Page 220 - Saunders Comprehensive Review For NCLEX-RN

Box 7-14

Emergency Department Triage

Emergent (Red): Priority 1 (Highest)
This classification is assigned to clients who have life-threatening injuries and need
immediate attention and continuous evaluation but have a high probability for
survival when stabilized.
Such clients include trauma victims, clients with chest pain, clients with severe
respiratory distress or cardiac arrest, clients with limb amputation, clients with
acute neurological deficits, and clients who have sustained chemical splashes to the
eyes.

Urgent (Yellow): Priority 2
This classification is assigned to clients who require treatment and whose injuries
have complications that are not life-threatening, provided that they are treated
within 30 minutes to 2 hours; these clients require continuous evaluation every 30 to
60 minutes thereafter.
Such clients include clients with an open fracture with a distal pulse and large
wounds.

Nonurgent (Green): Priority 3
This classification is assigned to clients with local injuries who do not have
immediate complications and who can wait at least 2 hours for medical treatment;
these clients require evaluation every 1 to 2 hours thereafter.
Such clients include clients with conditions such as a closed fracture, minor
lacerations, sprains, strains, or contusions.
Note: Some triage systems include tagging a client “Black” if the victim is dead or
soon will be deceased because of severe injuries; these are victims that would not
benefit from any care because of the severity of injuries.

From Ignatavicius D, Workman M: Medical surgical nursing: patient-centered
collaborative care, ed 7, Philadelphia, 2013, Saunders.

Practice Questions

29. The nurse is assigned to care for four clients. In planning client rounds,
which client should the nurse assess first?
1. A postoperative client preparing for discharge with a new
medication
2. A client requiring daily dressing changes of a recent surgical
incision
3. A client scheduled for a chest x-ray after insertion of a nasogastric
tube
4. A client with asthma who requested a breathing treatment during
the previous shift

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