CHAPTER 2

39. What are the five level system of triage?

a. Level 1: Resuscitation

b. Level 2: Emergent

c. Level 3: Urgent

d. Level 4: Less urgent

e. Level 5: Nonurgent

40.Resuscitation requires what?

a. Immediate treatment to prevent death

41. What is required for nonurgent triage (level 5)?

a. Non life threatening condition requiring simple evaluation and care management

42.What is the standard precaution for primary survey during triage?

a. Gloves

b. Gowns

c. Eye protection

d. Face masks

e. Shoe covers

f. ABCDE guides the primary survey

43.What is the ABCDE principle?

a. Airway/Cervical Spine brain injury/death = 3-5 min. if airway not patent.

b. Breathing assess presence & effectiveness of breathing.

c. Circulation

d. Disability

e. Exposure

44. How to implement airway for patients who is unresponsive without suspicious of trauma?

a. Airway opened head tilt, chin lift maneuver

45. How to implement airway for patients who is unresponsive WITH suspicious trauma?

a. Airway opened modified jaw thrust maneuver

46.How is the modified jaw thrust maneuver performed?

a. Nurse place both hands on either side of the client’s head. Locate the connection

between maxilla and mandible. Lift the jaw superiorly while maintaining alignment

of the cervical spine.

47. During triage, what mask is given to patient who are spontaneously breathing?

a. Non-breather mask with 100% O2 source

48.What does the breathing assessment include?

a. Auscultation of breath sounds

b. Observation of chest expansion and respiratory effort

c. Notation of rate and depth of respiration

d. Identification of chest trauma

e. Assessment of tracheal position

f. Assessment of JVD

49.How to assess for circulation?

a. Nurse assess HR, BP, peripheral pulses, and capillary refill for adequate perfusion.