Emergency - Triage and Prioritization Latest Exam Questions With All Correct Answers.
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Course
ESI Practice Cases
Institution
ESI Practice Cases
What ESI level should be considered for a 2 year-old child who presents with a measured temperature of 103.0 F, who is not current on their vacinations, and has no obvious cause for the fever? - Answer ESI 3
What does the ESI decision process require? - Answer •Requires an experienced ED...
Emergency - Triage and Prioritization
Latest Exam Questions With All Correct
Answers.
What ESI level should be considered for a 2 year-old child who presents with a measured temperature of
103.0 F, who is not current on their vacinations, and has no obvious cause for the fever? - Answer ESI 3
What does the ESI decision process require? - Answer •Requires an experienced ED nurse
•Decision points:
-A. Does this patient require immediate life-saving intervention?
-B. Is this a patient who should wait?
-C. How many resources will this patient need?
-D. What are the patient's vital signs?
Components of Decision point A - Answer •Does the patient require immediate life-saving
intervention?
-Is their airway patent?
-Are they breathing?
-Do they have a pulse?
-Is their pulse adequate?
-Were they intubated pre hospital?
-Can they maintain oxygenation?
-Do they need meds to support their hemodynamic stability or volume replacement?
*•If you answered YES to any previous questions this patient is a ESI 1 and needs to be taken to a room
immediately with RN and MD at bedside immediately
•ESI 1 require immediate physician intervention*
,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?
- Grab the child from mom and run immediately to a room.
- Call the Flow Facilitator and attempt room placement.
- Call the ER physician to request orders.
- Shake the child to attempt to arouse the child.
- Immediately push the "code" button on the wall and administer high flow oxygen via a large volume
device while in the triage room. - Answer Immediately push the "code" button on the wall and
administer high flow oxygen via a large volume device while in the triage room.
What are some examples of an ESI 1 level patient? - Answer •Cardiac Arrest
•Respiratory Arrest
•Severe Respiratory Distress
•Level 1 Trauma
•OD with GCS < 8
•Severe bradycardia/tachycardia
•Hypotension/hypoperfusion
•STEMI
•Anaphylactic shock
•Baby who is flaccid
•Hypoglycemia with AMS
•Unresponsive Child
Components of Decision Point B - Answer •Should the patient wait?
-If you as the nurse believe this patient should not wait to be seen - ESI 2
-If the patient can wait- move to decision point C
Questions to think about in Decision Point B? - Answer -Is this a high risk patient?
•The "sixth sense" that something is wrong-trust your instinct
•Is their medical history significant?
, •Could their condition deteriorate quickly?
•The clinical portrait
-"worst headache of my life"
-"severe pain between my shoulder blades radiating to my chest"
-Does this patient have a change in mental status?
•New onset in elderly patient
•Lethargic infant/child
•Teenager "not acting right"
-Are they in severe pain or distress?
•Pain level 7/10 or higher? Consider ESI 2
•Where is the pain and how does the patient appear?
-Abdominal pain, diaphoretic, pain rate 7/10 - ESI 2
-Twisted ankle, no swelling, pain rate 8/10 - move to Decision Point C
*•If you determine the patient to be an ESI 2 the patient should be taken to a room immediately and the
RN should initiate protocols to care for the patient and notify the MD of the patient status
•ESI 2 the MD needs to see the patient quickly*
What are some examples of an ESI 2 level patient? - Answer •Chest pain (suspicious of ACS)
•Signs of stroke
•Rule out ectopic pregnancy
•Immunocompromised patient with a fever
•Suicidal/homicidal patient
*•Approximately 20-30% of ED patients
•50-60% of ESI 2 patients get admitted to the hospital*
Components of Decision Point C - Answer •What resources will they need?
-In other words, what is typically done for patients presenting to the ED with this chief complaint?
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