# A nurse in a busy emergency department is triaging five clients who arrive simultaneously. Place the clients in the correct order from first (1, highest priority) to last (5, lowest priority) using the Emergency Severity Index (ESI). > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=368320&lang=en > language: en > subject: Establishing Priorities > category: MOC ## Question A nurse in a busy emergency department is triaging five clients who arrive simultaneously. Place the clients in the correct order from first (1, highest priority) to last (5, lowest priority) using the Emergency Severity Index (ESI). A 45-year-old with severe back pain rated 8/10, vitals stable, no neurologic deficit A 25-year-old requesting a routine refill for stable, well-controlled hypertension A 32-year-old with a closed forearm laceration after a fall, bleeding now controlled with pressure A 78-year-old with fever 39.5 C, BP 80/52, HR 124, lethargic and disoriented A 60-year-old with crushing chest pain and diaphoresis radiating to the left arm, BP 142/88, HR 102 ## Explanation The ESI 5-level triage tool prioritizes by life-threat then resource needs. (1) ESI 1 (resuscitation) — the 78-year-old with hypotension, tachycardia, fever, and altered mental status meets sepsis or septic shock criteria; immediate life-threat with hemodynamic instability. (2) ESI 2 (emergent, high-risk) — the 60-year-old with classic STEMI presentation needs door-to-balloon within 90 minutes; high-risk but currently stable. (3) ESI 3 (urgent, multiple resources, stable) — the 45-year-old with severe back pain stable but requires multiple resources (imaging, labs, pain control). (4) ESI 4 (less urgent, one resource) — the 32-year-old laceration with controlled bleeding needs sutures (one resource). (5) ESI 5 (non-urgent, no resources) — the 25-year-old refill request needs only assessment, no resources. ## In-depth explanation ESI Triage Levels (1 to 5) Life-threat first, then resources. Level Definitions ESI 1 — Resuscitation: immediate life-saving intervention required (cardiac arrest, severe trauma, septic shock, acute respiratory failure) ESI 2 — Emergent: high-risk situation (STEMI, severe asthma, altered LOC, severe pain in high-risk client) ESI 3 — Urgent: multiple resources needed but stable (abdominal pain, fracture, severe back pain) ESI 4 — Less urgent: one resource needed (laceration requiring sutures, minor injury) ESI 5 — Non-urgent: no resources needed beyond exam (refill, sore throat, prescription request) This Triage 1. Septic shock (ESI 1) — hypotension plus altered LOC plus tachycardia plus fever 2. STEMI (ESI 2) — high-risk cardiac 3. Severe back pain (ESI 3) — multiple resources, stable 4. Laceration (ESI 4) — one resource 5. Refill (ESI 5) — no resources Reassessment Intervals - ESI 1: continuous - ESI 2: every 15 minutes - ESI 3: every 30 minutes - ESI 4: every 60 minutes - ESI 5: every 60 to 120 minutes NCSBN Theme MOC — Establishing priorities and triage. ## Clinical scenario Scenario 5 clients arrive at the ED simultaneously. Required Place in ESI priority order from first (1, highest) to last (5, lowest). Quick ESI Recall - 1: Dying - 2: Could die soon - 3: Stable, multiple resources - 4: Stable, one resource - 5: Stable, no resources Red Flags Among Clients - 78yo with hypotension plus altered LOC = septic shock (ESI 1) - 60yo crushing chest pain plus diaphoresis = STEMI (ESI 2) ## Key concepts - **Emergency Severity Index (ESI)** — Five-level triage system used in emergency departments in the United States. Level 1 (immediate life-saving), Level 2 (high-risk situation, severe pain or distress, altered LOC, vital sign abnormality), Level 3 (multiple resources but stable), Level 4 (one resource), Level 5 (no resources beyond exam). Decision aid algorithm asks: dying? Could die soon? How many resources? Vital sign danger zone? - **Septic shock recognition** — Sepsis-3 criteria: suspected or documented infection plus acute change in SOFA score 2 or more. Septic shock: persisting hypotension requiring vasopressors to maintain MAP at or above 65 mm Hg AND lactate above 2 mmol/L despite adequate fluid resuscitation. qSOFA bedside screen: RR 22 or more, altered mental status, SBP 100 or less. Hour-1 bundle: lactate, blood cultures, broad-spectrum antibiotics, 30 mL/kg crystalloid for hypotension or lactate above 4, vasopressors if MAP under 65 after fluids. - **STEMI recognition** — ST-elevation myocardial infarction: classic presentation of crushing substernal chest pain, diaphoresis, radiation to left arm or jaw, anxiety, nausea. ECG findings: ST elevation 1 mm or more in 2 contiguous leads. Door-to-balloon goal under 90 minutes for percutaneous coronary intervention; door-to-needle under 30 minutes for fibrinolytics if PCI not available within 120 minutes. MONA-B initial care: morphine, oxygen if SpO2 less than 90, nitroglycerin, aspirin 325 mg, beta-blocker if no contraindication. ## Related questions - [At shift change, a charge nurse receives six postoperative reports. 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