Emergency Nursing Orientation 3.0: Triage -
ENA-ENO-C15. Exam 2025 Questions and
Answers
Which function differentiates the Emergency Severity Index from the Canadian Triage and
Acuity Scale? - ANS It identifies specific vital signs that place a patient at acuity level 2.
When triaging a potential psychiatric patient, which action is the triage nurse's priority? -
ANS Assess patient and staff safety.
Which question is most likely to assess the quality of a patient's symptom? - ANS "What does
it feel like?"
Detection of severe jaundice during an across-the-room assessment falls under which category
of assessment? - ANS Skin color
Which question best elicits details from a patient seeking treatment in the emergency
department? - ANS "Why do you think you fell?"
Triage documentation must include which element? - ANS Assessment of pain
Using the CIAMPEDS mnemonic, the triage nurse evaluates fever control for a pediatric patient.
This reflects which component of the mnemonic? - ANS Medication
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, What should the nurse do when a person calls on the telephone for medical advice? -
ANS Politely inform the caller that the emergency department does not give out any medical
advice.
A pediatric patient with increased work of breathing is likely to display which assessment
finding? - ANS Grunting
The triage nurse notes a fruity smell during an across-the-room assessment. This finding may be
a sign of which condition? - ANS Diabetic ketoacidosis
When triaging a geriatric patient, the triage nurse should routinely perform which action? -
ANS Evaluate the patient's interactions with his or her family.
The triage nurse should bring which patient to the patient care area first? - ANS A man who
presents to triage with diaphoresis and complaints of chest pain
The triage nurse should perform which important infection control measure? - ANS Place an
immunosuppressed patient in a separate waiting area.
In the CIAMPEDS mnemonic, which component helps the triage nurse decide if the pediatric
patient should be placed separately from others in the waiting room? - ANS Immunization
status and isolation
Which activity is part of the Pediatric Assessment Triangle? - ANS Observe general
appearance.
The CIAMPEDS mnemonic can determine which assessment parameter? - ANS Last meal
The triage nurse should begin the interview with which activity? - ANS Confirming the
patient's identity
Pg. 2 Copyright © 2025 Jasonmcconell. ALL RIGHTS RESERVED.
ENA-ENO-C15. Exam 2025 Questions and
Answers
Which function differentiates the Emergency Severity Index from the Canadian Triage and
Acuity Scale? - ANS It identifies specific vital signs that place a patient at acuity level 2.
When triaging a potential psychiatric patient, which action is the triage nurse's priority? -
ANS Assess patient and staff safety.
Which question is most likely to assess the quality of a patient's symptom? - ANS "What does
it feel like?"
Detection of severe jaundice during an across-the-room assessment falls under which category
of assessment? - ANS Skin color
Which question best elicits details from a patient seeking treatment in the emergency
department? - ANS "Why do you think you fell?"
Triage documentation must include which element? - ANS Assessment of pain
Using the CIAMPEDS mnemonic, the triage nurse evaluates fever control for a pediatric patient.
This reflects which component of the mnemonic? - ANS Medication
Pg. 1 Copyright © 2025 Jasonmcconell. ALL RIGHTS RESERVED.
, What should the nurse do when a person calls on the telephone for medical advice? -
ANS Politely inform the caller that the emergency department does not give out any medical
advice.
A pediatric patient with increased work of breathing is likely to display which assessment
finding? - ANS Grunting
The triage nurse notes a fruity smell during an across-the-room assessment. This finding may be
a sign of which condition? - ANS Diabetic ketoacidosis
When triaging a geriatric patient, the triage nurse should routinely perform which action? -
ANS Evaluate the patient's interactions with his or her family.
The triage nurse should bring which patient to the patient care area first? - ANS A man who
presents to triage with diaphoresis and complaints of chest pain
The triage nurse should perform which important infection control measure? - ANS Place an
immunosuppressed patient in a separate waiting area.
In the CIAMPEDS mnemonic, which component helps the triage nurse decide if the pediatric
patient should be placed separately from others in the waiting room? - ANS Immunization
status and isolation
Which activity is part of the Pediatric Assessment Triangle? - ANS Observe general
appearance.
The CIAMPEDS mnemonic can determine which assessment parameter? - ANS Last meal
The triage nurse should begin the interview with which activity? - ANS Confirming the
patient's identity
Pg. 2 Copyright © 2025 Jasonmcconell. ALL RIGHTS RESERVED.
