Emergency Severity Index Questions With Complete
Solutions
Aggressive Life saving interventions Correct Answers -
Airway and breathing: Incubation, Surgical Airway, CPAP,
BiPAP, Bag Valve Mask, Ventilation
- Defibrillation
- External Pacing
- Chest needle decompression
- Hemodynamics: Significant IV fluid resuscitation, blood
administration, IV meds
- Control Major bleeding
Danger zone vital signs Correct Answers <3m: HR > 180, RR
> 50, O2 <92%
3m - 3y: HR > 160, RR > 40, O2 <92%
3 - 8y: HR > 140, RR > 30, O2 <92%
>8y: HR > 100, RR > 20, O2 <92%
Decision point B Correct Answers Is this a high risk situation?
- Determination is based on a brief patient interview, gross
observations, and "sixth sense"
- Do not require full set of vital signs
- Unsafe for the patient to wait
- Suggestive of a condition that could easily deteriorate
- Symptoms of condition that's treatment is Time sensitive
- Potential major life or organ threat
, Decision point B; Is the patient confused, lethargic, or
disorientated? Correct Answers • Is there an acute change in
level of consciousness?
• Is this a situation where the brain is structurally or chemically
compromised?
(Eg. onset of confusion)
Decision Point B; Is this patient in distress? Physiological or
psychological? Correct Answers • Sexual assault victim
• Combative patient
• Homicidal/suicidal patient
• Bipolar patient who is manic
• Acute grief reaction
• Known alcoholic with signs of minor head trauma
Decision point B; Is this patient in severe pain or distress?
Correct Answers • Is this patient currently in pain?
• Pain is subjective. It is what ever the patient says it is! • How
can we quantify it?
• Research based
• Documented on all ED patients
• Pain intensity rating
• Chief complaint
• PMH. Medications
• VS, physical assessment findings
• ASSIGN ESI level 2 if and only if
• Self reported 7/10 or greater and RN can not intervene and
they require
immediate intervention
• Do you want to give your last bed to this patient??
Solutions
Aggressive Life saving interventions Correct Answers -
Airway and breathing: Incubation, Surgical Airway, CPAP,
BiPAP, Bag Valve Mask, Ventilation
- Defibrillation
- External Pacing
- Chest needle decompression
- Hemodynamics: Significant IV fluid resuscitation, blood
administration, IV meds
- Control Major bleeding
Danger zone vital signs Correct Answers <3m: HR > 180, RR
> 50, O2 <92%
3m - 3y: HR > 160, RR > 40, O2 <92%
3 - 8y: HR > 140, RR > 30, O2 <92%
>8y: HR > 100, RR > 20, O2 <92%
Decision point B Correct Answers Is this a high risk situation?
- Determination is based on a brief patient interview, gross
observations, and "sixth sense"
- Do not require full set of vital signs
- Unsafe for the patient to wait
- Suggestive of a condition that could easily deteriorate
- Symptoms of condition that's treatment is Time sensitive
- Potential major life or organ threat
, Decision point B; Is the patient confused, lethargic, or
disorientated? Correct Answers • Is there an acute change in
level of consciousness?
• Is this a situation where the brain is structurally or chemically
compromised?
(Eg. onset of confusion)
Decision Point B; Is this patient in distress? Physiological or
psychological? Correct Answers • Sexual assault victim
• Combative patient
• Homicidal/suicidal patient
• Bipolar patient who is manic
• Acute grief reaction
• Known alcoholic with signs of minor head trauma
Decision point B; Is this patient in severe pain or distress?
Correct Answers • Is this patient currently in pain?
• Pain is subjective. It is what ever the patient says it is! • How
can we quantify it?
• Research based
• Documented on all ED patients
• Pain intensity rating
• Chief complaint
• PMH. Medications
• VS, physical assessment findings
• ASSIGN ESI level 2 if and only if
• Self reported 7/10 or greater and RN can not intervene and
they require
immediate intervention
• Do you want to give your last bed to this patient??
