Emergency

Nursing: TRIAGE
Natalie Serna, Courtney Kermani, Nina
Farinella & Nikki Howell
 OVERVIEW OF TRIAGE
- LEVELS OF TRIAGE

- ABCD LIFE- THREATENING CONDITIONS

- ABCDEFGHI

- PAIN

- HEALTH HISTORY
 Triage: sorting a collection of patients rapidly
on critical basis, patients being seen first being
the most critical.
Using the TABLES below:
FIVE LEVEL EMERGENCY SEVERITY INDEX (M/S: Page
1675 Table 69-2).
EMERGENCY ASSESSMENT: PRIMARY SURVEY (M/S:
Page 1676 Table 69-3).
LIFE-THREATENING CONDITIONS: PRIMARY
SURVEY (M/S: Page 1677 Table 69-4).
EMERGENCY ASSESSMENT: SECONDARY SURVEY
(M/S: Page 1679 Table 69-5).

REMEMBER: YOURE A through I

Care of Emergency Patients
5 LEVELS SUMMARIZED: TABLE 69-2 M/S 1675
DEFINITION ESi- 1 ESi- 2 ESi- 3 ESi- 4 ESi-5
STABILITY? Unstable Threatened Stable Stable Stable
LIFE or
ORGAN LIKELY UNLIKELY
YES NO NO
THREAT? (not always) (possible)

HOW SOON Within UP to an Can be Can be

SEEN? ASAP/ STAT
10min hour delayed delayed
EXPECTED
RESOURCE HIGH
High
INTENSITY? as much staff Medium Low Low
multiple
& resources (Diagnostics) 1 diagnostic Exam only
resources
as available
EX. CARDIAC CHEST ABDOMINAL MINOR
PAIN
CYSTITIS
ARREST PAIN BURN
POTENTIAL LIFE-THREATENING
CONDITIONS FOUND DURING PRIMARY
SURVEY: TABLE 69-4 M/S 1677
TYPE OF
THREAT AIRWAY BREATHING CIRCULATION DISABLED

CAUSES INHALATION ANAPHYLAXIS MYOCARDIAL HEAD

INFARCTION INJURY
OBSTRUCTION FLAIL CHEST
PERICARDIAL STROKE
PENETRATING HEMOTHORAX TAMPONADE
WOUND
PNEUMOTHORAX SHOCK

HEMORRHAGE

HYPOTHERMIA

PRIMARY SURVEY
A I R W A Y : WITH CERVICAL SPINE STABILIZATION AND/OR
IMMOBILIZATION.

B R E A T H I N G : ADEQUATE AIRFLOW THROUGH THE UPPER

AIRWAY DOES NOT ENSURE ADEQUATE VENTILATION.

C I R C U L A T I O N : INTACT CIRCULATORY SYSTEM INCLUDES:

HEART, INTACT BLOOD VESSELS, AND ADEQUATE BLOOD
VOLUME.

DISABILITY: LOC, RESPONSE TO VERBAL AND PAINFUL

STIMULI, A V P U :
A- ALERT
V- RESPONSE TO VOICE
P- RESPONSE TO PAIN
U- UNRESPONSIVE
EXPOSURE OF ENVIRONMENTAL CONTROL: REMOVE ALL
CLOTHING IN ORDER TO DO A THOROUGH ASSESSMENT

PRIMARY SURVEY
F= FULL SET OF VITALS, FOCUSED ADJUNCTS, FACILITATE FAMILY PRESENCE:
(B/P, PULSE, HR, RR, 02 SAT, & TEMPERATURE)
- ECG, PULSE OXIMETER, URINARY CATHETER, ET TUBE,
LABS, & NEED FOR TETANUS SHOT.
- STAFF HELPERS TO PROVIDE COMFORT OR FAMILY
MEMEBERS (REMIND MEDICAL TEAM PERSONHOOD OF
THE PATIENT).
G= GIVE COMFORT MEASURES: PAIN MANAGEMENT, SPLINTING,

ELEVATING, & ICING INJURY.

H= HISTORY AND HEAD-TO-TOE ASSESSMENT: GIVE MEDICAL TEAM
AND IDEA OF THE CAUSE OF INJURY.

I= INSPECT POSTERIOR SURFACES: LOGROLLED ALWAYS! MAINTAIN

CERVICAL SPINE MOBILIZATION AND INSPECT. THREE- FOUR PEOPLE TO
LOGROLL: ECCHYMOSIS, ABRASIONS, PUNCTURE WOUNDS,
CUTS, AND DEFORMITIES.

SECONDARY SURVEY
OBTAINING HISTORY
CHIEF COMPLAINT: what caused patient to seek medical attention?
SUBECTIVE COMPLAINTS: patients stated s/s ?

DESCRIPTION OF PAIN:
P: Provocation/Palliation: started? Caused? Better/Worse?
Trigger: stress, position, & activities?
Q: Quality/Quantity: Sharp? Dull? Stabbing? Burning?
Crushing? Throbbing? Nauseating? Shooting? Twisting?
Stretching?
R: Region/Radiation: Located? Radiates to? Travels/radiates?
Localized?
S: Severity Scale: 0-10? Interfere w/activities? Worse with
sitting/standing/laying down? Episodes?
T: Timing: Started? Lasted? Often? First onset?
Sudden/Gradual? Time of day? Seasonal? AC/PC?

SECONDARY SURVEY
OBTAINING HISTORY
WHO WITNESSED: description of patients behavior since onset?

PATIENTS OWN HEALTH HISTORY:

A - allergies: drugs, food, latex, & environment?
M - medication history?
P - past heath history?
L - last meal?
E - events & environmental factors leading to the illness or injury.

SECONDARY SURVEY
 TRIAGE VIDEO
https://www.youtube.com/watch?v=9QHDs10e-G0
SCENARIOS/CASE STUDIES
 23 y/o Female, N.S. was found on the floor, unconscious
in her garage by her husband. He called 911. During
transport to the hospital she vomited and suffered a
seizure. When she arrived at the ER she had respirations
of 35, heart rate of 130, BP 98/55, temp 98.4, SaO2 sat
98%, lips are cyanotic.

PATIENT #1
 48 y/o female, C.K., found wondering on the roadway
wearing wet t-shirt, underwear and no shoes. It is a rainy,
cold and windy day. She is shivering, skin pale/cool to
touch, BP 90/60, pulse 84, respirations 14, SpO2 96%,
temperature 92.4 F, A&O x2, and reports no pain. Does
not understand why she was sent to the hospital and no
medical alert bracelet present.

PATIENT #2
 N.F. a 56 y/o female with a past medical history
significant for lymphoma (now in remission). She is a
health care worker who presented to the emergency
room because of a dog bite on the left side of her face
and along the left index finger. The dog belonged to
the patient and was up to date with all its shots.

PATIENT #3
 N.H. a 88 y/o female comes into the ER very upset about the
abusive behavior she received from police when she went to
report being beaten by her husband. N.H. also is upset
because she doesn't think the officer took her situation
seriously because he didn't take any notes. She is very fixated
on the police mishandling of her report. She presents with
anxiety, depression, and scattered bruising on her limbs in
various stages of healing. She declines to undress and don a
hospital gown for examination stating she only wants her
wrist examined due to the bruising and severe pain with
movement.

PATIENT #4
 OVERVIEW OF POISON
- DEFINITION
- TYPES OF POISONS
- MOST DANGEROUS POISONS
- PCC SUGGESTIONS
- MEDICAL MANAGEMENT
- PREVENTION
- CARBON MONOXIDE POISONINGS
S/S
TREATMENTS
 Poison- any chemical that harms the body and can be
ingested, injected, inhaled, splashed in the eye, or
absorbed through the skin
Types: accidental, intentional, recreational, occupational
Severity depends on type, concentration and route of
exposure

POISONING
Adults: Children:
Pain medications Cosmetics/personal care
products
Sedatives/hypnotics
Pain medications
Antidepressants
Foreign bodies (batteries)
Cardiac medications Topical preparations
Alcohol Plants/pesticides
Pesticides Vitamins
Envenomation

Most Common
 Carbon monoxide
Hydrocarbons (gasoline, kerosene, paint thinner)
Alcohol
Cleaning products
Pesticides

Most Dangerous
 Swallowed: immediately have the client drink a small amount of milk or
water before calling poison control if: the product is burning, irritating;
or caustic AND the client is conscious, NOT having convulsions, and is
able to swallow. Otherwise contact PCC first

Contact with the eyes irrigate immediately for 15-20 mins with water
that is at room temp. (Remove contacts).
Let water hit the bridge of the nose and gently run into the eyes and
blinking is encouraged

Contact with skin, remove contaminated clothing, rinse exposed skin

immediately for 15 minutes

Inhaled: move to fresh air immediately and thoroughly ventilate the area

PCC Suggestions
 Specific management focuses on decreasing absorption,
enhancing elimination, and implementing toxin-specific
interventions.

Remember to primarily to treat the client, not the poison.

Basic life support over decontamination. The patient may
show a variety of systemic manifestations with problem
occurring in several systems depending on the poison.

Medical Management
 Activated charcoal - most common and effective
intervention, administered within one hour of poisoning. Many
poisons will instead adhere to the charcoal and be eliminated
via GI tract. Does not work with: ethanol, hydrocarbons, alkali,
iron, lithium, or cyanide
Gastric lavage - insertion of gastric tube for irrigation with
large amounts of saline. Not done with caustic agents
Hemodialysis - for development of severe acidosis from
ingestion of toxic substances
Chelation therapy - for heavy metals
Vitamin C - added to IV fluids to help excrete amphetamines

MEDICAL MANAGEMENT
Type Example Signs & Symptoms Treatments
Corrosives toilet/oven Severe burning in mouth, DO NOT induce
cleaners; throat, stomach, violent vomiting (re-damages
batteries vomiting, drooling, signs of mucosa)
DO NOT neutralize
bleach shock, anxiety
(exothermic reaction)
May drink milk or
water
Hydrocarbons Gasoline Gagging, chocking coughing, DO NOT induce
Kerosene N/V, lethargy, tachypnea, vomiting
Lighter fluid immediate danger of aspiration gastric lavage (depends
(chemical PNA) on chemical)
Paint thinner

Acetaminophen Found in Initial: N/V, sweating, pallor ANTIDOTE:

various meds Latent: improves N-Acetylcysteine
(making it Hepatic: RUQ pain, jaundice, (dilute with juice-
confusion, coagulation
easy to OD) bad odor)
abnormalities
Recovery phase Activated charcoal

Acetylsalicylic ASA N/V, dehydration, Activated charcoal,

Acid diaphoresis, hyperpyrexia, lavage & emesis
tinnitus, oliguria, coma, Sodium bicarbonate;
external cooling
seizures, bleeding
Anticonvulsants
tendencies Oxygen
Vitamin K
 Keep poison control number near a phone

Toxic substances, including batteries, placed on high shelf, locked cabinet

Toxic plants placed out of reach of children

Medications stored in original containers, clearly labeled, and placed in a

childproof container out of reach
Read labels on medications and cleaning products before use

Household cleaners, disinfectants, and insecticides kept in their original

containers separate from food and out of reach
Smoking in areas away from children

Teach children hazards of ingesting nonfood items

Carbon monoxide alarms

Discuss abuse of drugs and household products and effects with

children/adolescents

Prevention
 Odorless, colorless, tasteless
gas produced when ordinary
fuels burn

Affinity for Hgb is 200 times

greater than that of oxygen-
binds to Hgb quickly,
preventing oxygen from
binding
(carboxyhemoglobin)

Carbon Monoxide
Poisoning
 An even greater affinity for myoglobin causing
hypotension, myocardial depression/ischemia

Eliminated by the lungs

Half life of 3-4 hours in room air

Levels detected with ABGs

CARBON MONOXIDE POISONING

Minor Doses Major Doses
5-10% impaired vision 31-40% Confusion,
11%-20% Flushing, vomiting, dizziness
headache 41-50% tachypnea,
21-30%- weakness, tachycardia, cyanosis
nausea, poor over 50% Seizures, loss of
concentration, shortness consciousness, coma,
of breath, tinnitus death

Manifestations
 100% oxygen therapy via non-breather, mechanical
ventilation, or hyperbaric chamber (oxygen decreases the half
life to 30-90 min)

Cardiac monitoring

Assessment of other body systems

Pulse oximetry readings are most likely to be normal

Treatments
OVERVIEW OF HYPOTHERMIA
- DEFINITION
- DIFFERENCE OF HYPOTHERMIA AND HYPERTHERMIA
- S/S
- MEDICAL MANAGEMENT
- TREATMENT
- PREVENTION
 Hypothermia is a medical emergency, body loses heat faster than it
can produce heat.

Normal body temperature is 98.6 F (37 C)

Hypothermia: body temperature passes below 95 F (35 C)

HYPOTHERMIA
 HYPOTHERMIA: Table 69-9 M/S 1685
ETIOLOGY ASSESSMENT INTERVENTIONS

ENVIRONMENTAL: CORE BODY TEMP: INITIAL:

- INADEQUATE CLOTHING a. MILD 93.2-96.8 F - REMOVE PT. FROM COLD
- PROLONGED EXPOSURE TO b. MOD. 86-93.2 F - MAINTAIN ABCs
COLD c. SEVERE <86 F - O2 REB-MASK/ BVM

- PROLONGED IMMERSION - SHIVERING - IV Large bore resuscitate

OR NEAR-DROWNINIG - HYPOVENTILATION - Rewarm pt.
- HYPOTENSION a. PASSIVE- remove clothes, apply

METABOLIC: - ALOC Dry, use radiant lights

- HYPOGLYCEMIA - AREFLEXIA (ABSENT b. ACTIVE EX- apply heating devices,
- HYPOTHYROIDISM REFLEXES) warm water immersion
- PALE, CYANOTIC c. ACTIVE IN- provide warm IV

HEALTH CARE ASSOC.: - BLUE, WHITE, FROZEN Fluids, heated/ humidified O2, peritoneal
- NEUROMUSCULAR AGENT EXTREMITIES lavage with warmed fluids, hemodialysis
- BLOOD ADM. - DYSRHYTHMIAS - OBTAIN 12 LEAD ECG
- COLD IV FLUIDS Bradycardia, V. Fib & Asystole - REWARMING SHOCK avoid
- INADEQUATE WARMING - FIXED DILATED PUPILS - GENTLY TX. AVOID INCREAD CO
- DEFIB MAY BE NEEDED

OTHER: ONGOING:
- ALCOHOL - MONITOR ABCs, VS, LOC, TEMP,
- BARBITUATES O2 SAT, HR, Rhythm, BS, F&E
- PHENOTHIAZINES
- SHOCK
- TRAUMA
CORE BODY TEMP:
a. MILD 93.2-96.8 F
b. MOD. 86-93.2 F
c. SEVERE <86 F

- SHIVERING
- HYPOVENTILATION
- HYPOTENSION
- ALOC
- AREFLEXIA (ABSENT REFLEXES)
- PALE, CYANOTIC

- BLUE, WHITE, FROZEN EXTREMITIES

- DYSRHYTHMIAS
Bradycardia, V. Fib, and Asystole
- FIXED DILATED PUPILS

Manifestations
INITIAL:
REMOVE PATIENT FROM COLD
MAINTAIN ABCs
O2 REB-MASK/ BVM
IV Large bore resuscitate
Rewarm pt.
a. PASSIVE- remove clothes, apply
Dry, use radiant lights
b. ACTIVE EX- apply heating devices, warm water immersion
c. ACTIVE IN- provide warm IV
Fluids, heated/ humidified O2, peritoneal lavage with warmed fluids, hemodialysis
OBTAIN 12 LEAD ECG
REWARMING SHOCK avoid
GENTLY TX. AVOID INCREAD CO
DEFIBRILLATION MAY BE NEEDED

MANAGEMENT
 ONGOING:
MONITOR
1. Vitals
2. LOC
3. Temperature
4. O2 Saturation
5. Heart Rate
6. Rhythm
7. Blood Sugar
8. F&E

TREATMENTS
OVERVIEW OF BITES
FACTS
TYPES OF WOUNDS
SIGNS & SYMPTOMS
VACCINATIONS
DISEASES
CASE STUDY
ASSESSMENT
- MEDICAL MANAGEMENT
- TREATMENT
- PREVENTION
Approximately 4.5 million dog bites occur each year in the
United States. Almost 1 out of 5 bites becomes infected.
Who is most at risk for dog bites?

Children. Among children, the rate of dog-biterelated

injuries is highest for those 5 to 9 years old. Children are
more likely than adults to receive medical attention for dog
bites.

Men. Men are more likely than women to be bitten by a

dog.

FACTS
Over half of dog-bite injuries occur at home
with dogs that are familiar to us. Among
children and adults, having a dog in the
household is associated with a higher likelihood

FACTS
of being bitten than not having a dog.
Dog bite wound care:

Minor wounds
Wash the wound thoroughly with soap and water.
Apply an antibiotic cream.
Cover the wound with a clean bandage.
See a healthcare provider if the wound becomes red, painful, warm, or
swollen; if you develop a fever; or if the dog that bit you was acting
strangely.

Deep wounds
Apply pressure with a clean, dry cloth to stop the bleeding.
If you cannot stop the bleeding or you feel faint or weak, call 911 or your
local emergency medical services immediately.
See a healthcare provider as soon as possible.

TYPES OF WOUNDS
Tetanus Vaccines and TIG for Wound
DISEASES FROM DOG BITES:
RABIES IS ONE OF THE MOST SERIOUS DISEASES PEOPLE CAN GET FROM
DOG BITES. RABIES IS A VIRUS THAT AFFECTS THE BRAIN AND IS ALMOST
ALWAYS FATAL. THE MOST COMMON WAY RABIES VIRUS IS SPREAD IS
THROUGH THE BITE AND SALIVA OF AN INFECTED ANIMAL. THE DISEASE
CAN BE PREVENTED BY VACCINATING DOGS. PEOPLE WHO ARE EXPOSED
TO A DOG OR ANY ANIMAL THAT COULD HAVE RABIES SHOULD RECEIVE
TREATMENT IMMEDIATELY TO PREVENT RABIES.

CAPNOCYTOPHAGA SPP. ARE BACTERIA THAT LIVE IN THE MOUTHS OF

HUMANS, DOGS, AND CATS. THESE BACTERIA DO NOT MAKE DOGS OR
CATS SICK. RARELY, CAPNOCYTOPHAGA SPP. CAN SPREAD TO HUMANS
THROUGH BITES, SCRATCHES, OR CLOSE CONTACT FROM A DOG OR CAT
AND CAUSE ILLNESS. MOST PEOPLE WHO HAVE CONTACT WITH DOGS OR
CATS DO NOT BECOME SICK. PEOPLE WITH A WEAKENED IMMUNE SYSTEM
(MAKING IT MORE DIFFICULT FOR THEIR BODIES TO FIGHT INFECTION) ARE
AT GREATER RISK OF BECOMING SICK.

DISEASES
Pasteurella is a type of bacteria seen in over 50% of infected dog bite
wounds. Pasteurella commonly causes a painful, red infection at the site of the bite
but can cause more serious disease in people with a weak immune system. Often these
signs are accompanied by swollen glands, swelling in the joints, and difficulty
moving.

MRSA (methicillin-resistant Staphylococcus aureus) is type of Staph infection that is

resistant to a certain group of antibiotics. Dogs and other animals can carry MRSA
without showing any symptoms, but the bacteria can cause skin, lung, and urinary
tract infections in people. In some people, MRSA can spread to the bloodstream or
lungs and cause life-threatening infections.

Tetanus is a toxin produced by a type of bacteria called Clostridium tetani. This

toxin causes rigid paralysis in people and could be a problem in deep bite wounds.

DISEASES
Collaborative care:
Initial treatment includes cleaning with copious irrigation, debridement, tetanus
prophylaxis, and analgesics as needed.

Prophylactic antibiotics (broad spectrum antibiotic).

Antibacterial cream (Bacitracin cream).

Rabies post-exposure prophylaxis if necessary.

Antipyretic agent (NSAIDs, acetaminophen, salicylates) to reduce fever.

Analgesics for pain

CARE OF CLIENT
 Confine your dog immediately and check on the victim's
condition. Report the dog to the Animal Control or
Humane Society for further assistance in regards to
quarantine time period.

Animals that have been impounded by an animal control

agency must complete their quarantine period in a
shelter. Many owned biting animals complete their
quarantine in their own home, if they can be kept
securely on site.

If your dog bit someone

VIOLENCE
- DEFINITION
- TYPES OF VIOLENCE
- PREVALENCE
- S/S
- MEDICAL MANAGEMENT
Violence is defined by the World Health Organization
as the intentional use of physical force or power,
threatened or actual, against oneself, another person,
or against a group or community, which results in or
has a high likelihood of resulting in injury, death,
psychological harm, maldevelopment, or deprivation.

The purpose behind the violence may be due to;

Anger at someone due to their actions or inactions, (assault/murder).
Fear of someone, something or anxiety of unknown, fight or flight response, (assault/murder).
Impairment due to organic disease or medication, Temporal Lobe Epilepsy/Tourette's,
(assault).
Psychosis altering the mental state, Schizophrenia/Bipolar/PTSD/Alzheimers,
(assault/murder).
Antisocial behavior, Antisocial Personality Disorder/Sociopath/Sadistic Personality Disorder,
(assault/rape/murder).
Medication or recreational drug use, Catovit/Ecstasy/Prolintane/Methamphetamine
(assault/rape/murder).
 TYPES OF VIOLENCE

Can occur in any environment or setting

- Work
- Home
- Community
Assault
- When one person tries to or does physically strike another
- Acts in a threatening manner to put another in fear or immediate harm
Rape
- Forcible perpetration of a sexual act on a person without consent
- With genitalia or foreign object
 MANDATED REPORTING

Mandated reporting of suspected child, elder or dependent

violence/abuse as well as confirmed violence/abuse.

Ethically as nurses we should report ALL suspected

violence/abuse due to the psychiatric complications that
intimate partner abuse entails. Especially in cases where
the victim has admitted the abuse.
Family and intimate partner violence
 Family and intimate partner violence
FACT
74% of all murder-suicides involve an intimate partner
S by a partner
- 96% of all those were women killed
3 out of 4 Americans know a victim of IPV

15 million children a year are exposed to domestic violence, 90% are eye witnesses
- Boys who witness IPV growing up are twice as likely as adults to abuse their
family
- 1 in 3 will grow up to be an abuser
- 1 in 3 will grow up to be a victim of IPV
- 31,000 children globally die ear year from domestic violence
- 1 in every 10 calls to abuse hotlines are made by a child

71% of all IPV reported the abuser also targeted their pet
- 96% of IPV pet owners report their pet abused
- 1 million animals a year are abused/killed in connection with IPV
- 1,500 battered women shelters in the U.S. and 3,800 animal shelters
 Family and intimate partner violence
FACTS

On a typical day there are over 20,000 calls placed to U.S. domestic violence
hotlines
- 18% are male victims
- 1 in 4 men in their lifetime will be a victim of some form of IPV
(assault/rape/stalking)
- 15% of REPORTED victims are male
- Majority of male victim IPV goes unreported
- Of the reported case 2 of every 3 male victims stated they were laughed at,
mocked or ridiculed by the police or healthcare worker
- Majority say they do not feel their case was taken seriously
Family and intimate partner violence
FACTS

1 in 3 U.S. women in their lifetime will be a victim of IPV

- every 9 seconds a woman is a victim of IPV
- leading cause of homicides & injury related deaths during
pregnancy
- IPV is the single biggest health risk to women ages 15-44
- more than MVA, muggings, and rapes combined
 SIGNS
&
SYMPTOMS
Bruises/injuries that look like they came from choking, punching, or being thrown down.
Black eyes, red/purple marks at the neck, and sprained wrists are common injuries.
Attempting to hide bruises with makeup or clothing.
Making excuses like tripping, being accident-prone or clumsy.
Having few friends, being isolated from relatives/coworkers and kept from making friends.
Having to ask permission to meet, talk with or do things with other people.
Having little money available; may not have credit cards or a car.
Hx of fractures or injuries with suspicious causes. Often injuries do not match up with explanation.
Low self-esteem; being extremely apologetic and meek
Referring to the partner's temper but not disclosing the extent of the abuse
Drug or alcohol abuse problem
Symptoms of depression, such as sadness or hopelessness, or loss of interest in daily activities
 Medical Management

Screen for family violence and IPV while alone with patient
Is anyone is hurting you or your family?
Do you feel safe at home?
Is there anything else happening that could be affecting your health?
You seem very anxious, is everything all right at home?
When I see injuries like this, I wonder if someone hurt you?
Are you concerned about the safety of your children?
Victims are more likely to report to protect their children from harm

Healthcare workers should actively listen, confirm fear/worry, validate decision to disclose,
emphasize unacceptability of violence .

Assist in obtaining safety, provide help numbers as well as provide phone for patient to call.
The nurse prepares to administer acetylcysteine (Mucomyst) to the
client with an overdose of acetaminophen (Tylenol). What is the
appropriate action when administering this antidote?

A. Administer the medication subcutaneously in the deltoid muscle.

B. Administer the medication by intramuscular (IM) injection in the

gluteal muscle.

C. Mix the medication in a flavored ice drink and allowing the client
to drink the medication.

D. Administer the medication by an intravenous (IV) line, mixed in 50

mL of normal saline and piggybacked through the main IV line.

Question # 1
 ANSWER:
C. Mix the medication in a flavored ice drink
and allowing the client to drink the
medication.

QUESTION #1
Which of the following patients are NOT
considered ESI level 2 patients?

A. Suicidal ideation.
B. Rash with no shortness of breath or stridor.
C. Dialysis patient after fistula placement that same
day and having arm swelling.
D. Chest pain radiating to the left arm and into the
back.

Question # 2
 ANSWER:

B. Rash with no shortness of

breath or stridor.

QUESTION #2
What is a major issue as it relates to
"frequent flyers" to the Emergency
Department?
A. The tendency to anger the staff for consuming their time
B. The possibility that a future visit may turn out to be an
emergency need.
C. The increased amount of cost to the system.
D. The need to provide specialty consultation such as
behavioral health.

Question # 3
ANSWER:

B. The possibility that a future visit

may turn out to be an emergency
need.

QUESTION #3
What is the correct response to a mother presenting
to your triage window with a small child in her arms
that appears: dusky with discolored nail beds, listless,
and retractions?

A. Grab the child from mom and run immediately to a room.

B. Call the ER physician to request orders.
C. Shake the child to attempt to arouse the child.
D. Immediately push the "code" button on the wall and administer
high flow oxygen via a large volume device while in the triage
room.

Question # 4
ANSWER:
D. Immediately push the "code"
button on the wall and administer high
flow oxygen via a large volume device
while in the triage room.

QUESTION #4
What ESI level would a patient who is deemed a
"P" on the AVPU scale?

A. ESI 1
B. ESI 2
C. ESI 3
D. ESI 4
E. ESI 5

Question # 5
 ANSWER:

A. ESI 1

QUESTION #5
 While on the playground, a school child is
stung by a bee, resulting in redness and
swelling. The school nurse is nearby when it
happens. What does the nurse do first?

A. Applies an ice pack to the stinger

B. Gently scrapes out the stinger with a credit card
C. Injects the child with an epinephrine pen (Epi-Pen auto-
injector)
D. Removes the bee and saves it for evidence of the sting

Question #6
ANSWER:

B. Gently scrapes out the stinger

with a credit card

QUESTION #6
 A nurse is providing reminders to a Red Cross
class about safety procedures to prevent
drowning or submersion. In which situation
does this present the greatest risk?

A. An engaged couple going swimming together at a local

lake
B. Children swimming at the community pool
C. College students going to a fraternity party at a boat house
D. Families going to the quarry to swim

QUESTION #7
ANSWER:

C. College students going to a

fraternity party at a boat house

QUESTION #7
 A golfer who is caught in a thunderstorm is
struck by lightning. A fellow golfer, who is a
nurse, runs to the victim's aid. What does the
nurse do initially?

A. Applies a dressing over the skin burn where the lightening

entered
B. Instructs everyone to not touch the victim to avoid being
hurt
C. Moves the victim to a more secure area
D. Palpates to check for the presence of a pulse

QUESTION #8
ANSWER:

D. Palpates to check for the

presence of a pulse

QUESTION #8