ENA TRIAGE EXAMS SCRIPTED ANSWERS AND
QUESTIONS SET A+
✔✔Which question best elicits details from a patient seeking treatment in the
emergency department. - ✔✔"Why do you think you fell?"
✔✔The triage nurse should being the interview with which activity?
A. Conducting a focused assessment
B. Obtaining a set of vital signs
C. Determining the patient's chief complaint
D. Confirming the patient's identity - ✔✔D. Confirming the patient's identity
The triage nurse should begin the interview by confirming the patients identity,
introducing himself or herself to the patient, and explaining the purpose of triage. The
type of triage used in your facility determines when the triage nurse performs the other
activities.
✔✔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.
To protect immunosuppressed patients, make every effort to isolate them from patients
in the general waiting room. Infection control begins at triage with strict adherence to
hand hygiene guidelines. Ask any patient who presents with a cough to wear a surgical
or procedure mask (not an N95 mask) to prevent the spread of droplets to others.
Infectious disease screening is a routine part of any triage assessment. The triage
nurse must identify patients with a potentially infectious disease, take appropriate
infection control measures, document the situation, and then work with the charge nurse
to get the patient to an appropriate treatment area.
, ✔✔Detection of severe jaundice during an across-the-room assessment falls under
which category of assessment?
A. Activity level
B. Body habitus
C. Skin color
D. Hygiene - ✔✔C. Skin color
When using the sense of sight during an across-the-room assessment, detection of
severe jaundice results from observing the skin color. When assessing activity level, the
nurse notes whether the patient is walking with no difficulty or walking bent over, holding
the abdomen, or using an assistive device, such as a cane. When observing body
habitus, the nurse notes whether the patient is tall or short and cachectic, thin, or obese.
The nurse may use the sense of smell to help detect poor hygiene and determine if the
patients living situation needs assessment.
✔✔In response to the triage nurse's question, a patient says, "The pain starts in my
lower abdomen and goes through to my back." This response reflects which component
of the PQRST mnemonic?
A. P
B. Q
C. R
D. S - ✔✔C. R - radiation
To determine the R (radiation) component, the triage nurse asks questions about where
the symptom is, where it goes, and if it is in one or more spots. To determine the P
(provokes) component, the nurse asks about what provokes the symptom, what makes
it better or worse, and what makes a difference. To determine the Q (quality)
component, the nurse uses open-ended questions such as "What does it feel like?" so
the patient can accurately describe the feeling. To determine the S (severity)
component, the nurse employs a pain scale appropriate for the patient's age and
understanding.
✔✔Which statement correctly reflects the requirements set forth in the Emergency
Medical Treatment and Active Labor Act?
A. If no emergency condition exists, the requirements of this act cease.
B. Triage meets the requirement for a medical screening examination.
C. Registration should occur before the patient is taken to the patient care area.
D. An adult hospital is not required to care for a pediatric patient. - ✔✔A. If no
emergency condition exists, the requirements of this act cease.
The Emergency Medical Treatment and Active Labor Act requires hospitals that
participate in Medicare to provide a medical screening examination to every patient who
presents for care to determine if an emergency medical condition exists. If no
QUESTIONS SET A+
✔✔Which question best elicits details from a patient seeking treatment in the
emergency department. - ✔✔"Why do you think you fell?"
✔✔The triage nurse should being the interview with which activity?
A. Conducting a focused assessment
B. Obtaining a set of vital signs
C. Determining the patient's chief complaint
D. Confirming the patient's identity - ✔✔D. Confirming the patient's identity
The triage nurse should begin the interview by confirming the patients identity,
introducing himself or herself to the patient, and explaining the purpose of triage. The
type of triage used in your facility determines when the triage nurse performs the other
activities.
✔✔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.
To protect immunosuppressed patients, make every effort to isolate them from patients
in the general waiting room. Infection control begins at triage with strict adherence to
hand hygiene guidelines. Ask any patient who presents with a cough to wear a surgical
or procedure mask (not an N95 mask) to prevent the spread of droplets to others.
Infectious disease screening is a routine part of any triage assessment. The triage
nurse must identify patients with a potentially infectious disease, take appropriate
infection control measures, document the situation, and then work with the charge nurse
to get the patient to an appropriate treatment area.
, ✔✔Detection of severe jaundice during an across-the-room assessment falls under
which category of assessment?
A. Activity level
B. Body habitus
C. Skin color
D. Hygiene - ✔✔C. Skin color
When using the sense of sight during an across-the-room assessment, detection of
severe jaundice results from observing the skin color. When assessing activity level, the
nurse notes whether the patient is walking with no difficulty or walking bent over, holding
the abdomen, or using an assistive device, such as a cane. When observing body
habitus, the nurse notes whether the patient is tall or short and cachectic, thin, or obese.
The nurse may use the sense of smell to help detect poor hygiene and determine if the
patients living situation needs assessment.
✔✔In response to the triage nurse's question, a patient says, "The pain starts in my
lower abdomen and goes through to my back." This response reflects which component
of the PQRST mnemonic?
A. P
B. Q
C. R
D. S - ✔✔C. R - radiation
To determine the R (radiation) component, the triage nurse asks questions about where
the symptom is, where it goes, and if it is in one or more spots. To determine the P
(provokes) component, the nurse asks about what provokes the symptom, what makes
it better or worse, and what makes a difference. To determine the Q (quality)
component, the nurse uses open-ended questions such as "What does it feel like?" so
the patient can accurately describe the feeling. To determine the S (severity)
component, the nurse employs a pain scale appropriate for the patient's age and
understanding.
✔✔Which statement correctly reflects the requirements set forth in the Emergency
Medical Treatment and Active Labor Act?
A. If no emergency condition exists, the requirements of this act cease.
B. Triage meets the requirement for a medical screening examination.
C. Registration should occur before the patient is taken to the patient care area.
D. An adult hospital is not required to care for a pediatric patient. - ✔✔A. If no
emergency condition exists, the requirements of this act cease.
The Emergency Medical Treatment and Active Labor Act requires hospitals that
participate in Medicare to provide a medical screening examination to every patient who
presents for care to determine if an emergency medical condition exists. If no
