ENA TRIAGE CORE REVIEWS ANSWERS AND
QUESTIONS SET A+
✔✔Using the Emergency Severity Index, the triage nurse should assign the highest
priority to which of these patients?
A. A man, age 59, with a head laceration who passed out and is disoriented
B. A child, age 7, with a dislocated arm and a heart rate of 120 beats per minute
C. A woman, age 38, with moderate abdominal pain who needs one resource
D. A infant, age 9 months, with a fever and a respiratory rate of 25 breaths per minute -
✔✔A. A man, age 59, with a head laceration who passed out and is disoriented
✔✔Which statement accurately characterizes measurement of a full set of vital signs in
triage?
A. Vital signs frequently change the assigned triage acuity.
B. Vital signs are needed to assign triage acuity accurately.
C. Vital signs are required to ensure that documentation is complete.
D. Vital signs provide additional information that may affect triage acuity. - ✔✔D. Vital
signs provide additional information that may affect triage acuity.
✔✔Triage - ✔✔comes from the French verb trier, which means to sort or to choose.
Triage is a process used to quickly: identify patients who require immediate care,
identify patients who are safe to wait for care, and to prioritize patient treatment in the
emergency department.
✔✔Four "rights" of Triage - ✔✔the right patient
in the right place
at the right time
for the right reason
✔✔Traffic Director Triage - ✔✔A nonclinical person is stationed at the ED entrance to
greet each patient upon presentation and, he or she decides whether the patient should
go to the waiting room or to an open bed in the ED. ED's with a lower volume of visits
may use this system because it would be less cost effective to staff with a nurse.
, ✔✔Spot-check Triage - ✔✔A system where when a patient presents to the emergency
department, a staff member notifies the registered nurse, who then does a quick look or
brief assessment to assign triage acuity. ED's with a lower volume of visits may use this
system because it would be less cost effective to staff with a nurse.
✔✔Comprehensive Triage - ✔✔The ED nurse assesses every patient and determines
the priority of care based on physical, developmental, and psychosocial needs, as well
as factors influencing flow through the emergency care system. Then the nurse assigns
an acuity level. This is the most advances system and the one recommended by the
Emergency Nurses Association.
✔✔Comprehensive Triage: Two-tiered Triage - ✔✔This system requires a minimum of
two triage nurses. The first triage nurse gives the patient a rapid assessment
immediately upon arrival to determine whether the patient has a life-threatening
emergency. Higher-acuity patients may be taken directly to the ED based on this initial
quick-look. for patients who do not have a life-threatening condition, the second triage
nurse performs a more comprehensive triage assessment in the triage area.
✔✔Comprehensive Triage: Provider at Triage - ✔✔The triage system places a
physician or mid-level provider, such as a NP or PA, in the triage area. These providers
work with the triage nurse to initiate laboratory, radiologic, and other appropriate
diagnostic and medical interventions before the patient is moved into the treatment
area.
✔✔Comprehensive Triage: Rapid Medical Examination - ✔✔A system that takes the
provider-at-triage system one step further. A physician of mid-level provider works
alongside the triage nurse in the triage area to provide a medical screening examination
as part of the traditional triage process. Only patients requiring a bed or admission are
placed in a treatment room. The remaining patients have their laboratory, radiologic,
and other diagnostic tests performed at triage. Patients wait in the waiting area until the
results of the diagnostic studies are available. Care is administered, and the patient is
discharged without having been placed in a bed in the treatment area.
✔✔Two-tiered Triage System - ✔✔Two phases that are completed by RNs: chief
complaint and rapid visual assessment and comprehensive triage assessment.
✔✔Best Practice for Triage - ✔✔A standardized five-level acuity system that nurses and
physicians understand. Focused triage with standing triage protocols to shorten the
length of stay. Electronic systems that assist in decision making. Specific education for
and competency in triage.
✔✔Triage Nurse - ✔✔assigns an acuity rating based on: an across-the-room
assessment, a brief interview, a focused examination.
QUESTIONS SET A+
✔✔Using the Emergency Severity Index, the triage nurse should assign the highest
priority to which of these patients?
A. A man, age 59, with a head laceration who passed out and is disoriented
B. A child, age 7, with a dislocated arm and a heart rate of 120 beats per minute
C. A woman, age 38, with moderate abdominal pain who needs one resource
D. A infant, age 9 months, with a fever and a respiratory rate of 25 breaths per minute -
✔✔A. A man, age 59, with a head laceration who passed out and is disoriented
✔✔Which statement accurately characterizes measurement of a full set of vital signs in
triage?
A. Vital signs frequently change the assigned triage acuity.
B. Vital signs are needed to assign triage acuity accurately.
C. Vital signs are required to ensure that documentation is complete.
D. Vital signs provide additional information that may affect triage acuity. - ✔✔D. Vital
signs provide additional information that may affect triage acuity.
✔✔Triage - ✔✔comes from the French verb trier, which means to sort or to choose.
Triage is a process used to quickly: identify patients who require immediate care,
identify patients who are safe to wait for care, and to prioritize patient treatment in the
emergency department.
✔✔Four "rights" of Triage - ✔✔the right patient
in the right place
at the right time
for the right reason
✔✔Traffic Director Triage - ✔✔A nonclinical person is stationed at the ED entrance to
greet each patient upon presentation and, he or she decides whether the patient should
go to the waiting room or to an open bed in the ED. ED's with a lower volume of visits
may use this system because it would be less cost effective to staff with a nurse.
, ✔✔Spot-check Triage - ✔✔A system where when a patient presents to the emergency
department, a staff member notifies the registered nurse, who then does a quick look or
brief assessment to assign triage acuity. ED's with a lower volume of visits may use this
system because it would be less cost effective to staff with a nurse.
✔✔Comprehensive Triage - ✔✔The ED nurse assesses every patient and determines
the priority of care based on physical, developmental, and psychosocial needs, as well
as factors influencing flow through the emergency care system. Then the nurse assigns
an acuity level. This is the most advances system and the one recommended by the
Emergency Nurses Association.
✔✔Comprehensive Triage: Two-tiered Triage - ✔✔This system requires a minimum of
two triage nurses. The first triage nurse gives the patient a rapid assessment
immediately upon arrival to determine whether the patient has a life-threatening
emergency. Higher-acuity patients may be taken directly to the ED based on this initial
quick-look. for patients who do not have a life-threatening condition, the second triage
nurse performs a more comprehensive triage assessment in the triage area.
✔✔Comprehensive Triage: Provider at Triage - ✔✔The triage system places a
physician or mid-level provider, such as a NP or PA, in the triage area. These providers
work with the triage nurse to initiate laboratory, radiologic, and other appropriate
diagnostic and medical interventions before the patient is moved into the treatment
area.
✔✔Comprehensive Triage: Rapid Medical Examination - ✔✔A system that takes the
provider-at-triage system one step further. A physician of mid-level provider works
alongside the triage nurse in the triage area to provide a medical screening examination
as part of the traditional triage process. Only patients requiring a bed or admission are
placed in a treatment room. The remaining patients have their laboratory, radiologic,
and other diagnostic tests performed at triage. Patients wait in the waiting area until the
results of the diagnostic studies are available. Care is administered, and the patient is
discharged without having been placed in a bed in the treatment area.
✔✔Two-tiered Triage System - ✔✔Two phases that are completed by RNs: chief
complaint and rapid visual assessment and comprehensive triage assessment.
✔✔Best Practice for Triage - ✔✔A standardized five-level acuity system that nurses and
physicians understand. Focused triage with standing triage protocols to shorten the
length of stay. Electronic systems that assist in decision making. Specific education for
and competency in triage.
✔✔Triage Nurse - ✔✔assigns an acuity rating based on: an across-the-room
assessment, a brief interview, a focused examination.
