TRIAGE AND INITIAL PATIENT MANAGEMENT COMPETENCY 2014

1.

Pain management protocol during invasive procedures may include all of the following EXCEPT:

A.

2% Lidocaine jelly topically prior to insertion of urethral catheter
B.

Lidocaine and Priolocaine cream 2.5%/2.5% topically to anticipated IV site. Cover with transparent dressing for at least 30 minutes.
C.

Lidocaine Solution 2% 4 ml via nebulization prior to insertion of nasogastric tube
D.

Lidocaine 1% intradermally prior to IV insertion
E.

Pain Ease spray for 4-10 seconds from a distance of 3-7 inches for vascular access

Correct Answer
D. Lidocaine 1% intradermally prior to IV insertion

Explanation
The given options list various methods for pain management during invasive procedures. All of the options, except for "Lidocaine 1% intradermally prior to IV insertion," involve the use of lidocaine or other numbing agents to alleviate pain. Therefore, the correct answer is "Lidocaine 1% intradermally prior to IV insertion" as it is the exception to the pain management methods listed.

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2.

True or false? A patient with a Finger Stick Blood Sugar (FSBG) of 68 mg/dl should be treated regardless whether the patient is symptomatic or not. The FSBG must be rechecked in 15 minutes and treatment repeated until FSBG >70 mg/dl.

A.

True
B.

False

Correct Answer
A. True

Explanation
A patient with a Finger Stick Blood Sugar (FSBG) of 68 mg/dl should be treated regardless of whether the patient is symptomatic or not. This is because a FSBG level of 68 mg/dl is considered low and can indicate hypoglycemia. Treatment should be administered to raise the blood sugar level to a safe range. The FSBG must be rechecked in 15 minutes and treatment repeated until the FSBG is above 70 mg/dl, ensuring that the blood sugar level has stabilized and is within a normal range.

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3.

All of the following interventions maybe initiated by the nurse to manage sepsis in adults 18 years of age and above EXCEPT:

A.

Blood culture x2
B.

CBC and CMP
C.

Lactic Acid
D.

Normal Saline 2 L bolus

Correct Answer
D. Normal Saline 2 L bolus

Explanation
The nurse can initiate blood culture x2, CBC and CMP, and lactic acid tests to manage sepsis in adults. These tests help in identifying the causative organism, assessing organ function, and monitoring the severity of sepsis. However, a 2 L bolus of normal saline is not recommended in the management of sepsis as it can lead to fluid overload and worsen the patient's condition. Instead, fluid resuscitation is done using balanced crystalloids or albumin based on the patient's hemodynamic status.

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4.

All of the following interventions maybe initiated by the nurse to manage pain and nausea EXCEPT:

A.

Acetaminophen 15 mg/kg to a max of 1000 mg po x 1 for mild pain in adult patients
B.

Morphine Sulfate 0.15 mg/kg IM or IV x1 dose for moderate pain (4-7 on 10 point scale) and severe pain (8-10 on 10 point scale) in adults
C.

Morphine Sulfate 0.1 mg/kg IM or IV x1 dose for moderate and severe pain in pediatric patients
D.

Zofran ODT 8 mg SL x 1 dose or Zofran 4 mg IV x 1 dose for nausea control in adult patients
E.

Zofran ODT 4 mg SL x 1 dose for peds 6 months to 3 years of age

Correct Answer
E. Zofran ODT 4 mg SL x 1 dose for peds 6 months to 3 years of age

Explanation
The correct answer is "Zofran ODT 4 mg SL x 1 dose for peds 6 months to 3 years of age". This intervention is not appropriate for managing pain, as it is specifically indicated for nausea control in pediatric patients. The other interventions listed are all appropriate for managing pain and nausea in adult and pediatric patients, based on the severity of the pain and the age of the patient.

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5.

The family of a 74-year-old male called 911 when he developed severe mid-abdominal pain and shoulder pain. “My husband is not a complainer,” reports his wife. “The only medication he takes is for high blood pressure.” On arrival in the ED, patient’s HR is 140, RR 28, SpO2 94%, BP 72/56.

A.

ESI 1
B.

ESI 2
C.

ESI 3
D.

ESI 4
E.

ESI 5

Correct Answer
A. ESI 1

Explanation
The patient's symptoms of severe mid-abdominal pain and shoulder pain, along with vital signs indicating tachycardia, tachypnea, and hypotension, suggest a potentially life-threatening condition. ESI 1 is the correct answer because it represents the highest level of acuity, indicating that the patient requires immediate intervention and should be seen by a healthcare provider within minutes.

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6.

An 88-year-old female is brought to the ED by EMS. This morning she had an episode of slurred speech and weakness of her left arm that lasted about 45 minutes. She has a history of HTN and a previous stroke. She is alert and oriented with slightly slurred speech. VS: T-97.7, HR 92, BP 163/93, RR 28, SpO2 98% RA.

A.

ESI 1
B.

ESI 2
C.

ESI 3
D.

ESI 4
E.

ESI 5

Correct Answer
B. ESI 2

Explanation
The patient is an 88-year-old female with a history of hypertension and a previous stroke who presented to the ED with symptoms consistent with a transient ischemic attack (TIA). She had an episode of slurred speech and weakness of her left arm that lasted for about 45 minutes. Despite having slightly slurred speech, she is alert and oriented. Her vital signs are stable, with a slightly elevated blood pressure. Based on the information provided, the patient's condition is stable and does not require immediate intervention or admission to a higher acuity level, therefore she can be classified as ESI 2.

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7.

A 72-year-old female with obvious chronic obstructive pulmonary disease (COPD) and increased work of breathing is wheeled into triage. Between breaths she tells you that she “is having a hard time breathing and has had a fever since yesterday.” The SpO2 monitor is alarming and displaying a saturation of 82 percent. The patient appears in severe distress.

A.

ESI 1
B.

ESI 2
C.

ESI 3
D.

ESI 4
E.

ESI 5

Correct Answer
A. ESI 1

Explanation
Based on the given information, the patient is a 72-year-old female with obvious COPD, increased work of breathing, difficulty breathing, fever, and a low oxygen saturation level of 82 percent. This indicates a severe respiratory distress and a potentially life-threatening condition. Therefore, the appropriate triage level for this patient would be ESI 1, which represents patients with immediate life-threatening conditions requiring immediate intervention.

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8.

1. A 40-year-old male presents to triage with vague, midsternal chest discomfort, occurring intermittently for one month. This morning, he reports a similar episode, which has now resolved. Currently complains of mild nausea, but feels good otherwise. Medical history: smoker. He is alert, with skin warm and dry, does not appear to be in any distress.

A.

ESI 1
B.

ESI 2
C.

ESI 3
D.

ESI 4
E.

ESI 5

Correct Answer
B. ESI 2

Explanation
Based on the information provided, the patient is a 40-year-old male with vague, midsternal chest discomfort that has been occurring intermittently for one month. He also experienced a similar episode this morning, which has now resolved. He currently complains of mild nausea but otherwise feels good. The patient's medical history includes being a smoker. Although the patient is not in any distress and his vital signs are not mentioned, his symptoms of chest discomfort and nausea warrant further evaluation and monitoring. Therefore, the appropriate triage level for this patient would be ESI 2, which indicates a high priority but not immediate life-threatening condition.

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9.

A 63-year-old male is brought in from the local nursing home because of altered LOC. His blood pressure is 82/60 and Temp is 101.8. The patient was being treated with oral antibiotic for aspiration pneumonia at the nursing home. He is more unresponsive than usual and his HR 128.

A.

ESI 1
B.

ESI 2
C.

ESI 3
D.

ESI 4
E.

ESI 5

Correct Answer
A. ESI 1

Explanation
The patient's altered level of consciousness, low blood pressure, high temperature, and increased heart rate indicate a severe medical condition requiring immediate intervention. ESI 1 is the correct answer because it represents a patient with unstable vital signs and a high likelihood of deterioration. This patient needs immediate resuscitation and intensive care.

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Triage And Initial Patient Management Competency 2014

Pain management protocol during invasive procedures may include all of the following EXCEPT:

True or false? A patient with a Finger Stick Blood Sugar (FSBG) of 68 mg/dl should be treated regardless whether the patient is symptomatic or not. The FSBG must be rechecked in 15 minutes and treatment repeated until FSBG >70 mg/dl.

All of the following interventions maybe initiated by the nurse to manage sepsis in adults 18 years of age and above EXCEPT:

All of the following interventions maybe initiated by the nurse to manage pain and nausea EXCEPT:

The family of a 74-year-old male called 911 when he developed severe mid-abdominal pain and shoulder pain. “My husband is not a complainer,” reports his wife. “The only medication he takes is for high blood pressure.” On arrival in the ED, patient’s HR is 140, RR 28, SpO2 94%, BP 72/56.

A 63-year-old male is brought in from the local nursing home because of altered LOC. His blood pressure is 82/60 and Temp is 101.8. The patient was being treated with oral antibiotic for aspiration pneumonia at the nursing home. He is more unresponsive than usual and his HR 128.