BCEN Triage Systems 3

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:

Accepted Answer

Give 5 rescue breaths and reassess

Answer

Tag the child as Expectant (Black) immediately

Answer

Check capillary refill

Answer

Assess mental status using AVPU

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?

Accepted Answer

Green

Answer

Red

Answer

Yellow

Answer

Black

Question 3

The 'P' in the SALT triage method stands for:

Accepted Answer

Priority

Answer

Pulse

Answer

Perfusion

Answer

Position

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?

Accepted Answer

ESI 2

Answer

ESI 3

Answer

ESI 4

Answer

ESI 5

Question 5

In the SALT triage system, the initial sorting step instructs responders to first ask all patients to:

Accepted Answer

Walk to a designated area if able

Answer

Remove clothing for rapid assessment

Answer

Lie still until assessed individually

Answer

State their name and date of birth

Question 6

Which vital sign parameter is NOT directly assessed in the original START triage algorithm?

Accepted Answer

Blood pressure

Answer

Respiratory rate

Answer

Capillary refill or radial pulse

Answer

Mental status (ability to follow commands)

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:

Accepted Answer

Consider upgrading to ESI 2 due to concerning vital signs

Answer

Keep the level 3 assignment and place in the waiting room

Answer

Downgrade to ESI 4 because vitals are only mildly abnormal

Answer

Discharge to primary care for follow-up