NUR 2755 Multidimensional Care IV MDC4 FINAL EXAM

NUR 2755 Multidimensional Care IV MDC4 FINAL EXAM 

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 first?

• 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?