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Emergency Nursing Orientation 3.0_ Triage - ENA-ENO-C15.
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Emergency Nursing Orientation 3.0_ Triage - ENA-ENO-C15.
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Emergency Nursing Orientation 3.0: Triage- ENA-ENO-C15
Which function differentiates the Emergency Severity Index from the Canadian Triage
and Acuity Scale? - ANS-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? -
ANS-Assess patient and staff safety.
Which question is most likely to assess the quality of a patient's symptom? - ANS-"What
does it feel like?"
Detection of severe jaundice during an across-the-room assessment falls under which
category of assessment? - ANS-Skin color
Which question best elicits details from a patient seeking treatment in the emergency
department? - ANS-"Why do you think you fell?"
Triage documentation must include which element? - ANS-Assessment of pain
Using the CIAMPEDS mnemonic, the triage nurse evaluates fever control for a pediatric
patient. This reflects which component of the mnemonic? - ANS-Medication
What should the nurse do when a person calls on the telephone for medical advice? -
ANS-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? - ANS-Grunting
The triage nurse notes a fruity smell during an across-the-room assessment. This
finding may be a sign of which condition? - ANS-Diabetic ketoacidosis
When triaging a geriatric patient, the triage nurse should routinely perform which action?
- ANS-Evaluate the patient's interactions with his or her family.
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