NCLEX-RN practice › Management of Care
NCLEX triage question: four clients in the emergency department
Management of Care · Multiple choice · Clinical judgment step: Prioritize hypotheses
Client record
Triage
| Client | Complaint | Data |
|---|---|---|
| A | Ankle injury | Deformity, pedal pulse present, pain 8/10 |
| B | Chest pain for 1 hour | Diaphoretic, BP 142/88 mm Hg, HR 102/min, ECG pending |
| C | Asthma | Speaking full sentences, SpO2 96%, peak flow 70% of best |
| D | Laceration to hand | Bleeding controlled with pressure, tetanus overdue |
The triage nurse in the emergency department assesses four clients who arrived together. Which client should be seen first?
- A. Client A
- B. Client C
- C. Client D
- D. Client B
Show the answer and rationales
Answer: D
Possible acute coronary syndrome is high risk and needs an ECG within 10 minutes; stable injuries and mild exacerbations can wait.
- A. Incorrect. Painful deformity with an intact pulse is urgent but not life-threatening.
- B. Incorrect. A mild exacerbation with good oxygenation and full sentences is stable.
- C. Incorrect. Controlled bleeding is not an immediate threat.
- D. Correct. Correct. Chest pain with diaphoresis suggests acute coronary syndrome; an ECG is needed within 10 minutes of arrival.
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