NCLEX : Triage and Priority

Study concepts, example questions & explanations for NCLEX

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Example Questions

Example Question #771 : Nclex

The nurse performs triage in the emergency department for a patient with a bee sting. The family reports a history of allergic reactions to bee stings, and the patient complains of difficulty breathing and swelling in his mouth. Which of the following is the priority of the nurse?

Possible Answers:

Contact the physician.

Administer oral diphenhydramine.

Administer subcutaneous epinephrine.

Maintain an open airway.

Obtain a full patient history.

Correct answer:

Maintain an open airway.


Follow the ABC's of nursing priority: airway, breathing, circulation. It is most most important for the nurse to maintain a patent airway, as the symptoms manifested suggest an anaphylactic reaction. Epinephrine may be given after the airway is established. Oral diphenhydramine is usually given for mild allergic reactions. The physician may be contacted later; patient safety is the priority.

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