BKAT MEDSURG EMERGENCY ROOM NURSING
TRIAGE NURSING STUDY GUIDE WITH SOLUTION
On the Glasgow Coma Scale, what is the level that a patient must be intubate? - ANSWER A patient score
of 8 or less requires intubation
(check)
**anything less than 9 = respiratory effort not adequate
Heat Stroke vs. Heat Exhaustion (signs and symptoms) - ANSWER Heat Exhaustion: a condition whose
symptoms may include heavy sweating and a rapid pulse, a result of your body overheating
-Signs & Symptoms: faintness or dizziness; nausea or vomiting; heavy sweating often accompanied by
cold, clammy skin; weak, rapid pulse; pale or flushed face; muscle cramps; headache; weakness or
fatigue.
Heat Stroke:a condition caused by your body overheating, usually as a result of prolonged exposure to or
physical exertion in high temperatures. This most serious form of heat injury, heatstroke can occur if
your body temperature rises to 104 F (40 C) or higher.
-Signs & Symptoms: confusion; dark-colored urine (a sign of dehydration); dizziness; fainting; fatigue;
headache; muscle or abdominal cramps; nausea, vomiting, or diarrhea
SANE priorities - ANSWER Ensure that the patient feels safe and secure
SANEs will document the account of the assault, perform necessary medical exams, testing and
treatment, then collect crucial, time sensitive evidence
Provide preventative treatment for HIV, STDs, and pregnancy
These nurses are always on call
,Depression prioirities - ANSWER Safety!
,Respiratory Distress Treatment Priorities- when do you intubate and when do you use a non-rebreather?
- ANSWER You intubate when the patient is unable to maintain adequate respirations
You use non-rebreathers in all other situations
Trauma assessment-index of suspicision - ANSWER ABCDE assessment
Stabilize cervical spine is trauma is suspected (always suspect this until either confirmed by CT scan)
index of suspicion- suspecting the patients injuries or pathology based on the mechanism of injury
Antidotes for OD posioining - ANSWER Tylenol OD- Mucomyst (acetylcysteine solution)
Toilet bowl cleaner-
Baby Aspirin OD- Sodium bicarbonate
Gasoline-
Blood Pressure pills-
Acidic vs. Basic Emergency Treatment Plan in the ED (initial priorities) - ANSWER
When do you give ipecac, milk, activated charcoal? - ANSWER Ipecac induces vomiting and should be
given when the poison is not caustic
Milk- can be given pre hospital to neutralize acidic poisons (but you must call poison control first)
Activated charcoal decreased the absorption of the poison and can be given PO, through an NG tube, or
through a rectal tube within 60 minutes of poison ingestion
Chest Pain Priorities - ANSWER ECG
, IV access
Pain Management (nitroglycerin and then morphine if the nitro doesn't work)
Stat labs (Troponins & CPK)
Stat chest x-ray
Triage Color Codes-Who are the sickest vs the stronger, Who stays at the scene and who gets medical
treatment/transferred? - ANSWER (1) Green = good --> these patients can walk to a designated area
(2) Red = life threatening --> these people receive attention second
(3) Blue = life threatening injury more severe than red --> these people receive care third (because they
are not expected to survive their injuries)
(4) Black = dead --> these ones you deal with last
Triage Color Codes- what color represents the worst or best patient? - ANSWER Green (minor injury) or
yellow (non-life-threatening injury) tag indicates noncritical injury
Red tag indicates life-threatening injury
Blue tag indicates those who are worse and are expected to die --> for these patients if you see they
aren't breathing you do a head tilt, chin lift and walk away
Black tag identifies the dead
What is the purpose of the Office of Emergency Operation Plan? Critical Incident Stress Management
Team? What are their roles and responsibilities? - ANSWER Office of Emergency Operation Plan: details
policies and procedures applicable to the management of all-hazard events to include natural disasters,
accidents, and terrorist or significant criminal incidents. The scope of the plan extends from pre-incident
preparedness, prevention, and mitigation, to response and recovery activities.
Incident Stress Management Team: an intervention protocol developed specifically for dealing with
traumatic events. It is a formal, highly structured and professionally recognized process for helping those
TRIAGE NURSING STUDY GUIDE WITH SOLUTION
On the Glasgow Coma Scale, what is the level that a patient must be intubate? - ANSWER A patient score
of 8 or less requires intubation
(check)
**anything less than 9 = respiratory effort not adequate
Heat Stroke vs. Heat Exhaustion (signs and symptoms) - ANSWER Heat Exhaustion: a condition whose
symptoms may include heavy sweating and a rapid pulse, a result of your body overheating
-Signs & Symptoms: faintness or dizziness; nausea or vomiting; heavy sweating often accompanied by
cold, clammy skin; weak, rapid pulse; pale or flushed face; muscle cramps; headache; weakness or
fatigue.
Heat Stroke:a condition caused by your body overheating, usually as a result of prolonged exposure to or
physical exertion in high temperatures. This most serious form of heat injury, heatstroke can occur if
your body temperature rises to 104 F (40 C) or higher.
-Signs & Symptoms: confusion; dark-colored urine (a sign of dehydration); dizziness; fainting; fatigue;
headache; muscle or abdominal cramps; nausea, vomiting, or diarrhea
SANE priorities - ANSWER Ensure that the patient feels safe and secure
SANEs will document the account of the assault, perform necessary medical exams, testing and
treatment, then collect crucial, time sensitive evidence
Provide preventative treatment for HIV, STDs, and pregnancy
These nurses are always on call
,Depression prioirities - ANSWER Safety!
,Respiratory Distress Treatment Priorities- when do you intubate and when do you use a non-rebreather?
- ANSWER You intubate when the patient is unable to maintain adequate respirations
You use non-rebreathers in all other situations
Trauma assessment-index of suspicision - ANSWER ABCDE assessment
Stabilize cervical spine is trauma is suspected (always suspect this until either confirmed by CT scan)
index of suspicion- suspecting the patients injuries or pathology based on the mechanism of injury
Antidotes for OD posioining - ANSWER Tylenol OD- Mucomyst (acetylcysteine solution)
Toilet bowl cleaner-
Baby Aspirin OD- Sodium bicarbonate
Gasoline-
Blood Pressure pills-
Acidic vs. Basic Emergency Treatment Plan in the ED (initial priorities) - ANSWER
When do you give ipecac, milk, activated charcoal? - ANSWER Ipecac induces vomiting and should be
given when the poison is not caustic
Milk- can be given pre hospital to neutralize acidic poisons (but you must call poison control first)
Activated charcoal decreased the absorption of the poison and can be given PO, through an NG tube, or
through a rectal tube within 60 minutes of poison ingestion
Chest Pain Priorities - ANSWER ECG
, IV access
Pain Management (nitroglycerin and then morphine if the nitro doesn't work)
Stat labs (Troponins & CPK)
Stat chest x-ray
Triage Color Codes-Who are the sickest vs the stronger, Who stays at the scene and who gets medical
treatment/transferred? - ANSWER (1) Green = good --> these patients can walk to a designated area
(2) Red = life threatening --> these people receive attention second
(3) Blue = life threatening injury more severe than red --> these people receive care third (because they
are not expected to survive their injuries)
(4) Black = dead --> these ones you deal with last
Triage Color Codes- what color represents the worst or best patient? - ANSWER Green (minor injury) or
yellow (non-life-threatening injury) tag indicates noncritical injury
Red tag indicates life-threatening injury
Blue tag indicates those who are worse and are expected to die --> for these patients if you see they
aren't breathing you do a head tilt, chin lift and walk away
Black tag identifies the dead
What is the purpose of the Office of Emergency Operation Plan? Critical Incident Stress Management
Team? What are their roles and responsibilities? - ANSWER Office of Emergency Operation Plan: details
policies and procedures applicable to the management of all-hazard events to include natural disasters,
accidents, and terrorist or significant criminal incidents. The scope of the plan extends from pre-incident
preparedness, prevention, and mitigation, to response and recovery activities.
Incident Stress Management Team: an intervention protocol developed specifically for dealing with
traumatic events. It is a formal, highly structured and professionally recognized process for helping those
