The triage nurse in a hospital emergency department is determining the order of care for several patients. Which of the following would the nurse consider as having the highest priority?

Question

a. A 68-year-old patient suffering from dehydration and disorientation
b. A 14-year-old patient having respiratory distress and increasing anxiety
c. A 46-year-old patient with multiple cuts and abrasions to the upper extremities
d. A 38-year-old patient with a broken right hip and in severe pain

Answer 1

ANS: B
Triage, a form of emergency assessment, is the classification of patients according to treatment priority. Patients are categorized by the urgency of their condition. Most emergency departments use a three- or five-tier triage system; the trend is toward a five-tier system. The classifications in the three-tier system are emergent, urgent, and non-urgent. The five-tier system classifies patients by levels numbered 1 through 5. Level 1 is considered critical: life-threatening conditions require immediate and continuous care such as severe trauma, cardiac arrest, respiratory distress, seizure, or shock. Level 2 emergencies can be imminently life-threatening conditions requiring care within 30 minutes, such as chest pain or major fractures, with severe pain. Level 3 is considered urgent: potentially life-threatening conditions that require care within 30-60 minutes, such as minor fractures, lacerations, and dehydration. Level 4 is considered non-urgent, stable health conditions that require care within 60-120 minutes, such as sore throats and abrasions.