After assessing four clients, which will the triage nurse identify to be seen first in the ED?

Client with fever of 101.2°F

Client who reports slurred speech

Client who reports bilateral ear pain

Client with urinary burning and frequency

Answer and Explanation

The Correct Answer is B

A. Fever alone indicates an infectious process but is generally not immediately life-threatening unless accompanied by systemic instability, altered mental status, or hypotension. This client can safely wait for evaluation after clients with higher-acuity conditions are assessed.

B. Slurred speech is a neurological symptom that may indicate acute stroke, transient ischemic attack (TIA), hypoglycemia, or other central nervous system compromise. According to triage principles, time-sensitive conditions affecting neurological function are considered high priority because delays in treatment can lead to permanent disability or death. Rapid assessment and intervention, including imaging and stabilization, are crucial. This client should be seen immediately, following the “golden hour” concept for stroke care.

C. While these symptoms may indicate a urinary tract infection, they are low-acuity in the absence of systemic symptoms such as fever, hypotension, or altered mental status. This client’s evaluation can be safely delayed after more urgent cases are addressed.

D. Ear pain is usually non-life-threatening and represents a low-acuity complaint, even if discomfort is significant. The client can wait until higher-priority patients, such as the one with neurological compromise, have been stabilized.

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Correct Answer is C

Explanation

A. Non-urgent patients have stable vital signs, mild symptoms, and conditions that do not pose an immediate threat to life or limb. This patient’s chest pain, diaphoresis, and dizzinessindicate a potential acute cardiac event, which is life-threateningand cannot be categorized as non-urgent.

B. Urgent classification applies to patients with conditions that require timely care but are not immediately life-threatening, such as minor infections or moderate pain. The patient’s symptoms suggest myocardial ischemia, which is more serious.

C. Emergent patients have life-threatening conditions requiring immediate interventionto prevent death or severe complications. Diaphoresis, dizziness, and left-sided chest pain in a 65-year-oldstrongly indicate a possible myocardial infarction or acute coronary syndrome, making immediate triage and intervention essential.

D. High urgent is sometimes used for serious but not immediately life-threatening conditionsrequiring attention within 1–2 hours. While serious, this patient’s presentation requires immediate evaluation and treatment, placing them in the emergent category.

A. "I prop myself up at night to sleep." B. "I decided to put on some makeup today." C. I have a productive cough in the morning." D. "I have gained weight since I was here last."

Correct Answer is A

Explanation

A. The statement "I prop myself up at night to sleep"indicates orthopnea, which is difficulty breathing when lying flat. Orthopnea occurs because in clients with COPD, the lungs have reduced elastic recoil and airflow obstruction, leading to air trapping and hyperinflation. When lying flat, the diaphragm is compressed, and the lungs cannot fully expand, worsening shortness of breath. Needing to use pillows or sit upright to sleep is a key sign of worsening respiratory function or increased dyspnea. This symptom signals that the client’s COPD may be progressing or that there is an acute exacerbation, requiring prompt assessment of oxygenation, lung sounds, and respiratory effort.

B. Saying "I decided to put on some makeup today"reflects engagement in activities of daily livingand suggests that the client has functional capacity and energy. This statement does not indicate increased shortness of breath.

C. A productive morning coughis a chronic symptom of COPD caused by excess mucus productionand impaired mucociliary clearance. While it is part of the disease process, it does not necessarily indicate an acute increase in dyspneaunless it is accompanied by other symptoms such as increased sputum, wheezing, or shortness of breath.

D. Weight gaincould be related to fluid retention, dietary changes, or other factors, but on its own it does not directly indicate worsening dyspnea. If associated with edema or orthopnea, it may suggest heart failure, but without these signs, it is not the primary indicator of increased respiratory distress.

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After assessing four clients, which will the triage nurse identify to be seen first in the ED?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is triaging a 65-year-old patient who arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. What category is appropriate?

Correct Answer is C

Explanation

A client with COPD who smokes 1 PPD presents for a routine appointment. Which client statement causes the nurse to suspect an increase in dyspnea?

Correct Answer is A

Explanation

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