Emergency Nursing & Triage NCLEX Practice
(Part 2: 20 Questions)
1. 1. Question
Michael works as a triage nurse, and four clients arrive at the
emergency department at the same time. List the order in which he
will assess these clients from first to last.
View Answers:
o An ambulatory dazed 25-year-old male with a bandaged head
wound
o A 35-year-old jogger with a twisted ankle, having a pedal
pulse, and no deformity
o A 50-year-old female with moderate abdominal pain and
occasional vomiting
o An irritable infant with a fever, petechiae, and nuchal rigidity
Incorrect
The correct order is shown above
Rationale:
5. An irritable infant with fever and petechiae should be further
assessed for other meningeal signs. Meningitis is a life-
threatening disorder that is most often caused by bacteria or
viruses. Before the era of antibiotics, the condition was
universally fatal. Nevertheless, even with great innovations in
healthcare, the condition still carries a mortality rate of close to
25%.
6. The patient with the head wound needs additional history and
assessment for intracranial pressure. Traumatic brain injury (TBI)
due to head trauma is a common presentation in emergency
departments and usually accounts for more than one million
visits annually. It is a common cause of death and disability
among children and adults.
7. The patient with moderate abdominal pain is uncomfortable, but
not unstable at this point. An acute abdomen is a condition that
demands urgent attention and treatment. The acute abdomen
may be caused by an infection, inflammation, vascular occlusion,
, or obstruction. The patient will usually present with sudden onset
of abdominal pain with associated nausea or vomiting.
8. For the ankle injury, a medical evaluation can be delayed 24 – 48
hours if necessary. Acute ankle sprains are commonly seen in
both primary care practices and emergency departments and can
result in significant short-term morbidity, recurrent injuries, and
functional instability. Appropriate initial evaluation and treatment
can decrease the likelihood of these complications.
2. 2. Question
In conducting a primary survey on a trauma patient, which of the
following is considered one of the priority elements of the primary
survey?
o A. Brief neurologic assessment
o B. Client's allergy history
o C. Initiation of pulse oximetry
o D. Complete set of vital signs
Incorrect
Correct Answer: A. Brief neurologic assessment
A brief neurologic assessment to determine the level of consciousness
and pupil reaction is part of the primary survey. Once the patient is
stabilized, a neurologic examination should be conducted. CT scan is
the diagnostic modality of choice in the initial evaluation of patients
with head trauma.
Option B: Primary injury includes injury upon the initial impact
that causes displacement of the brain due to direct impact, rapid
acceleration-deceleration, or penetration. These injuries may
cause contusions, hematomas, or axonal injuries.
Option C: Identify any condition which might compromise the
airway, such as pneumothorax. The cervical spine should be
maintained in-line during intubation. Nasotracheal intubation
should be avoided in patients with facial trauma or basilar skull
fracture.
Option D: Vital signs are considered part of the secondary
survey. Avoid hypotension. Normal blood pressure may not be
adequate to maintain adequate flow and CPP if ICP is elevated.
, Isolated head trauma usually does not cause hypotension. Look
for another cause if the patient is in shock.
3. 3. Question
A 65-year-old patient arrived at the triage area with complaints of
diaphoresis, dizziness, and left-sided chest pain. This patient should be
prioritized into which category?
A. Non-urgent
B. Urgent
C. Emergent
D. High urgent
Incorrect
Correct Answer: C. Emergent
Chest pain is considered an emergent priority, which is defined as
potentially life-threatening. If the nurse can accurately diagnose the
patient with these criteria and mark as a Level 1 trauma patient, the
patient will need immediate life-saving therapy. Immediate physician
involvement in the care of the patient is critical and is one of the
differences between level 1 and level 2 patient designations.
Option A: Non-urgent conditions can wait for hours or even days.
If the patient meets a certain group of discriminators, he or she is
categorized into an urgency category that ranges from
immediate to non-urgent.
Option B: Clients with urgent priority need treatment within 2
hours of triage (e.g. kidney stones). If the patient is not
categorized as a level 1, the nurse then decides if the patient
should wait or not. This is determined by three questions; is the
patient in a high-risk situation, confused, lethargic, or
disoriented? Or is the patient in severe pain or distress?
Option D: High urgency is not commonly used; however, in 5-tier
triage systems, High urgent patients fall between emergent and
urgent in terms of the time elapsing prior to treatment. The
urgency categorization is tied to a maximum waiting time, with
the immediate maximum waiting time being 0 minutes, very
urgent is 10 minutes max. Urgent waiting time is maxed at 60
minutes, standard 120 minutes, and non-urgent waiting time is
maxed at 240 minutes.
(Part 2: 20 Questions)
1. 1. Question
Michael works as a triage nurse, and four clients arrive at the
emergency department at the same time. List the order in which he
will assess these clients from first to last.
View Answers:
o An ambulatory dazed 25-year-old male with a bandaged head
wound
o A 35-year-old jogger with a twisted ankle, having a pedal
pulse, and no deformity
o A 50-year-old female with moderate abdominal pain and
occasional vomiting
o An irritable infant with a fever, petechiae, and nuchal rigidity
Incorrect
The correct order is shown above
Rationale:
5. An irritable infant with fever and petechiae should be further
assessed for other meningeal signs. Meningitis is a life-
threatening disorder that is most often caused by bacteria or
viruses. Before the era of antibiotics, the condition was
universally fatal. Nevertheless, even with great innovations in
healthcare, the condition still carries a mortality rate of close to
25%.
6. The patient with the head wound needs additional history and
assessment for intracranial pressure. Traumatic brain injury (TBI)
due to head trauma is a common presentation in emergency
departments and usually accounts for more than one million
visits annually. It is a common cause of death and disability
among children and adults.
7. The patient with moderate abdominal pain is uncomfortable, but
not unstable at this point. An acute abdomen is a condition that
demands urgent attention and treatment. The acute abdomen
may be caused by an infection, inflammation, vascular occlusion,
, or obstruction. The patient will usually present with sudden onset
of abdominal pain with associated nausea or vomiting.
8. For the ankle injury, a medical evaluation can be delayed 24 – 48
hours if necessary. Acute ankle sprains are commonly seen in
both primary care practices and emergency departments and can
result in significant short-term morbidity, recurrent injuries, and
functional instability. Appropriate initial evaluation and treatment
can decrease the likelihood of these complications.
2. 2. Question
In conducting a primary survey on a trauma patient, which of the
following is considered one of the priority elements of the primary
survey?
o A. Brief neurologic assessment
o B. Client's allergy history
o C. Initiation of pulse oximetry
o D. Complete set of vital signs
Incorrect
Correct Answer: A. Brief neurologic assessment
A brief neurologic assessment to determine the level of consciousness
and pupil reaction is part of the primary survey. Once the patient is
stabilized, a neurologic examination should be conducted. CT scan is
the diagnostic modality of choice in the initial evaluation of patients
with head trauma.
Option B: Primary injury includes injury upon the initial impact
that causes displacement of the brain due to direct impact, rapid
acceleration-deceleration, or penetration. These injuries may
cause contusions, hematomas, or axonal injuries.
Option C: Identify any condition which might compromise the
airway, such as pneumothorax. The cervical spine should be
maintained in-line during intubation. Nasotracheal intubation
should be avoided in patients with facial trauma or basilar skull
fracture.
Option D: Vital signs are considered part of the secondary
survey. Avoid hypotension. Normal blood pressure may not be
adequate to maintain adequate flow and CPP if ICP is elevated.
, Isolated head trauma usually does not cause hypotension. Look
for another cause if the patient is in shock.
3. 3. Question
A 65-year-old patient arrived at the triage area with complaints of
diaphoresis, dizziness, and left-sided chest pain. This patient should be
prioritized into which category?
A. Non-urgent
B. Urgent
C. Emergent
D. High urgent
Incorrect
Correct Answer: C. Emergent
Chest pain is considered an emergent priority, which is defined as
potentially life-threatening. If the nurse can accurately diagnose the
patient with these criteria and mark as a Level 1 trauma patient, the
patient will need immediate life-saving therapy. Immediate physician
involvement in the care of the patient is critical and is one of the
differences between level 1 and level 2 patient designations.
Option A: Non-urgent conditions can wait for hours or even days.
If the patient meets a certain group of discriminators, he or she is
categorized into an urgency category that ranges from
immediate to non-urgent.
Option B: Clients with urgent priority need treatment within 2
hours of triage (e.g. kidney stones). If the patient is not
categorized as a level 1, the nurse then decides if the patient
should wait or not. This is determined by three questions; is the
patient in a high-risk situation, confused, lethargic, or
disoriented? Or is the patient in severe pain or distress?
Option D: High urgency is not commonly used; however, in 5-tier
triage systems, High urgent patients fall between emergent and
urgent in terms of the time elapsing prior to treatment. The
urgency categorization is tied to a maximum waiting time, with
the immediate maximum waiting time being 0 minutes, very
urgent is 10 minutes max. Urgent waiting time is maxed at 60
minutes, standard 120 minutes, and non-urgent waiting time is
maxed at 240 minutes.
