Author Question: The triage nurse in a hospital emergency department is determining the order of care for several ... (Read 130 times)

RODY.ELKHALIL · **on:** Jul 23, 2018

The triage nurse in a hospital emergency department is determining the order of care for several patients. Which of the following would the nurse consider as having the highest priority?

a. A 68-year-old patient suffering from dehydration and disorientation
b. A 14-year-old patient having respiratory distress and increasing anxiety
c. A 46-year-old patient with multiple cuts and abrasions to the upper extremities
d. A 38-year-old patient with a broken right hip and in severe pain

Question 2

The nurse is performing a physical exam on a patient diagnosed with liver failure resulting from chronic alcoholism. The nurse notes that the abdomen is swollen and decides to assess for abdominal skin tenderness and temperature.

Which of the following techniques would the nurse use to collect this data?
a.
Inspection
b.
Percussion
c.
Palpation
d.
Auscultation

ryrychapman11 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: B
Triage, a form of emergency assessment, is the classification of patients according to treatment priority. Patients are categorized by the urgency of their condition. Most emergency departments use a three- or five-tier triage system; the trend is toward a five-tier system. The classifications in the three-tier system are emergent, urgent, and non-urgent. The five-tier system classifies patients by levels numbered 1 through 5. Level 1 is considered critical: life-threatening conditions require immediate and continuous care such as severe trauma, cardiac arrest, respiratory distress, seizure, or shock. Level 2 emergencies can be imminently life-threatening conditions requiring care within 30 minutes, such as chest pain or major fractures, with severe pain. Level 3 is considered urgent: potentially life-threatening conditions that require care within 30-60 minutes, such as minor fractures, lacerations, and dehydration. Level 4 is considered non-urgent, stable health conditions that require care within 60-120 minutes, such as sore throats and abrasions.

Answer to Question 2

ANS: C
Palpation uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness. Inspection involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems. Percussion involves tapping the patient's skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures. Auscultation is a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity. Vibration is reflected by the tissues, and the character of the sound heard depends on the density of the structures that reflect the sound.