Which nursing skill is essential for the triage process in the emergency department quizlet?

ANS: 4

Tracheal deviation and jugular vein distention are not associated with hemorrhage,
compensatory shock, or hypovolemic shock.
2 Tracheal deviation and jugular vein distention are not associated with hemorrhage,
compensatory shock, or hypovolemic shock.
3 Tracheal deviation and jugular vein distention are not associated with hemorrhage,
compensatory shock, or hypovolemic shock.
4 A tension pneumothorax is life threatening and requires immediate intervention. On
inspiration, air enters the pleural space, does not escape on expiration, and increases the
intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal
contents, compressing the heart, great vessels, trachea, and eventually the uninjured
lung.

ANS: 2

Feedback
1 Evaluating care, formulating diagnoses, and implementing interventions are all nursing
skills used in the emergency department; however, these are not essential during the
triage process.
2 Setting priorities is an essential nursing skill for the triage, or assessment, process that
occurs in the emergency department.
3 Evaluating care, formulating diagnoses, and implementing interventions are all nursing
skills used in the emergency department; however, these are not essential during the
triage process.
4 Evaluating care, formulating diagnoses, and implementing interventions are all nursing
skills used in the emergency department; however, these are not essential during the
triage process.

ANS: 4

Feedback
1 Dyspnea, not eupnea, would indicate the need for priority intervention. This patient is
experiencing normal respirations.
2 Tachycardia and hypotension are also priority assessment data that indicate the need for
intervention; however, this data indicates circulatory, and not respiratory, compromise.
3 Tachycardia and hypotension are also priority assessment data that indicate the need for
intervention; however, this data indicates circulatory, and not respiratory, compromise.
4 Dyspnea, agonal breaths, and an inability to speak are all assessment data that indicate a
compromised airway and the need for priority intervention by the nurse.

ANS: 2, 4, 5

Feedback
1. This is incorrect. The secondary survey begins after addressing each step of the primary
survey and starting any lifesaving interventions. The secondary survey is a brief, systematic
process that aims to identify all injuries. Nursing actions appropriate during the secondary, not
primary, survey include inserting a nasogastric tube and arranging for diagnostic studies.
2. This is correct. The primary survey focuses on airway, breathing, circulation (ABC),
disability, and exposure or environmental control. It aims to identify life-threatening
conditions so that appropriate interventions can be started. Nursing actions that are appropriate
during the primary survey include immobilizing the cervical spine, preparing for chest tube
insertion, and applying direct pressure to a wound.
3. This is incorrect. The secondary survey begins after addressing each step of the primary
survey and starting any lifesaving interventions. The secondary survey is a brief, systematic
process that aims to identify all injuries. Nursing actions appropriate during the secondary, not
primary, survey include inserting a nasogastric tube and arranging for diagnostic studies.
4. This is correct. The primary survey focuses on airway, breathing, circulation (ABC),
disability, and exposure or environmental control. It aims to identify life-threatening
conditions so that appropriate interventions can be started. Nursing actions that are appropriate
during the primary survey include immobilizing the cervical spine, preparing for chest tube
insertion, and applying direct pressure to a wound.
5. This is correct. The primary survey focuses on airway, breathing, circulation (ABC),
disability, and exposure or environmental control. It aims to identify life-threatening
conditions so that appropriate interventions can be started. Nursing actions that are appropriate
during the primary survey include immobilizing the cervical spine, preparing for chest tube
insertion, and applying direct pressure to a wound.

ANS: 1, 3, 4, 5

Feedback
1. This is correct. Clinical priorities for the treatment of gunshot wound are the following:
maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia.
Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as
prevention of infection.
2. This is incorrect. While obtaining the patient's medical history is important, this action would
not be priority and would take place after the priority assessment and treatment. Once the
safety of the patient is assured, then the nurse will manage the patient's emotional state and
obtain the medical history.
3. This is correct. Clinical priorities for the treatment of gunshot wound are the following:
maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia.
Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as
prevention of infection.
4. This is correct. Clinical priorities for the treatment of gunshot wound are the following:
maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia.
Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as
prevention of infection.
5. This is correct. Clinical priorities for the treatment of gunshot wound are the following:
maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia.
Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as
prevention of infection.

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Which client would the nurse prioritize when triaging clients in the emergency department?

What is the primary goal of a triage system used by the nurse with patients presenting to the emergency department quizlet?

Which is the nurse's first action when caring for any patient in an emergency?