Emergency Nursing Orientation 3.0: Triage -
ENA-ENO-C15 – Exam Questions & Answers
Which function differentiates the Emergency Severity Index from the
Canadian Triage and Acuity Scale? - -It identifies specific vital signs that
place a patient at acuity level 2.
-When triaging a potential psychiatric patient, which action is the triage
nurse's priority? - -Assess patient and staff safety.
-Which question is most likely to assess the quality of a patient's symptom?
- -"What does it feel like?"
-Detection of severe jaundice during an across-the-room assessment falls
under which category of assessment? - -Skin color
-Which question best elicits details from a patient seeking treatment in the
emergency department? - -"Why do you think you fell?"
-Triage documentation must include which element? - -Assessment of pain
-Using the CIAMPEDS mnemonic, the triage nurse evaluates fever control for
a pediatric patient. This reflects which component of the mnemonic? - -
Medication
-What should the nurse do when a person calls on the telephone for medical
advice? - -Politely inform the caller that the emergency department does not
give out any medical advice.
-A pediatric patient with increased work of breathing is likely to display
which assessment finding? - -Grunting
-The triage nurse notes a fruity smell during an across-the-room
assessment. This finding may be a sign of which condition? - -Diabetic
ketoacidosis
-When triaging a geriatric patient, the triage nurse should routinely perform
which action? - -Evaluate the patient's interactions with his or her family.
-The triage nurse should bring which patient to the patient care area first? -
-A man who presents to triage with diaphoresis and complaints of chest pain
-The triage nurse should perform which important infection control
measure? - -Place an immunosuppressed patient in a separate waiting area.
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