Which client will the emergency nurse triage as the priority?
21-year old with ankle fracture
33-year old with vomiting, flank pain, and a history of kidney stones
49-year-old with profound weakness and 103° F fever
59-year-old with sweating, jaw pain,, and pain in the left arm
The Correct Answer is D
A. An ankle fracture is painful and requires medical attention, but it is not immediately life-threatening. This client can be triaged after patients with more urgent cardiovascular or systemic emergencies.
B. Vomiting and flank pain from a history of kidney stones can cause dehydration and severe discomfort, but it is not immediately life-threatening unless complications such as obstruction or infection occur.
C. Profound weakness and fever of 103° F indicate a possible infection that requires prompt evaluation, but the client is currently less acutely at risk for sudden deterioration compared with someone having possible acute coronary syndrome.
D. Sweating, jaw pain, and pain in the left arm are classic signs of acute myocardial infarction (heart attack). This condition is life-threatening and requires immediate triage and intervention. Prompt recognition and rapid treatment can prevent cardiac tissue damage and reduce mortality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. An ankle fractureis painful and requires medical attention, but it is not immediately life-threatening. This client can be triaged after patients with more urgent cardiovascular or systemic emergencies.
B. Vomiting and flank pain from a history of kidney stonescan cause dehydration and severe discomfort, but it is not immediately life-threateningunless complications such as obstruction or infection occur.
C. Profound weakness and fever of 103° Findicate a possible infection that requires prompt evaluation, but the client is currently less acutely at risk for sudden deteriorationcompared with someone having possible acute coronary syndrome.
D. Sweating, jaw pain, and pain in the left armare classic signs of acute myocardial infarction (heart attack). This condition is life-threateningand requires immediate triage and intervention. Prompt recognition and rapid treatment can prevent cardiac tissue damage and reduce mortality.
Correct Answer is B
Explanation
A. This client would be triaged red or blackdepending on the setting. Extensive third-degree burns over 80% of the body are life-threatening, often requiring immediate advanced care (red) or may be considered unsalvageable in a mass casualty setting(black) if resources are limited.
B. Closed fractures are serious but not immediately life-threatening. In mass casualty triage, this client would receive a yellow tag (delayed), meaning treatment can be delayed while priority is given to more critical patients.
C. Respiratory distress indicates a high-acuity condition, requiring immediate intervention. This client would be tagged red (immediate priority).
D. Abrasions and contusions are minor injuries, usually triaged green (minimal), meaning care can be delayed significantly and the patient is considered walking wounded.
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