Recall that notes made in a clients record must be

Focus on the data in the question. Recall that notes made in a client’s
record must be objective. Eliminate the options that are comparable or alike in that they indicate
that an incorrect dose of medication was administered. Next note that the correct option clearly
and accurately describes the incident in an objective manner. Review documentation of a
medication error or other incident if you had difficulty with this question.
References: Huber, D. (2010 ). Leadership and nursing care management (4th ed., pp. 557, 558).
St. Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 704, 705). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
77.77.ID: 283672737
A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All
victims are alert. Which of these clients does the nurse assign to the emergent category? Select
all that apply.
 A victim with respiratory distress Correct
 A victim with a fractured humerus
 A victim with partial amputation of the foot Correct
 A victim with a forehead laceration that is not bleeding
 A victim with multiple nonbleeding bruises of the arms and legs Incorrect
Rationale: One rating system commonly used in the ED consists of three tiers — emergent,
urgent, and nonurgent — with the categories sometimes identified with color coding or
numbers. The emergent classification (a.k.a. red or priority 1) is given to clients with life-
threatening injuries (here, the clients with respiratory distress [airway] and partial amputation of
the foot [bleeding/circulation]) who require immediate attention and continuous evaluation but
have a high chance of survival once their conditions have been stabilized. The urgent (a.k.a.
yellow or priority 2) classification is given to clients whose injuries and complications are not life
threatening (here, the client with the fractured humerus), provided that they are treated within
1 to 2 hours; such clients require evaluation every 30 to 60 minutes thereafter. The nonurgent

(a.k.a. green or priority 3) classification is given to clients with local injuries (here, the clients
with the forehead laceration and bruises of the arms and legs) who do not have immediate
complications and can wait several hours for medical treatment; these clients require evaluation
every 1 to 2 hours thereafter.
Test-Taking Strategy: Use the ABCs — airway, breathing, and circulation — which will easily direct
you to the correct options. Respiratory distress involves the airway, and the victim with
amputation is at risk for bleeding (i.e., circulation). Review the triage system and priorities of
care if you had difficulty with this question.