ENA CCC: Triage Exam Questions and
Correct Answers
Question 1
Which finding in an infant is associated with compromised circulation?
A. Dry skin
B. Absence of tears
C. Capillary refill of 2 seconds
D. Pink skin
Correct Answer
B. Absence of tears
Signs of compromised circulation include absence of tears, cyanosis, mottled
extremities, sunken fontanel, capillary refill of 4 seconds or more, diaphoresis, and
lethargy. Dry skin, capillary refill of 2 seconds, and pink skin are normal findings
related to circulation.
Question 2
In the CIAMPEDS mnemonic, which component helps the triage nurse decide if the
pediatric patient should be placed separately from others in the waiting room?
A. Chief complaint
B. Immunization status and isolation
C. Events leading up to problem
D. Medications
Correct Answer
B. Immunization status and isolation
During the I (immunization status and isolation) portion of the CIAMPEDS
mnemonic, the nurse should ask if the pediatric patient has been exposed to a
communicable disease, such as meningitis, chickenpox, shingles, whooping cough,
or tuberculosis. If a pediatric patient is actively or potentially infectious, place him or
her in respiratory isolation on arrival in the emergency department.
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, Question 3
The triage nurse should perform which important infection control measure?
A. Wear gloves continuously so that hand hygiene is not required between patients.
B. Place an immunosuppressed patient in a separate waiting area.
C. Give an N95 mask to a patient who presents with a cough.
D. Expect an independent care practitioner to perform infectious disease screening.
Correct Answer
B. Place an immunosuppressed patient in a separate waiting area.
To protect immunosuppressed patients, make every effort to isolate them from
patients in the general waiting room. Infection control begins at triage with strict
adherence to hand hygiene guidelines. Ask any patient who presents with a cough
to wear a surgical or procedure mask (not an N95 mask) to prevent the spread of
droplets to others. Infectious disease screening is a routine part of any triage
assessment. The triage nurse must identify patients with a potentially infectious
disease, take appropriate infection control measures, document the situation, and
then work with the charge nurse to get the patient to an appropriate treatment
area.
Question 4
When triaging a geriatric patient, the triage nurse should routinely perform which
action?
A. Speak loudly to older adults.
B. Use only closed-ended questions to obtain medical history.
C. Determine if the patient has a plan to hurt others.
D. Evaluate the patient's interactions with his or her family.
Correct Answer
D. Evaluate the patient's interactions with his or her family.
Admission to the emergency department gives the triage nurse a chance to
evaluate the patients interactions with his or her family. Emergency medical services
may provide valuable information about the patients living conditions and ability to
manage activities of daily living. Also, screen for older adult abuse and neglect. Use
various open-ended and closed-ended questions to obtain information, including
medical history. Determining whether the patient has a plan for hurting others is
appropriate for an older adult patient who presents with behavioral health concerns.
When speaking to an older adult patient, block out extraneous noise and speak
slowly, facing the patient. You do not necessarily need to speak loudly.
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Correct Answers
Question 1
Which finding in an infant is associated with compromised circulation?
A. Dry skin
B. Absence of tears
C. Capillary refill of 2 seconds
D. Pink skin
Correct Answer
B. Absence of tears
Signs of compromised circulation include absence of tears, cyanosis, mottled
extremities, sunken fontanel, capillary refill of 4 seconds or more, diaphoresis, and
lethargy. Dry skin, capillary refill of 2 seconds, and pink skin are normal findings
related to circulation.
Question 2
In the CIAMPEDS mnemonic, which component helps the triage nurse decide if the
pediatric patient should be placed separately from others in the waiting room?
A. Chief complaint
B. Immunization status and isolation
C. Events leading up to problem
D. Medications
Correct Answer
B. Immunization status and isolation
During the I (immunization status and isolation) portion of the CIAMPEDS
mnemonic, the nurse should ask if the pediatric patient has been exposed to a
communicable disease, such as meningitis, chickenpox, shingles, whooping cough,
or tuberculosis. If a pediatric patient is actively or potentially infectious, place him or
her in respiratory isolation on arrival in the emergency department.
Page 1 of 15
, Question 3
The triage nurse should perform which important infection control measure?
A. Wear gloves continuously so that hand hygiene is not required between patients.
B. Place an immunosuppressed patient in a separate waiting area.
C. Give an N95 mask to a patient who presents with a cough.
D. Expect an independent care practitioner to perform infectious disease screening.
Correct Answer
B. Place an immunosuppressed patient in a separate waiting area.
To protect immunosuppressed patients, make every effort to isolate them from
patients in the general waiting room. Infection control begins at triage with strict
adherence to hand hygiene guidelines. Ask any patient who presents with a cough
to wear a surgical or procedure mask (not an N95 mask) to prevent the spread of
droplets to others. Infectious disease screening is a routine part of any triage
assessment. The triage nurse must identify patients with a potentially infectious
disease, take appropriate infection control measures, document the situation, and
then work with the charge nurse to get the patient to an appropriate treatment
area.
Question 4
When triaging a geriatric patient, the triage nurse should routinely perform which
action?
A. Speak loudly to older adults.
B. Use only closed-ended questions to obtain medical history.
C. Determine if the patient has a plan to hurt others.
D. Evaluate the patient's interactions with his or her family.
Correct Answer
D. Evaluate the patient's interactions with his or her family.
Admission to the emergency department gives the triage nurse a chance to
evaluate the patients interactions with his or her family. Emergency medical services
may provide valuable information about the patients living conditions and ability to
manage activities of daily living. Also, screen for older adult abuse and neglect. Use
various open-ended and closed-ended questions to obtain information, including
medical history. Determining whether the patient has a plan for hurting others is
appropriate for an older adult patient who presents with behavioral health concerns.
When speaking to an older adult patient, block out extraneous noise and speak
slowly, facing the patient. You do not necessarily need to speak loudly.
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