Emergency

Nursing: TRIAGE
Natalie Serna, Courtney Kermani, Nina
Farinella & Nikki Howell

OVERVIEW OF TRIAGE
- LEVELS OF TRIAGE

- ABCD LIFE- THREATENING CONDITIONS

- ABCDEFGHI

- PAIN

- HEALTH HISTORY

• Triage: sorting a collection of patients rapidly
on critical basis, patients being seen first being
the most critical.
Using the TABLES below:
• FIVE LEVEL EMERGENCY SEVERITY INDEX (M/S: Page
1675 Table 69-2).
• EMERGENCY ASSESSMENT: PRIMARY SURVEY (M/S:
Page 1676 Table 69-3).
• LIFE-THREATENING CONDITIONS: PRIMARY
SURVEY (M/S: Page 1677 Table 69-4).
• EMERGENCY ASSESSMENT: SECONDARY SURVEY
(M/S: Page 1679 Table 69-5).

• REMEMBER: YOU’RE A through I
Care of Emergency Patients

CARDIAC CHEST ABDOMINAL MINOR PAIN CYSTITIS ARREST PAIN BURN .4 ESi-5 STABILITY? Unstable Threatened Stable Stable Stable LIFE or ORGAN LIKELY UNLIKELY YES NO NO THREAT? (not always) (possible) HOW SOON Within UP to an Can be Can be SEEN? ASAP/ STAT 10min hour delayed delayed EXPECTED RESOURCE HIGH High INTENSITY? as much staff Medium Low Low multiple & resources (Diagnostics) 1 diagnostic Exam only resources as available EX.3 ESi.5 LEVELS SUMMARIZED: TABLE 69-2 M/S 1675 DEFINITION ESi.1 ESi.2 ESi.

POTENTIAL LIFE-THREATENING CONDITIONS FOUND DURING PRIMARY SURVEY: TABLE 69-4 M/S 1677 TYPE OF THREAT AIRWAY BREATHING CIRCULATION DISABLED CAUSES INHALATION ANAPHYLAXIS MYOCARDIAL HEAD INFARCTION INJURY OBSTRUCTION FLAIL CHEST PERICARDIAL STROKE PENETRATING HEMOTHORAX TAMPONADE WOUND PNEUMOTHORAX SHOCK HEMORRHAGE HYPOTHERMIA PRIMARY SURVEY .

A V P U : A.A I R W A Y : WITH CERVICAL SPINE STABILIZATION AND/OR IMMOBILIZATION. DISABILITY: LOC.ALERT V.RESPONSE TO VOICE P.UNRESPONSIVE EXPOSURE OF ENVIRONMENTAL CONTROL: REMOVE ALL CLOTHING IN ORDER TO DO A THOROUGH ASSESSMENT PRIMARY SURVEY . B R E A T H I N G : ADEQUATE AIRFLOW THROUGH THE UPPER AIRWAY DOES NOT ENSURE ADEQUATE VENTILATION.RESPONSE TO PAIN U. RESPONSE TO VERBAL AND PAINFUL STIMULI. INTACT BLOOD VESSELS. AND ADEQUATE BLOOD VOLUME. C I R C U L A T I O N : INTACT CIRCULATORY SYSTEM INCLUDES: HEART.

RR. .FOUR PEOPLE TO LOGROLL: ECCHYMOSIS. PULSE. FOCUSED ADJUNCTS. & ICING INJURY. FACILITATE FAMILY PRESENCE: (B/P. PULSE OXIMETER.F= FULL SET OF VITALS. ET TUBE. G= GIVE COMFORT MEASURES: PAIN MANAGEMENT. HR.ECG. 02 SAT. ABRASIONS. LABS. H= HISTORY AND HEAD-TO-TOE ASSESSMENT: GIVE MEDICAL TEAM AND IDEA OF THE CAUSE OF INJURY. ELEVATING.STAFF HELPERS TO PROVIDE COMFORT OR FAMILY MEMEBERS (REMIND MEDICAL TEAM “PERSONHOOD” OF THE PATIENT). URINARY CATHETER. SPLINTING. & TEMPERATURE) . THREE. & NEED FOR TETANUS SHOT. SECONDARY SURVEY . AND DEFORMITIES. CUTS. PUNCTURE WOUNDS. I= INSPECT POSTERIOR SURFACES: “LOGROLLED” ALWAYS! MAINTAIN CERVICAL SPINE MOBILIZATION AND INSPECT.

OBTAINING HISTORY CHIEF COMPLAINT: what caused patient to seek medical attention? SUBECTIVE COMPLAINTS: patients stated s/s ? DESCRIPTION OF PAIN: P: Provocation/Palliation: started? Caused? Better/Worse? Trigger: stress. & activities? Q: Quality/Quantity: Sharp? Dull? Stabbing? Burning? Crushing? Throbbing? Nauseating? Shooting? Twisting? Stretching? R: Region/Radiation: Located? Radiates to? Travels/radiates? Localized? S: Severity Scale: 0-10? Interfere w/activities? Worse with sitting/standing/laying down? Episodes? T: Timing: Started? Lasted? Often? First onset? Sudden/Gradual? Time of day? Seasonal? AC/PC? SECONDARY SURVEY . position.

allergies: drugs.medication history? P . SECONDARY SURVEY .events & environmental factors leading to the illness or injury. food.past heath history? L .OBTAINING HISTORY WHO WITNESSED: description of patients behavior since onset? PATIENTS OWN HEALTH HISTORY: A . latex. & environment? M .last meal? E .

youtube. TRIAGE VIDEO https://www.com/watch?v=9QHDs10e-G0 .

SCENARIOS/CASE STUDIES .

heart rate of 130.4.• 23 y/o Female. He called 911.S. temp 98. was found on the floor. SaO2 sat 98%. During transport to the hospital she vomited and suffered a seizure. PATIENT #1 . When she arrived at the ER she had respirations of 35. BP 98/55. N. unconscious in her garage by her husband. lips are cyanotic.

and reports no pain. SpO2 96%. respirations 14. pulse 84. Does not understand why she was sent to the hospital and no medical alert bracelet present. temperature 92.. BP 90/60. cold and windy day. PATIENT #2 .• 48 y/o female. She is shivering.K. A&O x2. It is a rainy. found wondering on the roadway wearing wet t-shirt.4 F. underwear and no shoes. skin pale/cool to touch. C.

PATIENT #3 .F. • N. She is a health care worker who presented to the emergency room because of a dog bite on the left side of her face and along the left index finger. a 56 y/o female with a past medical history significant for lymphoma (now in remission). The dog belonged to the patient and was up to date with all its shots.

also is upset because she doesn't think the officer took her situation seriously because he didn't take any notes.H. PATIENT #4 . She presents with anxiety. and scattered bruising on her limbs in various stages of healing.H. She is very fixated on the police mishandling of her report. a 88 y/o female comes into the ER very upset about the abusive behavior she received from police when she went to report being beaten by her husband. depression. N.• N. She declines to undress and don a hospital gown for examination stating she only wants her wrist examined due to the bruising and severe pain with movement.

MOST DANGEROUS POISONS . CARBON MONOXIDE POISONINGS • S/S • TREATMENTS . PREVENTION . DEFINITION . TYPES OF POISONS . PCC SUGGESTIONS . OVERVIEW OF POISON . MEDICAL MANAGEMENT .

splashed in the eye. injected. inhaled.• Poison. concentration and route of exposure POISONING . intentional. occupational • Severity depends on type. recreational. or absorbed through the skin • Types: accidental.any chemical that harms the body and can be ingested.

Adults: Children: • Pain medications • Cosmetics/personal care products • Sedatives/hypnotics • Pain medications • Antidepressants • Foreign bodies (batteries) • Cardiac medications • Topical preparations • Alcohol • Plants/pesticides • Pesticides • Vitamins • Envenomation Most Common .

kerosene. paint thinner) • Alcohol • Cleaning products • Pesticides Most Dangerous .• Carbon monoxide • Hydrocarbons (gasoline.

and is able to swallow. (Remove contacts). rinse exposed skin immediately for 15 minutes • Inhaled: move to fresh air immediately and thoroughly ventilate the area PCC Suggestions . Otherwise contact PCC first • Contact with the eyes irrigate immediately for 15-20 mins with water that is at room temp. • Let water hit the bridge of the nose and gently run into the eyes and blinking is encouraged • Contact with skin. NOT having convulsions. remove contaminated clothing. irritating. or caustic AND the client is conscious.• Swallowed: immediately have the client drink a small amount of milk or water before calling poison control if: the product is burning.

The patient may show a variety of systemic manifestations with problem occurring in several systems depending on the poison. enhancing elimination. Medical Management . not the poison. Basic life support over decontamination.• Specific management focuses on decreasing absorption. • Remember to primarily to treat the client. and implementing toxin-specific interventions.

• Activated charcoal .added to IV fluids to help excrete amphetamines MEDICAL MANAGEMENT . administered within one hour of poisoning. Does not work with: ethanol. or cyanide • Gastric lavage . lithium. iron. Not done with caustic agents • Hemodialysis .most common and effective intervention. Many poisons will instead adhere to the charcoal and be eliminated via GI tract.insertion of gastric tube for irrigation with large amounts of saline. alkali.for heavy metals • Vitamin C .for development of severe acidosis from ingestion of toxic substances • Chelation therapy . hydrocarbons.

Type Example Signs & Symptoms Treatments Corrosives toilet/oven Severe burning in mouth. anxiety (exothermic reaction) • May drink milk or water Hydrocarbons Gasoline Gagging. violent vomiting (re-damages batteries vomiting. signs of mucosa) • DO NOT neutralize bleach shock. • Sodium bicarbonate. chocking coughing. lethargy. vomiting Lighter fluid immediate danger of aspiration • gastric lavage (depends (chemical PNA) on chemical) Paint thinner Acetaminophen Found in Initial: N/V. throat. hyperpyrexia. drooling. stomach. jaundice. coagulation easy to OD) bad odor) abnormalities Recovery phase • Activated charcoal Acetylsalicylic ASA N/V. tachypnea. external cooling seizures. • Activated charcoal. • DO NOT induce cleaners. (dilute with juice- confusion. bleeding • Anticonvulsants tendencies • Oxygen • Vitamin K . Acid diaphoresis. lavage & emesis tinnitus. pallor ANTIDOTE: various meds Latent: improves • N-Acetylcysteine (making it Hepatic: RUQ pain. oliguria. sweating. dehydration. coma. • DO NOT induce Kerosene N/V.

• Keep poison control number near a phone • Toxic substances. disinfectants. placed on high shelf. and placed in a childproof container out of reach • Read labels on medications and cleaning products before use • Household cleaners. including batteries. locked cabinet • Toxic plants placed out of reach of children • Medications stored in original containers. and insecticides kept in their original containers separate from food and out of reach • Smoking in areas away from children • Teach children hazards of ingesting nonfood items • Carbon monoxide alarms • Discuss abuse of drugs and household products and effects with children/adolescents Prevention . clearly labeled.

• Odorless. preventing oxygen from binding (carboxyhemoglobin) Carbon Monoxide Poisoning . tasteless gas produced when ordinary fuels burn • Affinity for Hgb is 200 times greater than that of oxygen- binds to Hgb quickly. colorless.

myocardial depression/ischemia • Eliminated by the lungs • Half life of 3-4 hours in room air • Levels detected with ABGs CARBON MONOXIDE POISONING . • An even greater affinity for myoglobin causing hypotension.

vomiting.weakness. of breath. cyanosis nausea. • 21-30%. shortness consciousness. loss of concentration. dizziness headache • 41-50% tachypnea. tachycardia.Minor Doses Major Doses • 5-10% impaired vision • 31-40% Confusion. • 11%-20% Flushing. coma. tinnitus death Manifestations . poor • over 50% Seizures.

• 100% oxygen therapy via non-breather. mechanical ventilation. or hyperbaric chamber (oxygen decreases the half life to 30-90 min) • Cardiac monitoring • Assessment of other body systems • Pulse oximetry readings are most likely to be normal Treatments .

DIFFERENCE OF HYPOTHERMIA AND HYPERTHERMIA .MEDICAL MANAGEMENT .TREATMENT .DEFINITION .S/S .OVERVIEW OF HYPOTHERMIA .PREVENTION .

• Normal body temperature is 98.6 F (37 C) • Hypothermia: body temperature passes below 95 F (35 C) HYPOTHERMIA .• Hypothermia is a medical emergency. body loses heat faster than it can produce heat.

MONITOR ABCs. peritoneal .FIXED DILATED PUPILS . ACTIVE EX.apply heating devices. AVOID INCREAD CO . HYPOVENTILATION . CYANOTIC c. BS. BARBITUATES O2 SAT. TRAUMA . PROLONGED IMMERSION . SHOCK . . HYPOTENSION a. COLD IV FLUIDS Bradycardia. AREFLEXIA (ABSENT b. MOD. TEMP. HYPOTHERMIA: Table 69-9 M/S 1685 ETIOLOGY ASSESSMENT INTERVENTIONS ENVIRONMENTAL: CORE BODY TEMP: INITIAL: .remove clothes. PASSIVE. . FROZEN Fluids. SHIVERING . ALCOHOL . REMOVE PT. INADEQUATE CLOTHING a.IV Large bore resuscitate OR NEAR-DROWNINIG . apply METABOLIC: .Rewarm pt. use radiant lights . VS.8 F . BLOOD ADM.GENTLY TX. PHENOTHIAZINES . Fib & Asystole .provide warm IV HEALTH CARE ASSOC. HYPOTHYROIDISM REFLEXES) warm water immersion . F&E . BLUE.2 F . PALE. HYPOGLYCEMIA . PROLONGED EXPOSURE TO b.OBTAIN 12 LEAD ECG . WHITE. HR. MILD 93. heated/ humidified O2.DYSRHYTHMIAS . 86-93. MAINTAIN ABCs COLD c.DEFIB MAY BE NEEDED OTHER: ONGOING: . LOC. hemodialysis . FROM COLD . ALOC Dry. ACTIVE IN.: . O2 REB-MASK/ BVM . SEVERE <86 F . .REWARMING SHOCK avoid . INADEQUATE WARMING . V.2-96. Rhythm. NEUROMUSCULAR AGENT EXTREMITIES lavage with warmed fluids. .

DYSRHYTHMIAS Bradycardia. SEVERE <86 F . HYPOTENSION .8 F b. 86-93. MOD. FROZEN EXTREMITIES . BLUE. SHIVERING . CYANOTIC . HYPOVENTILATION .2-96. and Asystole .CORE BODY TEMP: a.2 F c. AREFLEXIA (ABSENT REFLEXES) . PALE. ALOC . MILD 93. WHITE. V.FIXED DILATED PUPILS Manifestations . Fib.

apply heating devices. use radiant lights • b. • a. heated/ humidified O2. peritoneal lavage with warmed fluids.remove clothes.provide warm IV Fluids. PASSIVE.INITIAL: • REMOVE PATIENT FROM COLD • MAINTAIN ABCs • O2 REB-MASK/ BVM • IV Large bore resuscitate Rewarm pt. warm water immersion • c. ACTIVE EX. AVOID INCREAD CO • DEFIBRILLATION MAY BE NEEDED MANAGEMENT . apply • Dry. ACTIVE IN. hemodialysis • OBTAIN 12 LEAD ECG • REWARMING SHOCK avoid • GENTLY TX.

ONGOING: MONITOR 1. O2 Saturation 5. Rhythm 7. Vitals 2. LOC 3. F&E TREATMENTS . Blood Sugar 8. Temperature 4. Heart Rate 6.

OVERVIEW OF BITES • FACTS • TYPES OF WOUNDS • SIGNS & SYMPTOMS • VACCINATIONS • DISEASES • CASE STUDY • ASSESSMENT .PREVENTION .MEDICAL MANAGEMENT .TREATMENT .

5 million dog bites occur each year in the United States. the rate of dog-bite–related injuries is highest for those 5 to 9 years old. Children are more likely than adults to receive medical attention for dog bites. FACTS . Almost 1 out of 5 bites becomes infected. Who is most at risk for dog bites? Children. Men.Approximately 4. Among children. Men are more likely than women to be bitten by a dog.

Among children and adults. having a dog in the household is associated with a higher likelihood FACTS of being bitten than not having a dog. .Over half of dog-bite injuries occur at home with dogs that are familiar to us.

painful. or swollen. if you develop a fever. • See a healthcare provider as soon as possible. Deep wounds • Apply pressure with a clean. call 911 or your local emergency medical services immediately. or if the dog that bit you was acting strangely. • If you cannot stop the bleeding or you feel faint or weak. • See a healthcare provider if the wound becomes red. dry cloth to stop the bleeding. • Cover the wound with a clean bandage.Dog bite wound care: Minor wounds • Wash the wound thoroughly with soap and water. warm. • Apply an antibiotic cream. TYPES OF WOUNDS .

Tetanus Vaccines and TIG for Wound .

CAPNOCYTOPHAGA SPP. DISEASES . OR CLOSE CONTACT FROM A DOG OR CAT AND CAUSE ILLNESS. PEOPLE WHO ARE EXPOSED TO A DOG OR ANY ANIMAL THAT COULD HAVE RABIES SHOULD RECEIVE TREATMENT IMMEDIATELY TO PREVENT RABIES. PEOPLE WITH A WEAKENED IMMUNE SYSTEM (MAKING IT MORE DIFFICULT FOR THEIR BODIES TO FIGHT INFECTION) ARE AT GREATER RISK OF BECOMING SICK. RARELY. MOST PEOPLE WHO HAVE CONTACT WITH DOGS OR CATS DO NOT BECOME SICK. ARE BACTERIA THAT LIVE IN THE MOUTHS OF HUMANS. CAN SPREAD TO HUMANS THROUGH BITES. AND CATS. RABIES IS A VIRUS THAT AFFECTS THE BRAIN AND IS ALMOST ALWAYS FATAL. THESE BACTERIA DO NOT MAKE DOGS OR CATS SICK. CAPNOCYTOPHAGA SPP. THE DISEASE CAN BE PREVENTED BY VACCINATING DOGS.DISEASES FROM DOG BITES: RABIES IS ONE OF THE MOST SERIOUS DISEASES PEOPLE CAN GET FROM DOG BITES. THE MOST COMMON WAY RABIES VIRUS IS SPREAD IS THROUGH THE BITE AND SALIVA OF AN INFECTED ANIMAL. SCRATCHES. DOGS.

lung.•Pasteurella is a type of bacteria seen in over 50% of infected dog bite wounds. swelling in the joints. and difficulty moving. Often these signs are accompanied by swollen glands. • MRSA (methicillin-resistant Staphylococcus aureus) is type of Staph infection that is resistant to a certain group of antibiotics. This toxin causes rigid paralysis in people and could be a problem in deep bite wounds. In some people. but the bacteria can cause skin. and urinary tract infections in people. Dogs and other animals can carry MRSA without showing any symptoms. MRSA can spread to the bloodstream or lungs and cause life-threatening infections. DISEASES . red infection at the site of the bite but can cause more serious disease in people with a weak immune system. Pasteurella commonly causes a painful. • Tetanus is a toxin produced by a type of bacteria called Clostridium tetani.

• Antipyretic agent (NSAIDs. • Analgesics for pain CARE OF CLIENT . • Rabies post-exposure prophylaxis if necessary. • Antibacterial cream (Bacitracin cream). debridement. salicylates) to reduce fever.Collaborative care: • Initial treatment includes cleaning with copious irrigation. and analgesics as needed. acetaminophen. • Prophylactic antibiotics (broad spectrum antibiotic). tetanus prophylaxis.

if they can be kept securely on site. If your dog bit someone . • Animals that have been impounded by an animal control agency must complete their quarantine period in a shelter. Many owned biting animals complete their quarantine in their own home. Report the dog to the Animal Control or Humane Society for further assistance in regards to quarantine time period.• Confine your dog immediately and check on the victim's condition.

TYPES OF VIOLENCE . S/S . DEFINITION .VIOLENCE . PREVALENCE . MEDICAL MANAGEMENT .

Temporal Lobe Epilepsy/Tourette's. Schizophrenia/Bipolar/PTSD/Alzheimer’s. (assault/murder). Anger at someone due to their actions or inactions.” The purpose behind the violence may be due to. Fear of someone.Violence is defined by the World Health Organization as “the intentional use of physical force or power. psychological harm. threatened or actual. (assault/rape/murder). Psychosis altering the mental state. fight or flight response. against oneself. which results in or has a high likelihood of resulting in injury. or against a group or community. maldevelopment. something or anxiety of unknown. Antisocial behavior. (assault/murder). Medication or recreational drug use. (assault/murder). Impairment due to organic disease or medication. death. (assault). Antisocial Personality Disorder/Sociopath/Sadistic Personality Disorder. . or deprivation. Catovit/Ecstasy/Prolintane/Methamphetamine (assault/rape/murder). another person.

When one person tries to or does physically strike another .Home . TYPES OF VIOLENCE Can occur in any environment or setting .Work .Acts in a threatening manner to put another in fear or immediate harm Rape .Community Assault .With genitalia or foreign object .Forcible perpetration of a sexual act on a person without consent .

. MANDATED REPORTING Mandated reporting of suspected child. elder or dependent violence/abuse as well as confirmed violence/abuse. Especially in cases where the victim has admitted the abuse. Ethically as nurses we should report ALL suspected violence/abuse due to the psychiatric complications that intimate partner abuse entails.

Family and intimate partner violence .

Family and intimate partner violence FACT 74% of all murder-suicides involve an intimate partner S by a partner .1 in 3 will grow up to be an abuser .96% of IPV pet owners report their pet abused .1. 90% are eye witnesses .S.1 in 3 will grow up to be a victim of IPV .800 animal shelters .000 children globally die ear year from domestic violence .Boys who witness IPV growing up are twice as likely as adults to abuse their family .31.500 battered women shelters in the U.1 million animals a year are abused/killed in connection with IPV . and 3.96% of all those were women killed 3 out of 4 Americans know a victim of IPV 15 million children a year are exposed to domestic violence.1 in every 10 calls to abuse hotlines are made by a child 71% of all IPV reported the abuser also targeted their pet .

Family and intimate partner violence FACTS On a typical day there are over 20.18% are male victims .1 in 4 men in their lifetime will be a victim of some form of IPV (assault/rape/stalking) .000 calls placed to U.S.15% of REPORTED victims are male .Of the reported case 2 of every 3 male victims stated they were laughed at. domestic violence hotlines .Majority say they do not feel their case was taken seriously . mocked or ridiculed by the police or healthcare worker .Majority of male victim IPV goes unreported .

muggings.Family and intimate partner violence FACTS 1 in 3 U.more than MVA. and rapes combined .IPV is the single biggest health risk to women ages 15-44 . women in their lifetime will be a victim of IPV .S.every 9 seconds a woman is a victim of IPV .leading cause of homicides & injury related deaths during pregnancy .

punching. • Low self-esteem. and sprained wrists are common injuries. Often injuries do not match up with explanation. red/purple marks at the neck. • Having little money available. SIGNS & SYMPTOMS • Bruises/injuries that look like they came from choking. • Black eyes. being isolated from relatives/coworkers and kept from making friends. being extremely apologetic and meek • Referring to the partner's temper but not disclosing the extent of the abuse • Drug or alcohol abuse problem • Symptoms of depression. • Making excuses like tripping. or loss of interest in daily activities . being accident-prone or clumsy. such as sadness or hopelessness. • Having to ask permission to meet. or being thrown down. • Attempting to hide bruises with makeup or clothing. • Having few friends. • Hx of fractures or injuries with suspicious causes. may not have credit cards or a car. talk with or do things with other people.

I wonder if someone hurt you? • Are you concerned about the safety of your children? • Victims are more likely to report to protect their children from harm Healthcare workers should actively listen. Assist in obtaining safety. . validate decision to disclose. Medical Management Screen for family violence and IPV while alone with patient • Is anyone is hurting you or your family? • Do you feel safe at home? • Is there anything else happening that could be affecting your health? • You seem very anxious. emphasize unacceptability of violence . provide help numbers as well as provide phone for patient to call. confirm fear/worry. is everything all right at home? • When I see injuries like this.

C. Administer the medication subcutaneously in the deltoid muscle. What is the appropriate action when administering this antidote? A. Mix the medication in a flavored ice drink and allowing the client to drink the medication. Question # 1 . D. mixed in 50 mL of normal saline and piggybacked through the main IV line. B.The nurse prepares to administer acetylcysteine (Mucomyst) to the client with an overdose of acetaminophen (Tylenol). Administer the medication by intramuscular (IM) injection in the gluteal muscle. Administer the medication by an intravenous (IV) line.

QUESTION #1 . ANSWER: C. Mix the medication in a flavored ice drink and allowing the client to drink the medication.

C. Dialysis patient after fistula placement that same day and having arm swelling. D. Question # 2 . Suicidal ideation. Chest pain radiating to the left arm and into the back. Rash with no shortness of breath or stridor.Which of the following patients are NOT considered ESI level 2 patients? A. B.

ANSWER: B. QUESTION #2 . Rash with no shortness of breath or stridor.

What is a major issue as it relates to
"frequent flyers" to the Emergency
Department?
A. The tendency to anger the staff for consuming their time
B. The possibility that a future visit may turn out to be an
emergency need.
C. The increased amount of cost to the system.
D. The need to provide specialty consultation such as
behavioral health.

Question # 3

ANSWER:

B. The possibility that a future visit
may turn out to be an emergency
need.

QUESTION #3

What is the correct response to a mother presenting
to your triage window with a small child in her arms
that appears: dusky with discolored nail beds, listless,
and retractions?

A. Grab the child from mom and run immediately to a room.
B. Call the ER physician to request orders.
C. Shake the child to attempt to arouse the child.
D. Immediately push the "code" button on the wall and administer
high flow oxygen via a large volume device while in the triage
room.

Question # 4

QUESTION #4 .ANSWER: D. Immediately push the "code" button on the wall and administer high flow oxygen via a large volume device while in the triage room.

ESI 4 E.What ESI level would a patient who is deemed a "P" on the AVPU scale? A. ESI 3 D. ESI 5 Question # 5 . ESI 2 C. ESI 1 B.

ANSWER: A. ESI 1 QUESTION #5 .

Removes the bee and saves it for evidence of the sting Question #6 . What does the nurse do first? A. The school nurse is nearby when it happens. While on the playground. resulting in redness and swelling. a school child is stung by a bee. Injects the child with an epinephrine pen (Epi-Pen auto- injector) D. Applies an ice pack to the stinger B. Gently scrapes out the stinger with a credit card C.

ANSWER: B. Gently scrapes out the stinger with a credit card QUESTION #6 .

A nurse is providing reminders to a Red Cross class about safety procedures to prevent drowning or submersion. In which situation does this present the greatest risk? A. Children swimming at the community pool C. College students going to a fraternity party at a boat house D. An engaged couple going swimming together at a local lake B. Families going to the quarry to swim QUESTION #7 .

ANSWER: C. College students going to a fraternity party at a boat house QUESTION #7 .

runs to the victim's aid. What does the nurse do initially? A. Applies a dressing over the skin burn where the lightening entered B. Moves the victim to a more secure area D. Instructs everyone to not touch the victim to avoid being hurt C. Palpates to check for the presence of a pulse QUESTION #8 . A golfer who is caught in a thunderstorm is struck by lightning. A fellow golfer. who is a nurse.

ANSWER: D. Palpates to check for the presence of a pulse QUESTION #8 .