TRIAGE NURSING TEST QUESTIONS
WITH CORRECT ANSWERS
A 40-year-old woman currently on chemotherapy, with a temperature of 102 F.
What level triage this? - ANSWER Level 2
Neutropenic Fever
5- A yr-old has a sudden onset of left foot pain. They have a history of diabetes
requiring insulin and their left foot is cold to touch - no pulses. What level of
triage would you place this? - ANSWER Level 2
High-risk acute arterial occlusion
A 19-year-old male was brought in by police, with ETOH on breath, an
unsteady gait, large head lac, and slurred speech but oriented. What level triage
would you place this? - ANSWER Level 2
High risk of serious head injury
A 24-year-old patient is brought in with severe respiratory distress. Their Spo2
is 80%. What level triage would you place this? - ANSWER Level 1
Severe respiratory compromise
A woman brings in her 3-year-old child who fell down the steps. They are
unresponsive to a sternal rub. What level triage would you place this? -
ANSWER Level 1
High risk head or spinal cord injury and unresponsive
A healthy 52-year-old man is brought into the ED. He ran out of BP medication
and his blood pressure is 150/92. What level triage would you place this? -
ANSWER Level 5
No resources needed
A 12-year-old girl is brought into the ED with poison ivy. What level triage
would you place this? - ANSWER Level 5
No resources needed
, A 19-year-old boy is brought in with a sore throat and fever. What level triage
would you place this? - ANSWER Level 4
One resource needed (Throat culture)
A 29-year-old woman is brought into the ED with a UTI. What level triage
would you place this? - ANSWER Level 4
One resource needed (UA/C&S)
A 22-year-old is brought into the ED with right LLQ pain since early am and
nausea. They have no appetite. What level triage would you place this? -
ANSWER Level 3
Risk of appendicitis
Two or more resources needed (Labs; IV fluids; Abd. Ct; surgical consult)
A 45-yr old obese female comes to the ED with complaints of LLE
pain/swelling. IT started 2 days ago after driving for 12 hrs What level triage
would you place this? - ANSWER Level 3
Risk of DVT
Two or more resources needed (Labs; lower extremity non-invasive vascular
studies)
A 56-year-old patient comes to the triage area with left-sided chest pain,
diaphoresis, and dizziness. What is the priority action?
a. Initiate continuous cardiac monitoring
b. Notify the ED physician
c. Administer oxygen via nasal cannula.
d. Establish IV access - ANSWER C. administer oxygen via nasal cannula
You respond to a call for help from the ED waiting room. An elderly patient is
lying on the floor. List the order in which you must carry out the following
actions.
1. Perform the chin lift or jaw thrust maneuver
2. Establish unresponsiveness
3. Initiate CPR
4. Call for help and activate the code team
5. Instruct a UAP to get the crash cart - ANSWER 2,4,1,3,5
WITH CORRECT ANSWERS
A 40-year-old woman currently on chemotherapy, with a temperature of 102 F.
What level triage this? - ANSWER Level 2
Neutropenic Fever
5- A yr-old has a sudden onset of left foot pain. They have a history of diabetes
requiring insulin and their left foot is cold to touch - no pulses. What level of
triage would you place this? - ANSWER Level 2
High-risk acute arterial occlusion
A 19-year-old male was brought in by police, with ETOH on breath, an
unsteady gait, large head lac, and slurred speech but oriented. What level triage
would you place this? - ANSWER Level 2
High risk of serious head injury
A 24-year-old patient is brought in with severe respiratory distress. Their Spo2
is 80%. What level triage would you place this? - ANSWER Level 1
Severe respiratory compromise
A woman brings in her 3-year-old child who fell down the steps. They are
unresponsive to a sternal rub. What level triage would you place this? -
ANSWER Level 1
High risk head or spinal cord injury and unresponsive
A healthy 52-year-old man is brought into the ED. He ran out of BP medication
and his blood pressure is 150/92. What level triage would you place this? -
ANSWER Level 5
No resources needed
A 12-year-old girl is brought into the ED with poison ivy. What level triage
would you place this? - ANSWER Level 5
No resources needed
, A 19-year-old boy is brought in with a sore throat and fever. What level triage
would you place this? - ANSWER Level 4
One resource needed (Throat culture)
A 29-year-old woman is brought into the ED with a UTI. What level triage
would you place this? - ANSWER Level 4
One resource needed (UA/C&S)
A 22-year-old is brought into the ED with right LLQ pain since early am and
nausea. They have no appetite. What level triage would you place this? -
ANSWER Level 3
Risk of appendicitis
Two or more resources needed (Labs; IV fluids; Abd. Ct; surgical consult)
A 45-yr old obese female comes to the ED with complaints of LLE
pain/swelling. IT started 2 days ago after driving for 12 hrs What level triage
would you place this? - ANSWER Level 3
Risk of DVT
Two or more resources needed (Labs; lower extremity non-invasive vascular
studies)
A 56-year-old patient comes to the triage area with left-sided chest pain,
diaphoresis, and dizziness. What is the priority action?
a. Initiate continuous cardiac monitoring
b. Notify the ED physician
c. Administer oxygen via nasal cannula.
d. Establish IV access - ANSWER C. administer oxygen via nasal cannula
You respond to a call for help from the ED waiting room. An elderly patient is
lying on the floor. List the order in which you must carry out the following
actions.
1. Perform the chin lift or jaw thrust maneuver
2. Establish unresponsiveness
3. Initiate CPR
4. Call for help and activate the code team
5. Instruct a UAP to get the crash cart - ANSWER 2,4,1,3,5
