Leadership Management - Triage

Card Set Information

Author:
nursedaisy98
ID:
256734
Filename:
Leadership Management - Triage
Updated:
2014-04-19 23:48:07
Tags:
NCLEX RN
Folders:
Leadership Management
Description:
Triage
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  1. The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?
    1. A client complaining of muscle aches, a headache, and malaise
    2. A client who twisted her ankle when she fell while rollerblading
    3. A client with a minor laceration on the index finger sustained while cutting an eggplant
    4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
    4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
  2. The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage, the nurse should attend to the client with which problem first?
    1. Fractured tibia
    2. Penetrating abdominal injury
    3. Bright red bleeding from a neck wound
    4. Open massive head injury in deep coma
    3. Bright red bleeding from a neck wound
  3. The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first?
    1. A victim experiencing excruciating pain
    2. A victim experiencing airway obstruction
    3. A victim experiencing moderate anxiety
    4. A victim experiencing altered level of consciousness
    2. A victim experiencing airway obstruction
  4. The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Select the clients who can be safely discharged. Select all that apply.
    1. A client with dyspnea
    2. A client experiencing sinus rhythm
    3. A client receiving oral anticoagulants
    4. A client with chronic atrial fibrillation
    5. A client experiencing third-degree heart block
    6. A client who has not voided since before surgery
    • 2. A client experiencing sinus rhythm
    • 3. A client receiving oral anticoagulants
    • 4. A client with chronic atrial fibrillation
  5. The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first?
    1. A middle-aged man with one foot trapped under the wreckage
    2. A crying teenager who is holding pressure on an arm laceration
    3. A young woman who appears dazed and confused and is shivering
    4. A screaming middle-aged woman looking frantically for her husband
    3. A young woman who appears dazed and confused and is shivering
  6. Which client should the emergency department triage nurse classify as emergent?
    1. A client with a displaced fracture who is crying
    2. A client with a simple laceration and soft tissue injury
    3. A client with crushing substernal pain who is short of breath
    4. A client with a temperature of 101° F with a productive cough
    3. A client with crushing substernal pain who is short of breath

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