Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority?
  1. A patient with low-grade fever, headache, and myalgias for the past 72 hours
  2. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident
  3. A patient with abdominal and chest pain following a large, spicy meal
  4. A child with a one-inch bleeding laceration on the chin, but otherwise well after falling while jumping on his bed
Explanation
Answer - C - The patient that should be assigned the highest priority is a patient with abdominal and chest pain following a large, spicy meal. The patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn; he also may be having an acute myocardial infarction and require urgent attention. The patient with fever, headache, and muscle aches (classic flu symptoms) should be classified as non-urgent. The patient with the foot injury may have sustained a sprain or fracture and the limb should be x-rayed as soon as is practical, but the damage is unlikely to worsen if there is a delay. The child's chin laceration may need to be sutured, but is also non-urgent.
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