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HESI Specialty Exam Bank: Prioritization and
Triage in Multi Patient Scenarios
Table of Contents
Subtopic 1: Principles of Prioritization Using ABCs, Maslow, and Time-Sensitivity .............. 2
Subtopic 2: Emergency Triage and Color-Coded Tag Systems (Mass Casualty Focus) ....... 10
Subtopic 3: Clinical Judgment in Prioritizing Complex Medical-Surgical Patients ............. 19
Subtopic 4: Delegation, Supervision & Multidisciplinary Collaboration in Triage ............... 27
Subtopic 5: Prioritizing in Emergency Department (ED) Crowding and Mass Casualty Events
.................................................................................................................................. 36
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Subtopic 1: Principles of Prioritization Using ABCs,
Maslow, and Time-Sensitivity
Question 1:
A nurse on a medical-surgical unit is caring for four clients. Which client should the nurse
assess first?
A. A client reporting 6/10 abdominal pain
B. A client with stridor and difficulty speaking
C. A client with a temperature of 102°F (38.9°C)
D. A client scheduled for discharge today
Correct Answer: B
Rationale: Stridor indicates upper airway obstruction, a life-threatening emergency. Airway
comes first in ABC (Airway, Breathing, Circulation) prioritization.
Question 2:
A nurse in the emergency department receives four clients. Which client requires
immediate intervention?
A. A client with a sprained ankle and mild swelling
B. A client complaining of severe anxiety and chest tightness
C. A client with confusion and a blood glucose of 32 mg/dL
D. A client with a 2-day history of diarrhea
Correct Answer: C
Rationale: Hypoglycemia with altered mental status is a medical emergency that requires
immediate correction to prevent neurological damage.
Question 3:
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Which of the following patients should the nurse prioritize using Maslow’s hierarchy?
A. A client needing discharge teaching
B. A client experiencing shortness of breath
C. A client needing a dietary referral
D. A client requesting emotional support
Correct Answer: B
Rationale: Physiological needs (such as oxygenation) take priority over all other categories
in Maslow’s hierarchy of needs.
Question 4:
A client admitted for pneumonia becomes increasingly drowsy and confused. Which action
should the nurse take first?
A. Notify the provider
B. Check oxygen saturation
C. Reorient the client
D. Document findings
Correct Answer: B
Rationale: Altered mental status in pneumonia may indicate hypoxia; oxygenation must be
assessed and managed first.
Question 5:
Which client should the nurse prioritize for care?
A. A client reporting a headache
B. A post-op client with new-onset restlessness and low O2 saturation
C. A client with an indwelling catheter requesting assistance
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D. A client needing a wound dressing change
Correct Answer: B
Rationale: Restlessness and low oxygen saturation are early signs of hypoxia, requiring
immediate intervention.
Question 6:
A nurse is triaging clients in the ED. Which patient receives the highest priority?
A. A client with a fractured wrist
B. A client with facial burns and hoarseness
C. A client with fever and chills
D. A client with mild asthma reporting improvement
Correct Answer: B
Rationale: Facial burns and hoarseness suggest airway involvement, necessitating
immediate airway protection.
Question 7:
Which patient condition is the highest priority?
A. A client vomiting after chemotherapy
B. A client requesting medication for insomnia
C. A client with a stage 2 pressure ulcer
D. A client with slurred speech and right-sided weakness
Correct Answer: D
Rationale: Signs of stroke (slurred speech, unilateral weakness) require rapid assessment
and intervention (time = brain).
HESI Specialty Exam Bank: Prioritization and
Triage in Multi Patient Scenarios
Table of Contents
Subtopic 1: Principles of Prioritization Using ABCs, Maslow, and Time-Sensitivity .............. 2
Subtopic 2: Emergency Triage and Color-Coded Tag Systems (Mass Casualty Focus) ....... 10
Subtopic 3: Clinical Judgment in Prioritizing Complex Medical-Surgical Patients ............. 19
Subtopic 4: Delegation, Supervision & Multidisciplinary Collaboration in Triage ............... 27
Subtopic 5: Prioritizing in Emergency Department (ED) Crowding and Mass Casualty Events
.................................................................................................................................. 36
, 2
Subtopic 1: Principles of Prioritization Using ABCs,
Maslow, and Time-Sensitivity
Question 1:
A nurse on a medical-surgical unit is caring for four clients. Which client should the nurse
assess first?
A. A client reporting 6/10 abdominal pain
B. A client with stridor and difficulty speaking
C. A client with a temperature of 102°F (38.9°C)
D. A client scheduled for discharge today
Correct Answer: B
Rationale: Stridor indicates upper airway obstruction, a life-threatening emergency. Airway
comes first in ABC (Airway, Breathing, Circulation) prioritization.
Question 2:
A nurse in the emergency department receives four clients. Which client requires
immediate intervention?
A. A client with a sprained ankle and mild swelling
B. A client complaining of severe anxiety and chest tightness
C. A client with confusion and a blood glucose of 32 mg/dL
D. A client with a 2-day history of diarrhea
Correct Answer: C
Rationale: Hypoglycemia with altered mental status is a medical emergency that requires
immediate correction to prevent neurological damage.
Question 3:
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Which of the following patients should the nurse prioritize using Maslow’s hierarchy?
A. A client needing discharge teaching
B. A client experiencing shortness of breath
C. A client needing a dietary referral
D. A client requesting emotional support
Correct Answer: B
Rationale: Physiological needs (such as oxygenation) take priority over all other categories
in Maslow’s hierarchy of needs.
Question 4:
A client admitted for pneumonia becomes increasingly drowsy and confused. Which action
should the nurse take first?
A. Notify the provider
B. Check oxygen saturation
C. Reorient the client
D. Document findings
Correct Answer: B
Rationale: Altered mental status in pneumonia may indicate hypoxia; oxygenation must be
assessed and managed first.
Question 5:
Which client should the nurse prioritize for care?
A. A client reporting a headache
B. A post-op client with new-onset restlessness and low O2 saturation
C. A client with an indwelling catheter requesting assistance
, 4
D. A client needing a wound dressing change
Correct Answer: B
Rationale: Restlessness and low oxygen saturation are early signs of hypoxia, requiring
immediate intervention.
Question 6:
A nurse is triaging clients in the ED. Which patient receives the highest priority?
A. A client with a fractured wrist
B. A client with facial burns and hoarseness
C. A client with fever and chills
D. A client with mild asthma reporting improvement
Correct Answer: B
Rationale: Facial burns and hoarseness suggest airway involvement, necessitating
immediate airway protection.
Question 7:
Which patient condition is the highest priority?
A. A client vomiting after chemotherapy
B. A client requesting medication for insomnia
C. A client with a stage 2 pressure ulcer
D. A client with slurred speech and right-sided weakness
Correct Answer: D
Rationale: Signs of stroke (slurred speech, unilateral weakness) require rapid assessment
and intervention (time = brain).
