Author: Anonymous

A triage nurse in an emergency department is prioritizing five walk‑in patients using Emergency Severity Index (ESI) principles.ESI CategoriesESI 1 – Immediate (Emergent – highest need)ESI 2 – High Risk (Urgent, Unstable)ESI 3 – Urgent, Stable (Multiple Resources Needed)ESI 4 – Less UrgentESI 5 – NonurgentPatientsPatient A:  A 62‑year‑old with a history of coronary artery disease reports crushing chest pain that began 20 minutes ago. Skin is pale and diaphoretic. Blood pressure is 82/50 mmHg.Patient B:  A 44‑year‑old with abdominal pain for 8 hours, nausea, and vomiting. Pain is rated 8/10. Vital signs are stable, but the patient appears uncomfortable and will require lab work and imaging.Patient C: A 29‑year‑old with shortness of breath and wheezing after exposure to a cat. Oxygen saturation is 93% on room air. Able to speak full sentences but appears anxious.Patient D: A 22‑year‑old with sore throat, fever, and body aches for 3 days. Vital signs are stable. Requests testing for strep throat.Patient E: A 36‑year‑old requesting evaluation for removal of sutures placed 10 days ago on a forearm laceration. No pain, redness, or drainage.Question Prompt:Match each patient to the appropriate Emergency Severity Index (ESI) category. Each ESI category will be used once.

Which assessment is NOT part of initial mass‑casualty triage?

A nurse is providing discharge teaching to a client who was hospitalized with a pelvic fracture and liver laceration following a motor vehicle collision. Which statements by the client indicate understanding of strategies to reduce the risk of future motor vehicle accidents or injury? Select all that apply.

A client who sustained a C4 spinal cord injury one week ago demonstrates ineffective coughing and crackles on lung auscultation. To promote airway clearance, the nurse should [BLANK-1].

Which statement best describes spinal shock following an acute spinal cord injury?

Which actions are included in the primary survey of a trauma patient? Select all that apply.

A nurse is caring for a client who has pneumonia on a medical/surgical unit Nurse’s Notes Client admitted to the unit 12 hr ago with pneumonia, over the last 1 hr the client has exhibited dyspnea and restlessness. Respiratory rate is currently 32/min with deep breaths, BP 198/78 mm Hg. Oxygen has been increased from 2 L nasal cannula to 50% face mask with little improvement of oxygen saturation. Current oxygen saturation is 91% on 50% facemask. Arterial blood gases drawn and sent to lab. ABGs bowtie.PNG Complete the diagram by clicking on the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

A client with a severe traumatic brain injury is intubated, mechanically ventilated, and sedated in the ICU. Intracranial pressure (ICP) monitoring shows an elevation from 14 to 22 mm Hg during routine care activities. Vital signs are otherwise stable and SpO₂ is 98% on the ventilator.Which action should the nurse take first?

A nurse is developing a plan of care for a client who sustained a complete T2 spinal cord transection in a motor vehicle collision 24 hours ago. The client is in the intensive care unit and remains at risk for spinal shock and autonomic dysreflexia.Which collaborative and nursing interventions should the nurse anticipate to include in the plan of care at this time? Select all that apply.

A nurse is caring for a client with a head injury who is being closely monitored for changes in intracranial status. Which assessment finding, when reported to the health care provider, should the nurse anticipate will result in new prescriptions or additional interventions?