Triage is from a French word meaning to sort. Emergency services regularly face patient loads that overwhelm resources. To better serve patients and make sure the worst patients get treatment as quickly as possible, emergency medical providers use a method of prioritizing patients by medical severity

http://www.remm.nlm.gov/radtriage.htm#start

Triage Nurse has 2-3 minutes to decide how long each patient should wait for medical care and assign a corresponding Triage Category

The nurse will use their expertise to process data obtained from the presenting problem, physiological observations, general appearance and all important gut feelings

urgency based on vital signs, complaints, appearance, and history

Coming by ambulance think of the following Code 1 did not need ambulance Code 2 minor injuries Code 3 serious injury Code blue =coding

A client arrives in the emergency room with multiple crushing wounds of the chest, abdomen, and legs. The assessments that assume the greatest priority are: select all that apply:

A. Level of consciousness and pupil size B. Abdominal contusions and other wounds C. Pain, respiratory rate, and blood pressure D. Quality of respirations and presence of pulses

The charge nurse is overseeing care of 10 clients on a general obstetrical floor. Concerning which of the following patient-care situations should the nurse notify the physician FIRST?

a. Prenatal client at 7 weeks gestation with nausea and vomiting and a whitish vaginal discharge.

b. A gravida 2 para 1 client at 28 weeks gestation with brownish facial blotches and +1 glucose and trace protein in a random urinalysis.

c. Seventeen-year-old client at 15 weeks gestation with missed abortion and bleeding from IV site.

d. Rh-negative client at 38 weeks gestation with blood pressure of 150/105, brisk reflexes, and generalized edema in hands and ankles.

Answer D

You are asked what the correct steps in CPR are. Number them in the correct order. ___ initiate breathing ___ Open the client airway ___ Determine breathlessness ___ Perform chest compressions ___ check for carotid pulse ___ determine unconsciousness by shaking the

client and asking “ Are you Okay?”

Answer: 4, 2, 3, 6, 5, 1

You are preparing to suction a client with a trach. List the order of priority for the actions to take during this procedure. ____ hyperoxygenate the client ____ Place the client in a semi fowler position ____ turn the suction on and set regulator to 80

mmHG ____ Apply gloves and attach the suction tubing

to the suction catheter ____ Insert the Catheter into the trach until

resistance is met and pull back 1 cm ____ Apply intermittent suction and slowly

withdraw while rotating it back and forth

Answer: 4, 1, 2, 3, 5, 6

54/m c/o chest pain 2/10 had a CABG 6 months ago. Hr 92 BP 140/90 RR32 SAO2 95% on 4 liters

7 /F mom states has been vomiting and diarrhea x 2 days. She has not voided for 12 hours and can not keep fluids down. HR 112 RR24 lips and mouth dry, skin cool

70/m with general weakness and unable to due ADL. He is SOB and c/o abd pain. Bibasilar crackles, HR 123 irregular BP 150/72 sat 88% RA