BCEN Triage Systems 3 — Questions and Answers
Question 1: In the JumpSTART triage system, modified for pediatric patients, respirations are checked after positioning the airway; if the child is not breathing, the next step is:
- Tag the child as Expectant (Black) immediately
- Give 5 rescue breaths and reassess (Correct answer)
- Check capillary refill
- Assess mental status using AVPU
Correct answer: Give 5 rescue breaths and reassess
JumpSTART differs from START by providing 5 rescue breaths to apneic children before tagging Expectant, because pediatric apnea may be respiratory-origin and reversible.
Question 2: Which triage level in the four-level color system indicates a patient who is ambulatory with minor injuries and can wait for delayed care?
- Red
- Yellow
- Green (Correct answer)
- Black
Correct answer: Green
Green (Minor) patients are ambulatory, have minor injuries, and can tolerate delayed treatment without significant deterioration.
Question 3: The 'P' in the SALT triage method stands for:
- Priority (Correct answer)
- Pulse
- Perfusion
- Position
Correct answer: Priority
SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) uses 'P' for Priority after lifesaving interventions are applied.
Question 4: A nurse is triaging a patient who presents with chest pain radiating to the left arm, diaphoresis, and nausea. Which ESI level is most appropriate?
- ESI 3
- ESI 4
- ESI 2 (Correct answer)
- ESI 5
Correct answer: ESI 2
Classic ACS presentation represents a high-risk situation meeting ESI level 2 criteria; the patient should not wait for evaluation.
Question 5: In the SALT triage system, the initial sorting step instructs responders to first ask all patients to:
- Remove clothing for rapid assessment
- Walk to a designated area if able (Correct answer)
- Lie still until assessed individually
- State their name and date of birth
Correct answer: Walk to a designated area if able
SALT begins with a global sort by asking those who can walk to move to a designated area, quickly separating the ambulatory from non-ambulatory victims.
Question 6: Which vital sign parameter is NOT directly assessed in the original START triage algorithm?
- Respiratory rate
- Capillary refill or radial pulse
- Blood pressure (Correct answer)
- Mental status (ability to follow commands)
Correct answer: Blood pressure
START triage assesses respirations, perfusion (capillary refill/radial pulse), and mental status; blood pressure measurement is not part of the algorithm.
Question 7: A triage nurse notes that an ESI level 3 patient's vital signs are: HR 118, RR 24, SpO2 94%, Temp 39.4°C. The nurse should:
- Keep the level 3 assignment and place in the waiting room
- Downgrade to ESI 4 because vitals are only mildly abnormal
- Consider upgrading to ESI 2 due to concerning vital signs (Correct answer)
- Discharge to primary care for follow-up
Correct answer: Consider upgrading to ESI 2 due to concerning vital signs
Danger zone vital signs (elevated HR, RR, low SpO2, high fever) in an ESI-3 patient should prompt reassessment and possible upgrade to ESI-2.
BCEN Triage Systems 3
In the JumpSTART triage system, modified for pediatric patients, respirations are checked after positioning the airway; if the child is not breathing, the next step is: