A triage nurse is assessing six clients who arrived at the emergency department within 10 minutes. Which clients should the nurse assign Emergency Severity Index (ESI) level 1? Select all that apply.

Quick answer
Level 1: stridor after the sting, the drowsy asthma client at SpO2 88%, and the heroin user who responds only to pain with RR 8.

Why this is correct
Each diagnosis appears twice, so the diagnosis cannot decide the level; the vignette detail does. Stridor (not lip swelling) signals upper airway obstruction needing epinephrine now. Drowsiness with 1 to 2 word speech and SpO2 below 90% (not alert short phrases at 93%) signals fatigue and impending respiratory failure. Response only to pain with RR 8 (not answering to voice with RR 14) meets the ESI unresponsive criterion and needs ventilatory support or naloxone immediately.

Easy analogy or mental picture
Level 1 is the client who will not survive the walk to the room without you doing something right now; level 2 is the client you must see very soon.

Memory hook
Stridor, sleepy wheezer, pain-only: level 1.

NCLEX decision rule
Assign ESI 1 by the need for an immediate life-saving intervention, shown by airway obstruction, failing ventilation or oxygenation, or response only to pain, not by the diagnosis.

Why the other choices are wrong
Hives with lip swelling after a sting looks like anaphylaxis, but with a clear voice and normal BP there is no current airway or circulatory compromise, so this client is ESI 2 with close watching. The alert asthma client in short phrases at SpO2 93% is in significant distress and tempting as level 1, but still ventilating and oxygenating, so ESI 2 with prompt treatment. The drowsy heroin user who answers to voice with RR 14 is at risk and is ESI 2, but is breathing adequately and does not need naloxone or airway support right now.