ESI Triage
Which statement best defines the tension-building stage of intimate partner violence? - ANS
The batterer becomes more emotional and unreasonable.
Feedback:The tension-building stage is defined as the stage during which the batterer becomes
more emotional and unreasonable.
What is a requirement of the Health Insurance Portability and Accountability Act (HIPAA)? - ANS
Computer screens with patient information must be shielded from the view of others.
Based on the vital signs, which of these patients should be the highest triage priority? - ANS
1-month-old female infant with pulse of 210 beats per minute
Feedback:A pulse of 210 is a tachycardic response.
Which elderly patient should receive the highest triage priority? - ANS 84-year-old man with new
onset of back pain 1 hour ago
What special situation warrants a higher triage prioritization as a result of the unique
presentation? - ANS A 71-year-old woman with expressive aphasia as a result of a stroke she
suffered five years ago who is brought to triage by her husband. He states that she seems
agitated but that he cannot determine why.
Feedback:Even though this woman's aphasia is the result of a previous condition, the inability of
the triage nurse to appropriately assess for her apparent change in condition as a result of her
communication difficulties should result in a higher triage prioritization.
Which post-surgical bariatric patient is a triage priority? - ANS A patient with a pulse of 124
beats per minute
Which transcultural term is considered to be an "endpoint" in understanding other cultures? -
ANS Stereotyping
Feedback:Stereotyping occurs when certain characteristics are assumed to be true of all people
from an ethnic or geographical location. This is an endpoint that causes difficulty in caring for
that person. An example of this is assuming that all individuals from Mexico have large families.
Identify the interventions which DO meet the lifesaving interventions criterion as defined in the
ESI algorithm. Select ALL that apply: - ANS Mechanical ventilation
Rapid sequence intubation
Dopamine infusion
Chest needle decompression
Which of the following patients is an emancipated minor? - ANS A 17-year-old enrolled in the
army
, a 62-year old woman presents with swollen ankles & reports a history of heart failure. In
complete sentences, the patient describes mild discomfort upon ambulation for the past 2 days
& no other concerns. Her VS are HR 88; RR 20; SpO2 94% on RA; temp. 98F. The nurse
assigns an acuity of ESI 3 & the patient is asked to wait. About 45-minutes later, the patient
returns to the triage nurse & reports being SOB. She speaks in 4-5 word sentences, & her SpO2
is 91% on RA. She has not seen the physician & her condition has deteriorated. You would: -
ANS Uptriage her to an an ESI of 2 & call the bed nurse
You are collecting a urine sample from a patient as part of the triage process. What type of
consent is required? - ANS Express consent
A patient presents with shortness of breath and other symptoms suggestive of pneumonia.
Which comorbidity may complicate this scenario and should cause the triage nurse to consider
a higher triage prioritization? - ANS Obesity
Which situation is not considered a violation of HIPAA? - ANS Reporting a dog bite to animal
control
Feedback:Monitoring of the dog will be an important part of the patient's care, so the proper
authorities must be notified.
Which pregnant woman would receive the highest triage priority? - ANS A woman who is 36
weeks pregnant with a blood pressure of 156/92 mm Hg
Feedback:The nurse should suspect pregnancy-induced hypertension in a patient with
hypertension after the 20th week of pregnancy
A patient with mental disabilities presents to triage accompanied by his conservator. What is the
conservator's scope of authority? - ANS She is limited to making financial and property
decisions.
A patient presents to the triage desk with complaints of chest and back pain. Which comorbidity
may complicate this scenario and should cause the triage nurse to consider a higher triage
prioritization? - ANS Marfan syndrome
Feedback:Ninety percent of patients with Marfan syndrome develop cardiac complications. This
patient's presentation is suggestive of aortic rupture or dissection.
A visitor presents to triage and says, "There is a guy lying on the ground in the parking structure
on the other side of the hospital. I think he is drunk." What is the appropriate response of the
triage nurse? - ANS Because of the remote location, hospital policy indicates that an ambulance
response is the best way to get this patient to the proper services.
Feedback:RUHS "hospital property" is defined as 250 yards from hospital entrance. Exceptions
are: CPC building, Education Building, and Davita. If an emergency occurs at the above three
locations, you should dial 911
Which statement best defines the tension-building stage of intimate partner violence? - ANS
The batterer becomes more emotional and unreasonable.
Feedback:The tension-building stage is defined as the stage during which the batterer becomes
more emotional and unreasonable.
What is a requirement of the Health Insurance Portability and Accountability Act (HIPAA)? - ANS
Computer screens with patient information must be shielded from the view of others.
Based on the vital signs, which of these patients should be the highest triage priority? - ANS
1-month-old female infant with pulse of 210 beats per minute
Feedback:A pulse of 210 is a tachycardic response.
Which elderly patient should receive the highest triage priority? - ANS 84-year-old man with new
onset of back pain 1 hour ago
What special situation warrants a higher triage prioritization as a result of the unique
presentation? - ANS A 71-year-old woman with expressive aphasia as a result of a stroke she
suffered five years ago who is brought to triage by her husband. He states that she seems
agitated but that he cannot determine why.
Feedback:Even though this woman's aphasia is the result of a previous condition, the inability of
the triage nurse to appropriately assess for her apparent change in condition as a result of her
communication difficulties should result in a higher triage prioritization.
Which post-surgical bariatric patient is a triage priority? - ANS A patient with a pulse of 124
beats per minute
Which transcultural term is considered to be an "endpoint" in understanding other cultures? -
ANS Stereotyping
Feedback:Stereotyping occurs when certain characteristics are assumed to be true of all people
from an ethnic or geographical location. This is an endpoint that causes difficulty in caring for
that person. An example of this is assuming that all individuals from Mexico have large families.
Identify the interventions which DO meet the lifesaving interventions criterion as defined in the
ESI algorithm. Select ALL that apply: - ANS Mechanical ventilation
Rapid sequence intubation
Dopamine infusion
Chest needle decompression
Which of the following patients is an emancipated minor? - ANS A 17-year-old enrolled in the
army
, a 62-year old woman presents with swollen ankles & reports a history of heart failure. In
complete sentences, the patient describes mild discomfort upon ambulation for the past 2 days
& no other concerns. Her VS are HR 88; RR 20; SpO2 94% on RA; temp. 98F. The nurse
assigns an acuity of ESI 3 & the patient is asked to wait. About 45-minutes later, the patient
returns to the triage nurse & reports being SOB. She speaks in 4-5 word sentences, & her SpO2
is 91% on RA. She has not seen the physician & her condition has deteriorated. You would: -
ANS Uptriage her to an an ESI of 2 & call the bed nurse
You are collecting a urine sample from a patient as part of the triage process. What type of
consent is required? - ANS Express consent
A patient presents with shortness of breath and other symptoms suggestive of pneumonia.
Which comorbidity may complicate this scenario and should cause the triage nurse to consider
a higher triage prioritization? - ANS Obesity
Which situation is not considered a violation of HIPAA? - ANS Reporting a dog bite to animal
control
Feedback:Monitoring of the dog will be an important part of the patient's care, so the proper
authorities must be notified.
Which pregnant woman would receive the highest triage priority? - ANS A woman who is 36
weeks pregnant with a blood pressure of 156/92 mm Hg
Feedback:The nurse should suspect pregnancy-induced hypertension in a patient with
hypertension after the 20th week of pregnancy
A patient with mental disabilities presents to triage accompanied by his conservator. What is the
conservator's scope of authority? - ANS She is limited to making financial and property
decisions.
A patient presents to the triage desk with complaints of chest and back pain. Which comorbidity
may complicate this scenario and should cause the triage nurse to consider a higher triage
prioritization? - ANS Marfan syndrome
Feedback:Ninety percent of patients with Marfan syndrome develop cardiac complications. This
patient's presentation is suggestive of aortic rupture or dissection.
A visitor presents to triage and says, "There is a guy lying on the ground in the parking structure
on the other side of the hospital. I think he is drunk." What is the appropriate response of the
triage nurse? - ANS Because of the remote location, hospital policy indicates that an ambulance
response is the best way to get this patient to the proper services.
Feedback:RUHS "hospital property" is defined as 250 yards from hospital entrance. Exceptions
are: CPC building, Education Building, and Davita. If an emergency occurs at the above three
locations, you should dial 911
