ENA TRIAGE LATEST FINALS ANSWERS AND
QUESTIONS SET A+
✔✔Sense: Smell - ✔✔stool, urine, or vomit
ketones
alcohol or cigarettes
poor hygiene
pus
chemicals
✔✔SAMPLE Mnemonic - ✔✔S=symptoms associated with the illness or injury
A=allergies
M=medications currently used, including anticoagulant therapy
P=past medical history
L=last oral intake last output
E=events and environmental factors related to the illness or injury
✔✔Emergency Medical Treatment and Active Labor Act (EMTALA) - ✔✔Congress
passed in 1986, to ensure access to emergency care regardless of an individual's ability
to pay. This legislation was enacted in response to reports of hospitals "dumping" or
transferring patients to other facilities because of their inability to pay for care. It
requires all hospitals that receive Medicare payments to provide a medical screening
examination to every patient who presents for care. If the medical screening
examination detects an emergency medical condition, the patient must be stabilized
within the hospital's capabilities before transfer. If the patient cannot be stabilized and
needs care beyond the hospital's capabilities or if the patient requests a transfer, an
appropriate transfer can be arranged.
✔✔For a patient with a finger laceration, the triage nurse should assess which
parameter during the focused assessment?
A. Tetanus immunization status
B. Oxygen saturation
C. Tendon involvement
D. Pronator drift - ✔✔C. Tendon involvement
, ✔✔Which individual could qualify to be a triage nurse?
A. A new graduate who was a paramedic for several years
B. An experienced nurse who has just transferred from a medical unit
C. A nurse with 1 year of experience in emergency nursing
D. An orientee who has successfully completed Advanced Cardiac Life Support training
- ✔✔C. A nurse with 1 year of experience in emergency nursing
✔✔When a patient decides to leave the emergency department without being seen by
an independent care practitioner, what should the triage nurse do first?
A. Determine the reason the patient wants to leave.
B. Have the patient sign a statement saying he or she is leaving before receiving a
medical screening examination.
C. Document that the patient has left against medical advice.
D. If a patient does not answer when called, classify him or her as left without being
seen. - ✔✔A. Determine the reason the patient wants to leave.
✔✔When triaging a potential psychiatric patient, which action is the triage nurse's
priority?
A. Assess patient and staff safety.
B. Determine the patient's coping mechanisms.
C. Assess the work of breathing.
D. Contact the patient's psychiatrist. - ✔✔A. Assess patient and staff safety.
✔✔In which triage system does the nurse obtain the patient's chief complaint, medical
and medication history, and vital signs and perform a focused assessment before
assigning an acuity level?
A. Traffic director
B. Spot-check triage
C. Comprehensive
D. Two-tiered triage - ✔✔C. Comprehensive
✔✔When triaging an older adult patient, the triage nurse should routinely perform which
action?
A. Speak loudly to older adults.
B. Use only closed-ended questions to obtain medical history.
C. Determine if the patient has a plan to hurt others.
D. Evaluate the patient's interactions with his or her family. - ✔✔D. Evaluate the
patient's interactions with his or her family.
✔✔The triage nurse should perform which important infection control measure?
A. Wear gloves continuously so that hand hygiene is not required between patients.
B. Place an immunosuppressed patient in a separate waiting area.
C. Give an N95 mask to a patient who presents with a cough.
D. Expect an independent care practitioner to perform infectious disease screening. -
✔✔B. Place an immunosuppressed patient in a separate waiting area.
QUESTIONS SET A+
✔✔Sense: Smell - ✔✔stool, urine, or vomit
ketones
alcohol or cigarettes
poor hygiene
pus
chemicals
✔✔SAMPLE Mnemonic - ✔✔S=symptoms associated with the illness or injury
A=allergies
M=medications currently used, including anticoagulant therapy
P=past medical history
L=last oral intake last output
E=events and environmental factors related to the illness or injury
✔✔Emergency Medical Treatment and Active Labor Act (EMTALA) - ✔✔Congress
passed in 1986, to ensure access to emergency care regardless of an individual's ability
to pay. This legislation was enacted in response to reports of hospitals "dumping" or
transferring patients to other facilities because of their inability to pay for care. It
requires all hospitals that receive Medicare payments to provide a medical screening
examination to every patient who presents for care. If the medical screening
examination detects an emergency medical condition, the patient must be stabilized
within the hospital's capabilities before transfer. If the patient cannot be stabilized and
needs care beyond the hospital's capabilities or if the patient requests a transfer, an
appropriate transfer can be arranged.
✔✔For a patient with a finger laceration, the triage nurse should assess which
parameter during the focused assessment?
A. Tetanus immunization status
B. Oxygen saturation
C. Tendon involvement
D. Pronator drift - ✔✔C. Tendon involvement
, ✔✔Which individual could qualify to be a triage nurse?
A. A new graduate who was a paramedic for several years
B. An experienced nurse who has just transferred from a medical unit
C. A nurse with 1 year of experience in emergency nursing
D. An orientee who has successfully completed Advanced Cardiac Life Support training
- ✔✔C. A nurse with 1 year of experience in emergency nursing
✔✔When a patient decides to leave the emergency department without being seen by
an independent care practitioner, what should the triage nurse do first?
A. Determine the reason the patient wants to leave.
B. Have the patient sign a statement saying he or she is leaving before receiving a
medical screening examination.
C. Document that the patient has left against medical advice.
D. If a patient does not answer when called, classify him or her as left without being
seen. - ✔✔A. Determine the reason the patient wants to leave.
✔✔When triaging a potential psychiatric patient, which action is the triage nurse's
priority?
A. Assess patient and staff safety.
B. Determine the patient's coping mechanisms.
C. Assess the work of breathing.
D. Contact the patient's psychiatrist. - ✔✔A. Assess patient and staff safety.
✔✔In which triage system does the nurse obtain the patient's chief complaint, medical
and medication history, and vital signs and perform a focused assessment before
assigning an acuity level?
A. Traffic director
B. Spot-check triage
C. Comprehensive
D. Two-tiered triage - ✔✔C. Comprehensive
✔✔When triaging an older adult patient, the triage nurse should routinely perform which
action?
A. Speak loudly to older adults.
B. Use only closed-ended questions to obtain medical history.
C. Determine if the patient has a plan to hurt others.
D. Evaluate the patient's interactions with his or her family. - ✔✔D. Evaluate the
patient's interactions with his or her family.
✔✔The triage nurse should perform which important infection control measure?
A. Wear gloves continuously so that hand hygiene is not required between patients.
B. Place an immunosuppressed patient in a separate waiting area.
C. Give an N95 mask to a patient who presents with a cough.
D. Expect an independent care practitioner to perform infectious disease screening. -
✔✔B. Place an immunosuppressed patient in a separate waiting area.
