Practice Quiz

CCNS Certified Clinical Nurse Specialist

Category - Neonatal

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You previously worked as a triage nurse at the emergency department and are currently working in the neonatal intensive care unit. The staff nurse at the ER called you and requested to triage the following patients. Which patient should be assessed last?
  1. An adolescent patient who has been on pain medication for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 12
  2. A teenager who got a singed beard while in a barbeque party
  3. A patient who is complaining of chest pain and requesting for pain medication
  4. A patient with difficulty breathing and is drooling
Explanation
Answer - A - The patient that should be assessed last is an adolescent patient who has been on pain medication for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 12. The patient exhibits opiod toxicity with the pinpoint pupils and has the least risk of complications; moreover, the patient’s respiratory rate is still within the normal range.
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