# A nurse is working in the emergency department when multiple patients arrive simultaneously after a multi-vehicle accident. Which patient should the nurse assess first according to triage principles?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=177095  
> language: ko  
> subject: Adult Health

## 문제

A nurse is working in the emergency department when multiple patients arrive simultaneously after a multi-vehicle accident. Which patient should the nurse assess first according to triage principles?

The emergency department receives four patients from a motor vehicle accident scene. The nurse must quickly determine the priority order for assessment and treatment.

## 보기

1. A 45-year-old patient with an open femur fracture, blood pressure 90/60 mmHg, heart rate 120 bpm, and altered mental status. **✔ 정답**
2. A 30-year-old patient with multiple lacerations on arms and legs, blood pressure 110/70 mmHg, heart rate 80 bpm.
3. A 25-year-old patient complaining of severe back pain, blood pressure 130/80 mmHg, heart rate 90 bpm
4. A 60-year-old patient with chest pain rated 8/10, blood pressure 140/90 mmHg, heart rate 110 bpm, diaphoresis.

**정답: 1**

## 해설

The patient with an open femur fracture, hypotension, tachycardia, and altered mental status represents the highest priority according to triage principles, requiring immediate assessment and intervention.

This question evaluates the nurse's ability to perform triage in emergency situations. Triage is an approach that systematically determines treatment priorities based on patient severity and the likelihood of survival with treatment.

The correct answer, patient 1, shows multiple danger signs requiring immediate life-saving intervention. An open femur fracture can cause significant bleeding, potentially leading to hemorrhagic shock. The vital signs (blood pressure 90/60 mmHg, heart rate 120 beats/min) indicate hemodynamic instability consistent with hypovolemic shock. Altered mental status suggests inadequate brain perfusion, which is a late sign of shock and means the patient is in a dangerous state needing immediate intervention.

In triage systems, patients are generally classified by color codes: red (immediate/critical), yellow (urgent), green (delayed), black (deceased/expectant). This patient is classified as red/immediate due to the combination of significant bleeding potential, hemodynamic instability, and neurological status changes.

The femur is a highly vascular bone, and an open fracture can result in 1000-1500mL of blood loss, contributing to the patient's shock state. Pathophysiologically, massive bleeding leads to decreased circulating blood volume, reduced venous return, decreased cardiac output, and compensatory tachycardia. As shock progresses, peripheral vasoconstriction occurs to maintain perfusion to vital organs, and when compensatory mechanisms fail, hypotension develops, with altered mental status indicating inadequate brain perfusion.

Immediate nursing interventions include establishing large-bore IV access, fluid resuscitation, blood type and crossmatch, hemorrhage control, pain management, and preparation for surgical intervention.

## 심화 해설

Clinical Judgment
This question assesses priority setting (Triage) and clinical judgment in an emergency situation. The key is determining "which patient is most likely to deteriorate rapidly and become life-threatening." The patient in option 2 shows severe chest pain, diaphoresis, and difficulty breathing and is anxious. These symptoms are classic signs of Acute Coronary Syndrome or Myocardial Infarction, requiring immediate evaluation and intervention. The other patients are stable, have controlled bleeding, or have severe pain but no immediate life threat.

Memory Tip: Remember the "ABCs + potential for life threat." Patients with problems in Airway, Breathing, Circulation, or a very high likelihood of developing such problems, are the top priority. "Chest Pain + SOB + Diaphoresis" is a red flag for a cardiac emergency.

KR vs US: The basic principle of emergency triage (prioritizing life-threatening situations) is the same in both Korea and the US. The NGN exam requires judgment based on a standardized US triage system (e.g., ESI). Korea primarily uses a 5-level triage system, but the core logic is identical.

## 임상 시나리오

Clinical Practice Guide
During emergency severity classification, Hemodynamic Instability is the top-priority signal. For trauma patients with hypotension, tachycardia, and altered consciousness, suspect hemorrhagic shock and respond immediately. Open fractures can be a source of serious bleeding in addition to infection risk.

Caution
In SATA (Select All That Apply) questions asking you to choose the patient to assess "First," even if all patients appear urgent, you must carefully compare the immediacy and severity of the life threat. Symptoms like "severe pain" or "chest pain" are important, but if vital signs are stable and consciousness is clear, they may have a lower priority than a hemodynamically collapsed patient.

## 핵심 개념

- **Triage** — Triage. A systematic process of determining treatment priority for multiple patients within limited resources and time.
- **Hypovolemic Shock** — Hypovolemic shock. A life-threatening condition where tissue perfusion becomes insufficient due to a rapid decrease in circulating blood volume. Traumatic hemorrhage is the main cause.
- **Open Fracture** — Open fracture. A condition where the fracture site has pierced through the skin and is exposed to the outside. High risk of infection and massive bleeding.
- **Hemodynamic Instability** — Hemodynamic instability. A state in which the homeostasis of the circulatory system, including blood pressure, heart rate, and peripheral perfusion, cannot be maintained. Signs of shock.
- **Altered Mental Status** — Altered mental status. Includes confusion, lethargy, unresponsiveness, etc. An important indicator of insufficient brain perfusion or other systemic issues.

## 같은 주제 문제

- [A nurse is working in the emergency department when multiple patients arrive simultaneousl…](https://mymerci.kr/pages/nclex_q.php?qn_id=177083)
- [A nurse is working in the emergency department when multiple patients arrive simultaneousl…](https://mymerci.kr/pages/nclex_q.php?qn_id=177085)
- [A nurse is working in the emergency department when multiple patients arrive simultaneousl…](https://mymerci.kr/pages/nclex_q.php?qn_id=177086)
- [A nurse is working in the emergency department when a mass casualty incident occurs. Multi…](https://mymerci.kr/pages/nclex_q.php?qn_id=177088)
- [A nurse is working in the emergency department when a multi-casualty incident occurs. Mult…](https://mymerci.kr/pages/nclex_q.php?qn_id=177089)
- [A nurse is working in the emergency department when multiple patients arrive simultaneousl…](https://mymerci.kr/pages/nclex_q.php?qn_id=177096)
- [A nurse is working in the emergency department when multiple patients arrive simultaneousl…](https://mymerci.kr/pages/nclex_q.php?qn_id=177097)
- [A nurse is working in the emergency department during a mass casualty incident. Multiple p…](https://mymerci.kr/pages/nclex_q.php?qn_id=177098)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._