2755 Multidimensional Care IV/MDC 4 FINAL EXAM 3
What does triaging do? Correct Answer: *acts as gatekeeper*
helps prioritize patient care based on illness and severity level
According to triage, what patients would be seen firtst Correct Answer: highest acuity patients will
receive quickest intervention
(Most ill/severe will get seen first)
What is a good model for triaging patients? Correct Answer: ABCs
Is hospital triaging the same as mass casualty triaging? Correct Answer: NO
Which triage situation uses tags? Correct Answer: mass casualties
what are the categories of triage? Correct Answer: - emergent
- urgent
- nonurgent
- primary survey
what classifies a patient as emergent according to triage Correct Answer: - life threatening injuries
- needs immediate treatment
what patient conditions warrant an emergent status of triage Correct Answer: - respiratory distress
- chest pain with diaphoresis
- stroke
- active hemorrhage
- unstable vitals
what classifies a patient as urgent according to triage Correct Answer: patient should be treated quickly
but there is not and immediate threat to life
what patient conditions warrant an urgent status for triage Correct Answer: - severe abdominal pain
- renal colic
- displaced multiple fractures
- new onset of respiratory infection (pneumonia)
what classifies a patient as nonurgent according to triage Correct Answer: patient can wait several
hours without a risk to life
what patient conditions warrant a nonurgent status for triage Correct Answer: - skin rash
- strains/sprains
- colds
- simple fracture
what is a primary survey that should be performed while triaging? Correct Answer: ABCDE
, what does ABCDE stand for in triaging patients Correct Answer: A: Airway/cervical spine
B: Breathing
C: Circulation
D: Disability
E: Exposure
what does the "A" refer to in ABCDE Correct Answer: airway, cervical spine
- patent airway
- immobilize spine
**do NOT move patient
what does the "B" refer to in ABCDE Correct Answer: breathing
- assess sounds
- assess chest wall movement
what does the "C" refer to in ABCDE Correct Answer: circulation
- vitals (BP and pulse)
- maintain vascular access
- stop any bleeding
what does the "D" refer to in ABCDE Correct Answer: disability
*LOC
what does the "E" refer to in ABCDE Correct Answer: exposure
- get clothes off
- use blankets to prevent hypothermia
what is the one exception to ABCDE? Correct Answer: in excessive bleeding, you would prioritize "C"
before "AB"
what is a secondary survey? Correct Answer: comprehensive head to toe assessment
if warranted during the secondary survey, what would a nurse likely do? Correct Answer: - insert NG
tube
- insert catheter
- prep for diagnostics
what does drowning lead to? Correct Answer: leads to loss of surfactant in lungs which causes alveolar
collapse and pulmonary edema
is dehydration common in heat exhaustion? Correct Answer: YES
what can major diaphoresis cause? Correct Answer: severe dehydration and hyponatremia
What does triaging do? Correct Answer: *acts as gatekeeper*
helps prioritize patient care based on illness and severity level
According to triage, what patients would be seen firtst Correct Answer: highest acuity patients will
receive quickest intervention
(Most ill/severe will get seen first)
What is a good model for triaging patients? Correct Answer: ABCs
Is hospital triaging the same as mass casualty triaging? Correct Answer: NO
Which triage situation uses tags? Correct Answer: mass casualties
what are the categories of triage? Correct Answer: - emergent
- urgent
- nonurgent
- primary survey
what classifies a patient as emergent according to triage Correct Answer: - life threatening injuries
- needs immediate treatment
what patient conditions warrant an emergent status of triage Correct Answer: - respiratory distress
- chest pain with diaphoresis
- stroke
- active hemorrhage
- unstable vitals
what classifies a patient as urgent according to triage Correct Answer: patient should be treated quickly
but there is not and immediate threat to life
what patient conditions warrant an urgent status for triage Correct Answer: - severe abdominal pain
- renal colic
- displaced multiple fractures
- new onset of respiratory infection (pneumonia)
what classifies a patient as nonurgent according to triage Correct Answer: patient can wait several
hours without a risk to life
what patient conditions warrant a nonurgent status for triage Correct Answer: - skin rash
- strains/sprains
- colds
- simple fracture
what is a primary survey that should be performed while triaging? Correct Answer: ABCDE
, what does ABCDE stand for in triaging patients Correct Answer: A: Airway/cervical spine
B: Breathing
C: Circulation
D: Disability
E: Exposure
what does the "A" refer to in ABCDE Correct Answer: airway, cervical spine
- patent airway
- immobilize spine
**do NOT move patient
what does the "B" refer to in ABCDE Correct Answer: breathing
- assess sounds
- assess chest wall movement
what does the "C" refer to in ABCDE Correct Answer: circulation
- vitals (BP and pulse)
- maintain vascular access
- stop any bleeding
what does the "D" refer to in ABCDE Correct Answer: disability
*LOC
what does the "E" refer to in ABCDE Correct Answer: exposure
- get clothes off
- use blankets to prevent hypothermia
what is the one exception to ABCDE? Correct Answer: in excessive bleeding, you would prioritize "C"
before "AB"
what is a secondary survey? Correct Answer: comprehensive head to toe assessment
if warranted during the secondary survey, what would a nurse likely do? Correct Answer: - insert NG
tube
- insert catheter
- prep for diagnostics
what does drowning lead to? Correct Answer: leads to loss of surfactant in lungs which causes alveolar
collapse and pulmonary edema
is dehydration common in heat exhaustion? Correct Answer: YES
what can major diaphoresis cause? Correct Answer: severe dehydration and hyponatremia
