You are working in the triage area of an ED, and four patients approach the triage desk at the
same time. List the order in which you will assess these patients. a. An ambulatory, dazed 25-
year-old male with a bandaged head wound b. An irritable infant with a fever, petechiae, and
nuchal rigidity c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
d. A 50-year-old female with moderate abdominal pain and occasional vomiting
A. A B D C
B. B A D C
C. C D B A
D. C B A D
Ans: b
An irritable infant with fever and petechiae should be further assessed for other meningeal
signs. The patient with the head wound needs additional history and assessment for
intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not
unstable at this point. For the ankle injury, medical evaluation can be delayed 24 - 48 hours if
necessary.
Quiz In conducting a primary survey on a trauma patient, which of the following is considered
one of the priority elements of the primary survey?
,A. Complete set of vital signs
B. Palpation and auscultation of the abdomen
C. Brief neurologic assessment
D. Initiation of pulse oximetry
Ans: C
A brief neurologic assessment to determine level of consciousness and pupil reaction is part of
the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are
considered part of the secondary survey.
Quiz A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and
dizziness. This patient should be prioritized into which category?
A. High urgent
B. Urgent
C. Non-urgent
D. Emergent
Ans: D
Chest pain is considered an emergent priority, which is defined as potentially life-threatening.
Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). Non-
urgent conditions can wait for hours or even days. (High urgent is not commonly used;
however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in
terms of the time lapsing prior to treatment).
, Quiz The physician has ordered cooling measures for a child with fever who is likely to be
discharged when the temperature comes down. Which of the following would be appropriate
to delegate to the nursing assistant?
A. Assist the child to remove outer clothing.
B. Advise the parent to use acetaminophen instead of aspirin.
C. Explain the need for cool fluids.
D. Prepare and administer a tepid bath
Ans: A
The nursing assistant can assist with the removal of the outer clothing, which allows the heat
to dissipate from the child's skin. Advising and explaining are teaching functions that are the
responsibility of the RN. Tepid baths are not usually performed because of potential for
rebound and shivering.
Quiz It is the summer season, and patients with signs and symptoms of heat-related illness
present in the ED. Which patient needs attention first?
A. An elderly person complains of dizziness and syncope after standing in the sun for several
hours to view a parade
B. A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis,
pallor, and weakness are observed.
C. A previously healthy homemaker reports broken air conditioner for days. Tachypnea,
hypotension, fatigue, and profuse diaphoresis are observed.
D. A homeless person, poor historian, presents with altered mental status, poor muscle
coordination, and hot, dry, ashen skin. Duration of exposure is unknown.
Ans: D
same time. List the order in which you will assess these patients. a. An ambulatory, dazed 25-
year-old male with a bandaged head wound b. An irritable infant with a fever, petechiae, and
nuchal rigidity c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
d. A 50-year-old female with moderate abdominal pain and occasional vomiting
A. A B D C
B. B A D C
C. C D B A
D. C B A D
Ans: b
An irritable infant with fever and petechiae should be further assessed for other meningeal
signs. The patient with the head wound needs additional history and assessment for
intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not
unstable at this point. For the ankle injury, medical evaluation can be delayed 24 - 48 hours if
necessary.
Quiz In conducting a primary survey on a trauma patient, which of the following is considered
one of the priority elements of the primary survey?
,A. Complete set of vital signs
B. Palpation and auscultation of the abdomen
C. Brief neurologic assessment
D. Initiation of pulse oximetry
Ans: C
A brief neurologic assessment to determine level of consciousness and pupil reaction is part of
the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are
considered part of the secondary survey.
Quiz A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and
dizziness. This patient should be prioritized into which category?
A. High urgent
B. Urgent
C. Non-urgent
D. Emergent
Ans: D
Chest pain is considered an emergent priority, which is defined as potentially life-threatening.
Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). Non-
urgent conditions can wait for hours or even days. (High urgent is not commonly used;
however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in
terms of the time lapsing prior to treatment).
, Quiz The physician has ordered cooling measures for a child with fever who is likely to be
discharged when the temperature comes down. Which of the following would be appropriate
to delegate to the nursing assistant?
A. Assist the child to remove outer clothing.
B. Advise the parent to use acetaminophen instead of aspirin.
C. Explain the need for cool fluids.
D. Prepare and administer a tepid bath
Ans: A
The nursing assistant can assist with the removal of the outer clothing, which allows the heat
to dissipate from the child's skin. Advising and explaining are teaching functions that are the
responsibility of the RN. Tepid baths are not usually performed because of potential for
rebound and shivering.
Quiz It is the summer season, and patients with signs and symptoms of heat-related illness
present in the ED. Which patient needs attention first?
A. An elderly person complains of dizziness and syncope after standing in the sun for several
hours to view a parade
B. A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis,
pallor, and weakness are observed.
C. A previously healthy homemaker reports broken air conditioner for days. Tachypnea,
hypotension, fatigue, and profuse diaphoresis are observed.
D. A homeless person, poor historian, presents with altered mental status, poor muscle
coordination, and hot, dry, ashen skin. Duration of exposure is unknown.
Ans: D
