ENA: Triage Questions and Answers with complete solution

During triage, the nurse should perform which action first for a patient who presents after a fall? - Determine what caused the fall Which individual could qualify to be a triage nurse? - A nurse with 1 year of experience in emergency nursing. Which patient poses the greatest risk for violence at triage? - A patient who is speaking loudly and pacing in the waiting room Which function differentiates the Canadian Triage and Acuity Scale from the Emergency Severity Index? - It identifies a recommended time to physician examination for each triage level. The triage nurse should bring which patient to the patient care area first? - A man who presents to triage with diaphoresis and complaints of chest pain When using the three-level acuity rating system, you should assign which level to a man with abdominal pain? - urgent In which triage system would a nonclinical greeter determine the patient's chief complaint and determine if the patient was sick or not sick? - Traffic director When performing an across-the-room assessment, the triage nurse uses which senses? - Sight and hearing Which question best elicits details from a patient seeking treatment in the emergency department. - "Why do you think you fell?" The triage nurse should being the interview with which activity? - Confirming the patient's identityThe triage nurse should perform which important infection control measure? - Place an immunosuppressed patient in a separate waiting area. Detection of severe jaundice during an across-the-room assessment falls under which category of assessment? - Skin color In response to the triage nurse's question, a patient says, "The pain starts in my lower abdomen and goes through to my back." This response reflects which component of the PQRST mnemonic? - R - radiation Which statement correctly reflects the requirements set forth in the Emergency Medical Treatment and Active Labor Act? - If no emergency condition exists, the requirements of this act cease. For a patient with a finger laceration, the triage nurse should assess which parameter during the focused assessment? - Tendon involvement A pediatric patient with increased work of breathing is likely to display which assessment finding? - Grunting The triage nurse should be aware of which performance improvement measure? - The acceptable arrival time to triage time When triaging a potential psychiatric patient, which action is the triage nurse's priority? - Assess patient and staff safety. When triaging a geriatric patient, the triage nurse should routinely perform which action? - Evaluate the patient's interactions with his or her family.