ENA TRIAGE EXAM STUDY GUIDE: 200 MULTIPLE-CHOICE
QUESTIONS WITH CORRECT ANSWERS AND COMPREHENSIVE
RATIONALES FOR EMERGENCY NURSING CERTIFICATION
1. What is the primary purpose of the Emergency Severity Index (ESI)?
A. To diagnose medical conditions
B. To prioritize patients based on acuity and resource needs
C. To determine insurance eligibility
D. To assign patients to specific healthcare providers
Correct Answer: B
Rationale: The ESI is a five-level triage system used to prioritize patients
based on the severity of their condition and the number of resources
they are expected to consume.
2. A patient presents with a life-threatening condition requiring
immediate intervention. What ESI level should be assigned?
A. Level 1
B. Level 2
C. Level 3
D. Level 4
Correct Answer: A
Rationale: ESI Level 1 indicates a patient requiring immediate, life-
saving intervention (e.g., intubation, defibrillation, emergency blood
transfusion).
,3. Which of the following is a key component of the across-the-room
assessment?
A. Obtaining a full medical history
B. Measuring vital signs
C. Observing the patient's general appearance and work of breathing
D. Performing a detailed physical exam
Correct Answer: C
Rationale: The across-the-room assessment relies on visual and
auditory cues to quickly determine if a patient is stable, unstable, or in
distress before formal assessment begins.
4. A patient arrives with a deep laceration to the arm that requires
sutures but is hemodynamically stable. What ESI level is most
appropriate?
A. Level 1
B. Level 2
C. Level 3
D. Level 5
Correct Answer: C
Rationale: An ESI Level 3 patient requires multiple resources (e.g.,
sutures, imaging, labs) but vital signs are stable, and they are not in
immediate danger.
5. When should the triage nurse reassess a patient in the waiting
room?
A. Only when the patient complains
B. Every 4 hours
C. After a specified time based on the triage acuity and department
,policy
D. Only when a bed becomes available
Correct Answer: C
Rationale: Patients waiting for care must be reassessed at intervals
determined by their acuity level and departmental policy to detect
clinical deterioration.
6. Which of the following is a contraindication for using the Traffic
Director triage system?
A. High patient volume
B. Limited physical space
C. The presence of a non-clinical greeter
D. The need for rapid, expert clinical decision-making
Correct Answer: D
Rationale: The Traffic Director model uses a non-clinical person to
quickly sort patients, which is inappropriate for high-acuity patients
who require immediate clinical judgment.
7. A patient with a known history of asthma presents with audible
wheezing and using accessory muscles. What is the priority triage
action?
A. Place the patient in the waiting room
B. Assign an ESI level 4
C. Initiate immediate treatment or place in a monitored bed
D. Obtain a full set of vital signs before intervention
Correct Answer: C
Rationale: This patient is in respiratory distress and requires immediate
intervention; triage should be expedited, and the patient should not
wait.
, 8. What is the most common error made during the triage process?
A. Over-triaging patients
B. Under-triaging patients
C. Failing to document vital signs
D. Using the wrong triage system
Correct Answer: B
Rationale: Under-triaging, or assigning a lower acuity level than
warranted, is a major patient safety risk that can lead to delayed
treatment and poor outcomes.
9. A parent brings in a 2-year-old child with a fever of 104°F, lethargy,
and poor skin turgor. What ESI level is assigned?
A. Level 1
B. Level 2
C. Level 3
D. Level 4
Correct Answer: B
Rationale: The child is high-risk due to age, fever, and signs of
dehydration/lethargy, requiring prompt medical evaluation (ESI Level 2).
10. Which of the following describes the "right reason" in the four
rights of triage?
A. The patient is seen by the right doctor
B. The patient is assigned the correct acuity level based on their
condition
C. The patient is placed in the right bed
D. The patient is given the right medication
QUESTIONS WITH CORRECT ANSWERS AND COMPREHENSIVE
RATIONALES FOR EMERGENCY NURSING CERTIFICATION
1. What is the primary purpose of the Emergency Severity Index (ESI)?
A. To diagnose medical conditions
B. To prioritize patients based on acuity and resource needs
C. To determine insurance eligibility
D. To assign patients to specific healthcare providers
Correct Answer: B
Rationale: The ESI is a five-level triage system used to prioritize patients
based on the severity of their condition and the number of resources
they are expected to consume.
2. A patient presents with a life-threatening condition requiring
immediate intervention. What ESI level should be assigned?
A. Level 1
B. Level 2
C. Level 3
D. Level 4
Correct Answer: A
Rationale: ESI Level 1 indicates a patient requiring immediate, life-
saving intervention (e.g., intubation, defibrillation, emergency blood
transfusion).
,3. Which of the following is a key component of the across-the-room
assessment?
A. Obtaining a full medical history
B. Measuring vital signs
C. Observing the patient's general appearance and work of breathing
D. Performing a detailed physical exam
Correct Answer: C
Rationale: The across-the-room assessment relies on visual and
auditory cues to quickly determine if a patient is stable, unstable, or in
distress before formal assessment begins.
4. A patient arrives with a deep laceration to the arm that requires
sutures but is hemodynamically stable. What ESI level is most
appropriate?
A. Level 1
B. Level 2
C. Level 3
D. Level 5
Correct Answer: C
Rationale: An ESI Level 3 patient requires multiple resources (e.g.,
sutures, imaging, labs) but vital signs are stable, and they are not in
immediate danger.
5. When should the triage nurse reassess a patient in the waiting
room?
A. Only when the patient complains
B. Every 4 hours
C. After a specified time based on the triage acuity and department
,policy
D. Only when a bed becomes available
Correct Answer: C
Rationale: Patients waiting for care must be reassessed at intervals
determined by their acuity level and departmental policy to detect
clinical deterioration.
6. Which of the following is a contraindication for using the Traffic
Director triage system?
A. High patient volume
B. Limited physical space
C. The presence of a non-clinical greeter
D. The need for rapid, expert clinical decision-making
Correct Answer: D
Rationale: The Traffic Director model uses a non-clinical person to
quickly sort patients, which is inappropriate for high-acuity patients
who require immediate clinical judgment.
7. A patient with a known history of asthma presents with audible
wheezing and using accessory muscles. What is the priority triage
action?
A. Place the patient in the waiting room
B. Assign an ESI level 4
C. Initiate immediate treatment or place in a monitored bed
D. Obtain a full set of vital signs before intervention
Correct Answer: C
Rationale: This patient is in respiratory distress and requires immediate
intervention; triage should be expedited, and the patient should not
wait.
, 8. What is the most common error made during the triage process?
A. Over-triaging patients
B. Under-triaging patients
C. Failing to document vital signs
D. Using the wrong triage system
Correct Answer: B
Rationale: Under-triaging, or assigning a lower acuity level than
warranted, is a major patient safety risk that can lead to delayed
treatment and poor outcomes.
9. A parent brings in a 2-year-old child with a fever of 104°F, lethargy,
and poor skin turgor. What ESI level is assigned?
A. Level 1
B. Level 2
C. Level 3
D. Level 4
Correct Answer: B
Rationale: The child is high-risk due to age, fever, and signs of
dehydration/lethargy, requiring prompt medical evaluation (ESI Level 2).
10. Which of the following describes the "right reason" in the four
rights of triage?
A. The patient is seen by the right doctor
B. The patient is assigned the correct acuity level based on their
condition
C. The patient is placed in the right bed
D. The patient is given the right medication
