Answers 2024/2025
What does triaging do? - *answers* *acts as gatekeeper*
helps prioritize patient care based on illness and severity level
According to triage, what patients would be seen firtst - *answers* highest acuity
patients will receive quickest intervention
(Most ill/severe will get seen first)
What is a good model for triaging patients? - *answers* ABCs
Is hospital triaging the same as mass casualty triaging? - *answers* NO
Which triage situation uses tags? - *answers* mass casualties
what are the categories of triage? - *answers* - emergent
- urgent
- nonurgent
- primary survey
what classifies a patient as emergent according to triage - *answers* - life threatening
injuries
- needs immediate treatment
what patient conditions warrant an emergent status of triage - *answers* - respiratory
distress
- chest pain with diaphoresis
- stroke
- active hemorrhage
- unstable vitals
what classifies a patient as urgent according to triage - *answers* patient should be
treated quickly but there is not and immediate threat to life
what patient conditions warrant an urgent status for triage - *answers* - severe
abdominal pain
- renal colic
- displaced multiple fractures
- new onset of respiratory infection (pneumonia)
what classifies a patient as nonurgent according to triage - *answers* patient can wait
several hours without a risk to life
,what patient conditions warrant a nonurgent status for triage - *answers* - skin rash
- strains/sprains
- colds
- simple fracture
what is a primary survey that should be performed while triaging? - *answers* ABCDE
what does ABCDE stand for in triaging patients - *answers* A: Airway/cervical spine
B: Breathing
C: Circulation
D: Disability
E: Exposure
what does the "A" refer to in ABCDE - *answers* airway, cervical spine
- patent airway
- immobilize spine
**do NOT move patient
what does the "B" refer to in ABCDE - *answers* breathing
- assess sounds
- assess chest wall movement
what does the "C" refer to in ABCDE - *answers* circulation
- vitals (BP and pulse)
- maintain vascular access
- stop any bleeding
what does the "D" refer to in ABCDE - *answers* disability
*LOC
what does the "E" refer to in ABCDE - *answers* exposure
- get clothes off
- use blankets to prevent hypothermia
what is the one exception to ABCDE? - *answers* in excessive bleeding, you would
prioritize "C" before "AB"
what is a secondary survey? - *answers* comprehensive head to toe assessment
, if warranted during the secondary survey, what would a nurse likely do? - *answers* -
insert NG tube
- insert catheter
- prep for diagnostics
what does drowning lead to? - *answers* leads to loss of surfactant in lungs which
causes alveolar collapse and pulmonary edema
is dehydration common in heat exhaustion? - *answers* YES
what can major diaphoresis cause? - *answers* severe dehydration and hyponatremia
if heat exhaustion goes untreated, what can it cause? - *answers* heat stroke
what are the s/s of heat exhaustion - *answers* -dehydration
-decrease in blood volume
-decrease in BP
-tachycardia
what is the first intervention for a person expected to have heat exhaustion? - *answers*
stop their physical activity and transfer to a cool place
what is the quickest way to reduce someone's temperature? - *answers* - remove
clothing
- remove bed linen
what interventions are there for cooling patients down? - *answers* - cold pack on the
neck, chest, abdomen, and groin
- soak in cool water
when rehydrating someone with heat exhaustion, should you use water or a sports
drink/oral reydration solution? - *answers* Sports drink/oral hydration solution
why is a sports drink better at rehydrating patients with heat exhaustion? - *answers*
plain water can worsen sodium deficits
nursing care for patients hospitalized with heat exhaustion - *answers* - monitor vitals
- administer .9% NS in N/V is present
- draw labs to check electrolytes
how is heat stroke defined? - *answers* body temperature greater than 104F
T/F: heat stroke is a medical emergency - *answers* TRUE
T/F: if heat stroke is left untreated it becomes fatal - *answers* TRUE