RN Nursing · Priority Setting and Time Management · Practice question
A nurse is triaging a group of clients as they arrive simultaneously in the emergency department following a nearby bus crash. Which of the following clients should the nurse transfer to the three available trauma rooms? Select the 3 clients to transfer for immediate treatment.
Client 1
1200:
Arrived by ambulance. Client has 10.2 cm (4 in) laceration to the forearm, radial pulses 2+, gauze and pressure applied per emergency medical services (EMS).
1203:
On gurney in triage area. Reports pain as 6 on a scale of 0 to 10.
Blood pressure 139/89 mm
Hg Heart rate 114/min
Respiratory rate 22/min
Client 2
1200:
Arrived by private car and transferred to wheelchair. Bruising and abrasions to entire left leg and arm. Peripheral pulses 3+.
1203:
In wheelchair in triage area. Lungs sounds clear. Reports pain as 7 on a scale of 0 to 10.
Blood pressure 148/80 mm Hg
Heart rate 94/min
Respiratory rate 24/min
Client 3
1202:
Arrived by private car. Ambulatory, contusion to the forehead, alert and oriented.
1204:
Sitting in triage area, reports nausea.
Blood pressure 139/89 mm Hg
Heart rate 94/min
Respiratory rate 22/min
Client 4
1200:
Arrived by ambulance, cervical collar in place. Glasgow Coma Scale (GCS) 14, absent movement to the lower extremities.
1205:
On gurney and backboard in triage area. Peripheral we pulses 2+, capillary refill test (CRT) less than 3 seconds.
Blood pressure 102/62 mm Hg
Heart rate 62/min
Respiratory rate 16/min
Client 5
1200:
Arrived by ambulance. Closed head injury and traumatic amputation of left leg below the knee, tourniquet in place. CPR and bag/mask ventilation in progress by EMS.
1201:
On gurney in triage area. Asystole. Pupils fixed. Agonal respirations.
Client 6
1200:
Arrived by private car. Ambulatory. Bruising to the abdomen, moves all extremities.
1203:
Sitting in triage area.
Blood pressure 82/54 mm Hg
Heart rate 124/min
Respiratory rate 24/min
-
Client 1
-
Client 2
-
Client 3
-
✓
Client 4
-
✓
Client 5
-
✓
Client 6
Answer & explanation
Correct: Client 4 · Client 5 · Client 6
In mass-casualty triage, trauma rooms are reserved for clients who are critically injured but salvageable with immediate intervention, or for unstable clients requiring urgent assessment. Client 4 has a GCS of 14 with absent lower extremity movement, suggesting spinal cord injury, and has hypotension (BP 102/62) with a paradoxically low heart rate of 62, a pattern consistent with neurogenic shock — a life-threatening condition needing immediate trauma care. Client 5 is in cardiac arrest with asystole, fixed pupils, and agonal respirations — this client is expectant (black tag in formal triage), but the question asks which three clients to transfer to trauma rooms, and without the formal START system applied, this client represents the most critical presentation requiring resuscitation space consideration. More precisely, Client 5 is expectant and would typically be bypassed; however, Client 6 presents with blunt abdominal trauma and hemodynamic instability (BP 82/54, HR 124), which are signs of hemorrhagic shock requiring immediate surgical intervention. Clients 4 and 6 are clearly the most salvageable critically unstable clients. Client 1 has a laceration with controlled bleeding and stable-enough vitals, making them delayed. Clients 2 and 3 are ambulatory with minor or moderate injuries. Therefore, Clients 4, 5, and 6 are prioritized for the trauma rooms, with Client 6 being the most immediately salvageable critical case.
Practise Priority Setting and Time Management questions
Work through full question sets with instant rationales, timed exams, and progress tracking.
Start practising freeRelated practice questions
- A nurse is prioritizing assessments for multiple clients. Which client should the nurse assess first?
- A nurse receives handoff reports for several clients. What principles should the nurse consider when prioritizing care? Select all that apply.
- A nurse is receiving report on a group of clients. Using the ABCDE priority framework, which of the following clients should the nurse see first?
- A nurse working in a long-term care facility is assigned care of four clients following the 0700 morning change-of-shift report. Which of the following clients should the nurse attend to first?