Emergency Triage Practice Questions -
Answered Graded A+
The client is demonstrating vital signs consistent with fluid volume deficit, likely due to
bleeding and/or hypovolemic shock as a result of the automobile accident. The client
will need intravenous fluid volume replacement using an isotonic fluid (eg, 0.9% normal
saline) to expand or replace blood volume and normalize vital signs. The other
prescriptions can be implemented once the intravenous fluids have been initiated.
A car accident involves four vehicles on a remote highway. The nearest emergency
department is 15 minutes away. Which victim should be transported by helicopter to the
nearest hospital?
1. A 10-year-old with a simple fracture of the femur who is crying and cannot find his
parents.
2. Middle-aged woman with cold, clammy skin and a heart rate of 120 bpm who is
unconscious.
3. Middle-aged man with severe asthma and a heart rate of 120 bpm who is having
difficulty breathing.
4. A 70-year-old man with a severe headache who is conscious. - ANSWER-2.
The middle-aged woman is likely in shock. She is classified as a triage level I, requiring
immediate care. The child with moderate trauma is classified as triage level III (urgent
and should be treated within 30 minutes). The man with asthma and the man with the
severe headache are classified as triage level II (emergent) and can be transported by
ambulance and reach the hospital within 15 minutes.
A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable
about biochemical agents, is giving directions to the travelers. Which direction should
the nurse provide to the travelers?
1. Hold their breath as much as possible.
2. Stand up to avoid heavy exposure.
3. Lie down to stay under the exposure.
4. Attempt to breathe through their clothing. - ANSWER-2
Standing up will avoid heavy exposure because the chemical will sink toward the floor
or ground.
1. The absence of breathing is death, and this is neither a viable option nor a sensible
recommendation to terrified people.
3. Staying below the level of the smoke is the instruction for a fire. 4. Breathing through
the clothing, which is probably contaminated with the chemical, will not provide
protection from the chemical entering the lung.
,A client has been admitted to the emergency department diagnosed with food poisoning
following an outdoor picnic. The nurse should do which of the following? Select all that
apply.
1. Tell the family to discard contaminated food.
2. Collect specimens for laboratory examination.
3. Assess vital signs.
4. Initiate support for the respiratory system.
5. Monitor fluid and electrolyte status.
6. Provide antiemetics, as prescribed. - ANSWER-2, 3, 4, 5, 6.
Food poisoning is a sudden illness that occurs after ingestion of contaminated food or
drink. The nurse should first assess vital signs and then ensure that the client is not in
respiratory distress, because death from respiratory paralysis can occur with botulism,
fish poisoning, and other food poisonings. Measures to control nausea are important to
prevent vomiting, which could exacerbate fluid and electrolyte imbalance. Because
large volumes of electrolytes and water are lost by vomiting and diarrhea, fluid and
electrolyte status needs to be continuously monitored. The key to treatment is
determining the source and type of food poisoning. If possible, rather than discarding
the food, the suspected food should be brought to the medical facility and a history
obtained from the client or family.
A client is admitted to the emergency department after being found in a daze walking
away from her burning car after an accident. She was not injured in the accident, but the
other driver died. She states, "I can't handle it anymore. There's no point to it all." The
crisis nurse recommends hospital admission based on the identification of which of the
following concerns?
1. The client was walking around in a daze.
2. The client has a lack of knowledge of what to do next.
3. The client is having delusions and is not in touch with reality.
4. The client is expressing helplessness and hopelessness and is a risk for suicide. -
ANSWER-4.
The client is demonstrating helplessness and hopelessness during a crisis, as
evidenced by her statement, "I can't handle it. There is no point to it." Feelings of
helplessness and hopelessness are common factors associated with suicidal ideation.
Therefore, the client must be hospitalized to ensure safety to herself. There is not
sufficient information to know if the client has a lack of knowledge of what to do next.
The client is not having delusions, which would be evidenced by statements such as
"The devil set my car on fire," not just the inability to think clearly.
, A client is admitted to the emergency department with a full-thickness burn to the right
arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is
now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should:
1. Administer morphine sulfate IV push for the severe pain.
2. Call the physician to report the loss of the radial pulse.
3. Continue to assess the arm every hour for any additional changes.
4. Instruct the client to exercise his fingers and wrist. - ANSWER-2
Circulation can be impaired by circumferential burns and edema, causing compartment
syndrome. Early recognition and treatment of impaired blood supply is key. The
physician should be informed since an escharotomy (incision through full-thickness
eschar) is frequently performed to restore circulation. Pain management is important for
burn clients, but restoration of circulation is the priority. Assessments should be
performed more frequently. Exercise will not restore the obstructed circulation.
A client is brought to the emergency room via ambulance accompanied by her sister.
The sister states, "She was playing cards with us and had a seizure. Then she had
another seizure just as the first one was stopping, so I called the ambulance." The client
is currently not demonstrating any seizure activity, her eyes are closed, and she does
not respond to commands. Which intervention should the nurse implement first?
1. Make sure suction equipment is set up bedside.
2. Draw blood for a phenytoin (Dilantin) level.
3. Assess the client's vital signs.
4. Prepare the client for a head computed tomography (CT). - ANSWER-1
Following a seizure (postictal stage), the client will most likely be tired and want to
sleep. Maintaining the airway is the priority; the nurse should verify that suction
equipment is available in case the client aspirates or chokes. Assessing vital signs and
obtaining a Dilantin level are both appropriate actions by the nurse, but assuring safety
is the first priority. There is no indication of a need to obtain a head CT at this time.
A client who is hospitalized with burns after losing the family home in a fire becomes
angry and screams at a nurse when dinner is served late. How should the nurse
respond?
a. Do you need something for pain right now?
b. Please stop yelling. I brought dinner as soon as I could.
c. I suggest that you get control of yourself.
d. You seem upset. I have time to talk if you'd like. - ANSWER-D
Answered Graded A+
The client is demonstrating vital signs consistent with fluid volume deficit, likely due to
bleeding and/or hypovolemic shock as a result of the automobile accident. The client
will need intravenous fluid volume replacement using an isotonic fluid (eg, 0.9% normal
saline) to expand or replace blood volume and normalize vital signs. The other
prescriptions can be implemented once the intravenous fluids have been initiated.
A car accident involves four vehicles on a remote highway. The nearest emergency
department is 15 minutes away. Which victim should be transported by helicopter to the
nearest hospital?
1. A 10-year-old with a simple fracture of the femur who is crying and cannot find his
parents.
2. Middle-aged woman with cold, clammy skin and a heart rate of 120 bpm who is
unconscious.
3. Middle-aged man with severe asthma and a heart rate of 120 bpm who is having
difficulty breathing.
4. A 70-year-old man with a severe headache who is conscious. - ANSWER-2.
The middle-aged woman is likely in shock. She is classified as a triage level I, requiring
immediate care. The child with moderate trauma is classified as triage level III (urgent
and should be treated within 30 minutes). The man with asthma and the man with the
severe headache are classified as triage level II (emergent) and can be transported by
ambulance and reach the hospital within 15 minutes.
A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable
about biochemical agents, is giving directions to the travelers. Which direction should
the nurse provide to the travelers?
1. Hold their breath as much as possible.
2. Stand up to avoid heavy exposure.
3. Lie down to stay under the exposure.
4. Attempt to breathe through their clothing. - ANSWER-2
Standing up will avoid heavy exposure because the chemical will sink toward the floor
or ground.
1. The absence of breathing is death, and this is neither a viable option nor a sensible
recommendation to terrified people.
3. Staying below the level of the smoke is the instruction for a fire. 4. Breathing through
the clothing, which is probably contaminated with the chemical, will not provide
protection from the chemical entering the lung.
,A client has been admitted to the emergency department diagnosed with food poisoning
following an outdoor picnic. The nurse should do which of the following? Select all that
apply.
1. Tell the family to discard contaminated food.
2. Collect specimens for laboratory examination.
3. Assess vital signs.
4. Initiate support for the respiratory system.
5. Monitor fluid and electrolyte status.
6. Provide antiemetics, as prescribed. - ANSWER-2, 3, 4, 5, 6.
Food poisoning is a sudden illness that occurs after ingestion of contaminated food or
drink. The nurse should first assess vital signs and then ensure that the client is not in
respiratory distress, because death from respiratory paralysis can occur with botulism,
fish poisoning, and other food poisonings. Measures to control nausea are important to
prevent vomiting, which could exacerbate fluid and electrolyte imbalance. Because
large volumes of electrolytes and water are lost by vomiting and diarrhea, fluid and
electrolyte status needs to be continuously monitored. The key to treatment is
determining the source and type of food poisoning. If possible, rather than discarding
the food, the suspected food should be brought to the medical facility and a history
obtained from the client or family.
A client is admitted to the emergency department after being found in a daze walking
away from her burning car after an accident. She was not injured in the accident, but the
other driver died. She states, "I can't handle it anymore. There's no point to it all." The
crisis nurse recommends hospital admission based on the identification of which of the
following concerns?
1. The client was walking around in a daze.
2. The client has a lack of knowledge of what to do next.
3. The client is having delusions and is not in touch with reality.
4. The client is expressing helplessness and hopelessness and is a risk for suicide. -
ANSWER-4.
The client is demonstrating helplessness and hopelessness during a crisis, as
evidenced by her statement, "I can't handle it. There is no point to it." Feelings of
helplessness and hopelessness are common factors associated with suicidal ideation.
Therefore, the client must be hospitalized to ensure safety to herself. There is not
sufficient information to know if the client has a lack of knowledge of what to do next.
The client is not having delusions, which would be evidenced by statements such as
"The devil set my car on fire," not just the inability to think clearly.
, A client is admitted to the emergency department with a full-thickness burn to the right
arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is
now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should:
1. Administer morphine sulfate IV push for the severe pain.
2. Call the physician to report the loss of the radial pulse.
3. Continue to assess the arm every hour for any additional changes.
4. Instruct the client to exercise his fingers and wrist. - ANSWER-2
Circulation can be impaired by circumferential burns and edema, causing compartment
syndrome. Early recognition and treatment of impaired blood supply is key. The
physician should be informed since an escharotomy (incision through full-thickness
eschar) is frequently performed to restore circulation. Pain management is important for
burn clients, but restoration of circulation is the priority. Assessments should be
performed more frequently. Exercise will not restore the obstructed circulation.
A client is brought to the emergency room via ambulance accompanied by her sister.
The sister states, "She was playing cards with us and had a seizure. Then she had
another seizure just as the first one was stopping, so I called the ambulance." The client
is currently not demonstrating any seizure activity, her eyes are closed, and she does
not respond to commands. Which intervention should the nurse implement first?
1. Make sure suction equipment is set up bedside.
2. Draw blood for a phenytoin (Dilantin) level.
3. Assess the client's vital signs.
4. Prepare the client for a head computed tomography (CT). - ANSWER-1
Following a seizure (postictal stage), the client will most likely be tired and want to
sleep. Maintaining the airway is the priority; the nurse should verify that suction
equipment is available in case the client aspirates or chokes. Assessing vital signs and
obtaining a Dilantin level are both appropriate actions by the nurse, but assuring safety
is the first priority. There is no indication of a need to obtain a head CT at this time.
A client who is hospitalized with burns after losing the family home in a fire becomes
angry and screams at a nurse when dinner is served late. How should the nurse
respond?
a. Do you need something for pain right now?
b. Please stop yelling. I brought dinner as soon as I could.
c. I suggest that you get control of yourself.
d. You seem upset. I have time to talk if you'd like. - ANSWER-D
