NR 2755 MDC4 Final Exam -Questions with Correct Answers/
Verified/ latest Version 2024/2025
What does triaging do? - ✔✔*acts as gatekeeper*
helps prioritize patient care based on illness and severity level
According to triage, what patients would be seen firtst - ✔✔highest acuity patients will
receive quickest intervention
(Most ill/severe will get seen first)
What is a good model for triaging patients? - ✔✔ABCs
Is hospital triaging the same as mass casualty triaging? - ✔✔NO
Which triage situation uses tags? - ✔✔mass casualties
what are the categories of triage? - ✔✔- emergent
- urgent
- nonurgent
- primary survey
what classifies a patient as emergent according to triage - ✔✔- life threatening injuries
- needs immediate treatment
what patient conditions warrant an emergent status of triage - ✔✔- respiratory distress
- chest pain with diaphoresis
- stroke
- active hemorrhage
- unstable vitals
,what classifies a patient as urgent according to triage - ✔✔patient should be treated quickly
but there is not and immediate threat to life
what patient conditions warrant an urgent status for triage - ✔✔- severe abdominal pain
- renal colic
- displaced multiple fractures
- new onset of respiratory infection (pneumonia)
what classifies a patient as nonurgent according to triage - ✔✔patient can wait several
hours without a risk to life
what patient conditions warrant a nonurgent status for triage - ✔✔- skin rash
- strains/sprains
- colds
- simple fracture
what is a primary survey that should be performed while triaging? - ✔✔ABCDE
what does ABCDE stand for in triaging patients - ✔✔A: Airway/cervical spine
B: Breathing
C: Circulation
D: Disability
E: Exposure
what does the "A" refer to in ABCDE - ✔✔airway, cervical spine
- patent airway
- immobilize spine
,**do NOT move patient
what does the "B" refer to in ABCDE - ✔✔breathing
- assess sounds
- assess chest wall movement
what does the "C" refer to in ABCDE - ✔✔circulation
- vitals (BP and pulse)
- maintain vascular access
- stop any bleeding
what does the "D" refer to in ABCDE - ✔✔disability
*LOC
what does the "E" refer to in ABCDE - ✔✔exposure
- get clothes off
- use blankets to prevent hypothermia
what is the one exception to ABCDE? - ✔✔in excessive bleeding, you would prioritize "C"
before "AB"
what is a secondary survey? - ✔✔comprehensive head to toe assessment
if warranted during the secondary survey, what would a nurse likely do? - ✔✔- insert NG
tube
, - insert catheter
- prep for diagnostics
what does drowning lead to? - ✔✔leads to loss of surfactant in lungs which causes alveolar
collapse and pulmonary edema
is dehydration common in heat exhaustion? - ✔✔YES
what can major diaphoresis cause? - ✔✔severe dehydration and hyponatremia
if heat exhaustion goes untreated, what can it cause? - ✔✔heat stroke
what are the s/s of heat exhaustion - ✔✔-dehydration
-decrease in blood volume
-decrease in BP
-tachycardia
what is the first intervention for a person expected to have heat exhaustion? - ✔✔stop their
physical activity and transfer to a cool place
what is the quickest way to reduce someone's temperature? - ✔✔- remove clothing
- remove bed linen
what interventions are there for cooling patients down? - ✔✔- cold pack on the neck, chest,
abdomen, and groin
- soak in cool water
when rehydrating someone with heat exhaustion, should you use water or a sports
drink/oral reydration solution? - ✔✔Sports drink/oral hydration solution
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