Ambulatory Care Patient Assessment and Triage Questions and Answers

Question 1

A 58-year-old male calls the clinic reporting a sudden onset of chest pain that started 30 minutes ago.
He describes it as 'crushing' and radiating to his left arm.
He has a history of hypertension.
What is the ambulatory care nurse's most appropriate initial action?

Accepted Answer

Instruct the patient to hang up and call 911 immediately for an ambulance.

Answer

Instruct the patient to have someone drive him to the nearest emergency department immediately.

Answer

Schedule a same-day urgent appointment with his primary care provider.

Answer

Advise the patient to take a regular-strength aspirin and monitor his symptoms at home.

Question 2

Which of the following is the primary goal of using standardized protocols during telephone triage in an ambulatory care setting?

Accepted Answer

To ensure consistency and safety in directing patients to the appropriate level of care.

Answer

To provide a definitive medical diagnosis to the patient.

Answer

To decrease the number of calls transferred to a provider.

Answer

To reduce the overall time the nurse spends on the phone with each patient.

Question 3

An ambulatory care nurse is triaging a patient who walked into the clinic complaining of a sore throat, fever of 101°F (38.3°C), and body aches for two days. The patient is able to speak in full sentences and has no difficulty swallowing liquids. Based on this initial assessment, where should this patient be directed?

Accepted Answer

To a designated waiting area for patients with potentially infectious respiratory symptoms.

Answer

Immediately to an exam room for provider evaluation.

Answer

To the waiting room to be seen in the order of arrival.

Answer

To the nearest emergency department for a higher level of care.

Question 4

During a telephone triage call, a mother reports that her 4-year-old child has had a low-grade fever and a mild cough for one day. Which key question is most important for the nurse to ask to assess the urgency of the situation?

Accepted Answer

"How is your child's breathing?"

Answer

"Has the child had all of their immunizations?"

Answer

"Is anyone else in the house sick?"

Answer

"What is the child's exact temperature?"

Question 5

A patient calls the clinic for a medication refill. During the conversation, the patient mentions, 'I've been feeling really down and hopeless lately, and I just don't see the point anymore.' What is the nurse's priority action?

Accepted Answer

Perform an immediate suicide risk assessment using direct questions.

Answer

Complete the medication refill request as the patient asked.

Answer

Advise the patient to schedule a routine follow-up with their primary care provider.

Answer

Provide the patient with the phone number for a mental health crisis line.

Question 6

When conducting an in-person triage assessment in a busy ambulatory clinic, which of the following components should the nurse complete FIRST?

Accepted Answer

A 'across-the-room' assessment for general appearance and work of breathing.

Answer

A detailed past medical history review.

Answer

Measurement of a full set of vital signs.

Answer

Verification of the patient's insurance and demographic information.