MDC4 Final Exam - helps prioritize patient care based on illness ...

MDC4 Final Exam What does triaging do? (Answer)- *acts as gatekeeper* helps prioritize patient care based on illness and severity level According to triage, what patients would be seen first (Answer)- highest acuity patients will receive quickest intervention (Most ill/severe will get seen first) What is a good model for triaging patients? (Answer)- ABCs Is hospital triaging the same as mass casualty triaging? (Answer)- NO Which triage situation uses tags? (Answer)- mass casualties what are the categories of triage? (Answer)- - emergent

• urgent
• nonurgent
• primary survey

what classifies a patient as emergent according to triage (Answer)- - life threatening injuries

• needs immediate treatment

what patient conditions warrant an emergent status of triage (Answer)- - respiratory distress

• chest pain with diaphoresis
• stroke
• active hemorrhage
• unstable vitals

what classifies a patient as urgent according to triage (Answer)- patient should be treated quickly but there is not and immediate threat to life what patient conditions warrant an urgent status for triage (Answer)- - severe abdominal pain

• renal colic
• displaced multiple fractures 1 / 3

• new onset of respiratory infection (pneumonia)

what classifies a patient as nonurgent according to triage (Answer)- patient can wait several hours without a risk to life what patient conditions warrant a nonurgent status for triage (Answer)- - skin rash

• strains/sprains
• colds
• simple fracture

what is a primary survey that should be performed while triaging? (Answer)- ABCDE

what does ABCDE stand for in triaging patients (Answer)- A: Airway/cervical

spine

B: Breathing

C: Circulation

D: Disability

E: Exposure

what does the "A" refer to in ABCDE (Answer)- airway, cervical spine

• patent airway
• immobilize spine

**do NOT move patient what does the "B" refer to in ABCDE (Answer)- breathing

• assess sounds
• assess chest wall movement

what does the "C" refer to in ABCDE (Answer)- circulation

• vitals (BP and pulse)
• maintain vascular access
• stop any bleeding

what does the "D" refer to in ABCDE (Answer)- disability

*LOC 2 / 3

what does the "E" refer to in ABCDE (Answer)- exposure

• get clothes off
• use blankets to prevent hypothermia

what is the one exception to ABCDE? (Answer)- in excessive bleeding, you would prioritize "C" before "AB" what is a secondary survey? (Answer)- comprehensive head to toe assessment if warranted during the secondary survey, what would a nurse likely do? (Answer)-

• insert NG tube
• insert catheter
• prep for diagnostics

what does drowning lead to? (Answer)- leads to loss of surfactant in lungs which causes alveolar collapse and pulmonary edema is dehydration common in heat exhaustion? (Answer)- YES what can major diaphoresis cause? (Answer)- severe dehydration and hyponatremia if heat exhaustion goes untreated, what can it cause? (Answer)- heat stroke what are the s/s of heat exhaustion (Answer)- -dehydration -decrease in blood volume -decrease in BP -tachycardia what is the first intervention for a person expected to have heat exhaustion?(Answer)- stop their physical activity and transfer to a cool place what is the quickest way to reduce someone's temperature? (Answer)- - remove clothing

• remove bed linen

what interventions are there for cooling patients down? (Answer)- - cold pack on the neck, chest, abdomen, and groin

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