An emergency department nurse is assigned to triage. Which client should the nurse assess first?

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Triaging clients involves decision-making about whose needs/problems are most urgent and create the greatest risk to survival. Two popular frameworks can assist the nurse in making these decisions and setting priorities. In the "First, Second, and Third" priority level framework, the priority needs progress from the first (most immediate) to the third (least) level of risk. They include: ABCs plus V - airway, breathing, circulation, and vital signs Mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal laboratory values, and risk Longer-term issues such as health education, rest, and coping Maslow's Hierarchy of Needs is a 5-level framework in which the priority needs progress from the bottom to the top level of the pyramid. Infants have a high percentage of body water (70%-80% of body weight) and become dehydrated rapidly. This client is at increased risk for fluid and electrolyte disturbances. In addition, the infant is lethargic (listless), indicating a change in level of consciousness. This client would be assessed first (Option B). (Option A) Because this client's laceration is superficial, excessive bleeding is an unlikely risk and is a relatively minor problem. (Option C) The hematuria and elevated temperature may be associated with a urinary tract infection or glomerulonephritis in this client and do not present an immediate threat to survival. (Option D) Acute abdominal pain can be a medical emergency that could indicate appendicitis, ovarian cyst, ectopic pregnancy, ureteral colic, or bowel obstruction. This client would be seen second. Educational objective: The "First, Second, and Third" priority level framework is used in emergency and non-emergency settings to prioritize client needs from the highest to the lowest level of risk as follows: ABCs plus V - airway, breathing, circulation, and vital signs Mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal laboratory values, and risks Longer-term issues such as health education, rest, and coping

An Emergency Department Nurse Is Assigned to Triage