# A nurse is caring for multiple patients in the emergency department. Which patient should the nurse assess first? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542787 > language: ko > subject: Leadership Management ## 문제 A nurse is caring for multiple patients in the emergency department. Which patient should the nurse assess first? ## 보기 1. A 45-year-old patient with chest pain radiating to the left arm, diaphoretic, with blood pressure 90/60 mmHg 2. A 32-year-old patient with severe facial trauma from a motor vehicle accident, making gurgling sounds **✔ 정답** 3. A 28-year-old patient with a compound fracture of the tibia, bleeding moderately, complaining of severe pain 4. A 65-year-old patient with shortness of breath, oxygen saturation 88% on room air, using accessory muscles **정답: 2** ## 해설 The patient with gurgling sounds from facial trauma has a compromised airway, which is the highest priority per ABCs. Other patients (chest pain, fracture, shortness of breath) have urgent but lower-priority issues. ## 심화 해설 Prioritization in the Emergency Department When multiple patients present with urgent needs, the nurse must apply the principles of triage to determine the order of assessment. The core concept is to identify and address threats to life according to the ABC (Airway, Breathing, Circulation) framework. A patient with a compromised airway takes absolute priority over patients with breathing, circulatory, or other problems, regardless of the dramatic nature of other injuries. The systematic review protocol by Shankar et al. discusses how clinical decision support systems, including those driven by artificial intelligence, are designed to improve patient prioritization in the emergency department, a process fundamentally rooted in identifying the most immediate physiological threats [1]. Analysis of Each Option **Option 1:** The 45-year-old patient with chest pain radiating to the left arm, diaphoresis, and a blood pressure of 90/60 mmHg presents a classic picture of a possible acute myocardial infarction with cardiogenic shock. This is a critical circulatory (C) problem. The hypotension indicates that the heart's pumping ability is failing, leading to inadequate tissue perfusion. While this is a life-threatening emergency, a circulatory issue is addressed after securing the airway and ensuring adequate breathing. The machine learning model developed by Lee et al. aims to predict early deterioration in the emergency department by integrating data like vital signs and nursing notes to rank patients by risk, and a patient with this presentation would be flagged as a very high priority for circulatory collapse [3]. **Option 2:** The 32-year-old patient with severe facial trauma making gurgling sounds has a clear and immediate airway (A) problem. The gurgling sound is a classic sign of a partially obstructed airway, likely due to blood, secretions, or structural damage from the trauma. An airway obstruction leads to hypoxia and death within minutes. The nurse's first and most critical action is to suction the airway, perform a jaw-thrust maneuver, and prepare for a definitive airway. This patient's airway compromise is the most time-sensitive threat to life among all the options. The scoping review by Souza et al. highlights that the primary goal of any triage system, whether human-driven or AI-supported, is to ensure clinical safety by rapidly identifying patients with such immediately life-threatening conditions . **Option 3:** The 28-year-old patient with a compound fracture of the tibia, moderate bleeding, and severe pain has a musculoskeletal injury with a circulatory component. The "moderate" bleeding is a concern, but it is not described as a life-threatening arterial hemorrhage. This situation involves a disability and potential circulatory issue that can be managed after the airway and breathing problems are stabilized. Pain management and wound care are important but are lower priorities in the triage hierarchy. The qualitative analysis by Kalani et al. on surgical prioritization of abdominal trauma notes that clinicians integrate complex clinical reasoning beyond simple scoring tools, and this same reasoning applies here—a visible fracture and bleeding can seem dramatic but must be weighed against a silent, lethal airway obstruction . **Option 4:** The 65-year-old patient with shortness of breath, an oxygen saturation of 88% on room air, and use of accessory muscles has a severe breathing (B) problem. The low oxygen saturation and increased work of breathing indicate significant respiratory distress and a failure of oxygenation. This patient requires immediate intervention, such as supplemental oxygen and respiratory support. However, in the ABC hierarchy, a breathing problem is assessed and managed after a complete airway obstruction. A patient who cannot move air at all (airway issue) will die before a patient who is breathing poorly but still has some air exchange [1]. Clinical Reasoning and Triage Decision The correct sequence of assessment is dictated by the severity and immediacy of the physiological threat. The patient with the gurgling airway (Option 2) is at risk of complete obstruction and rapid respiratory arrest. The patient with breathing difficulty (Option 4) has a critical oxygen deficit but a patent airway. The patient with cardiogenic shock (Option 1) has a failing pump but is currently moving air and oxygenating blood. The patient with the fracture (Option 3) has a localized injury without an immediate threat to the ABCs. Therefore, the nurse must first assess the patient whose airway is compromised, as this is the most time-critical intervention. This decision-making process is precisely what AI-driven triage tools are being designed to support—providing a risk-based prioritization that helps clinicians cut through the "noise" of a busy emergency department to identify the patient most likely to deteriorate without immediate action [3,4].References (research sources) - [1]Emergency Nurses' Experiences With Artificial Intelligence-Driven Triage Clinical Decision Support Systems: A Protocol for a Systematic Review of Qualitative Studies.Meta-analysis/systematic reviewShankar R, Lim A, Xu Q. (2026) · DOI: 10.1016/j.jen.2026.05.010 - [3]Validation of a machine learning model for predicting early deterioration in the emergency department.Research articleLee YR, Ruffolo I, Mashouri P, Brudno M, Ben-Yakov M. (2026) · DOI: 10.1016/j.ajem.2026.05.007 ## 임상 시나리오 Clinical Priority Guide: Applying the ABC Framework in Triage When managing multiple patients, the nurse must systematically identify the most immediate threat to life. The ABC (Airway, Breathing, Circulation) framework is the definitive guide for this process. A completely or partially obstructed airway is always the first priority, as it leads to hypoxia and death within minutes. Step 1: Assess Airway (A) - **Immediate Action:** The patient with severe facial trauma and gurgling sounds has a partially obstructed airway due to blood, secretions, or anatomical disruption. This is the highest priority. - **Key Signs:** Look for gurgling, stridor, inability to speak, or obvious facial/neck trauma. These indicate an airway at risk of complete closure. - **Intervention:** Prepare for immediate airway suctioning, jaw-thrust maneuver (if cervical spine injury is suspected), and potential endotracheal intubation or surgical airway. Step 2: Assess Breathing (B) - **Second Priority:** Once the airway is secured, the patient with shortness of breath, SpO2 88%, and accessory muscle use is the next concern. This indicates severe respiratory distress and failure of gas exchange. - **Key Signs:** Evaluate respiratory rate, depth, oxygen saturation, breath sounds, and signs of increased work of breathing like nasal flaring and retractions. - **Intervention:** Administer high-flow oxygen, prepare for non-invasive positive pressure ventilation (e.g., BiPAP) or mechanical ventilation, and treat the underlying cause (e.g., pulmonary edema, COPD exacerbation). Step 3: Assess Circulation (C) - **Third Priority:** After airway and breathing are addressed, the patient with chest pain, diaphoresis, and hypotension (90/60 mmHg) is the priority. This presentation is classic for acute myocardial infarction with cardiogenic shock. - **Key Signs:** Assess level of consciousness, skin color/temperature, capillary refill, pulse rate/quality, and blood pressure. Hypotension signals inadequate perfusion. - **Intervention:** Obtain IV access, administer fluids cautiously (if pulmonary edema is not suspected), prepare for vasopressors, and obtain an immediate 12-lead ECG for potential cardiac catheterization lab activation. Step 4: Address Other Injuries (D/E) - **Lower Priority:** The patient with a compound tibia fracture, moderate bleeding, and severe pain has a serious but non-life-threatening condition. Disability (neurological status) and Exposure (full body exam) are addressed after the ABCs. - **Key Signs:** Assess neurovascular status distal to the fracture (pulses, sensation, motor function) and control bleeding with direct pressure. - **Intervention:** Apply a sterile dressing, splint the limb, administer analgesics, and prepare for surgical irrigation and debridement. This patient can wait while life-saving interventions are performed on others. **Core Principle:** The ABC framework is sequential and hierarchical. An 'A' problem always supersedes a 'B' or 'C' problem, regardless of how unstable the patient with the circulatory or breathing issue may appear. ## 핵심 개념 - **ABC Framework** — A prioritization method in emergency care: Airway, Breathing, Circulation. It dictates that life-threatening airway issues are managed before breathing and circulatory problems. - **Triage** — The process of sorting patients based on the severity of their condition to prioritize treatment when resources are limited, focusing on identifying the greatest immediate threat to life. - **Gurgling Sounds** — An abnormal respiratory sound indicating partial airway obstruction by fluid (e.g., blood, secretions), signifying an immediate threat to airway patency. - **Accessory Muscle Use** — The visible use of neck, chest, and abdominal muscles to assist with breathing, a key sign of severe respiratory distress and increased work of breathing. - **Cardiogenic Shock** — A state of inadequate tissue perfusion caused by the heart's inability to pump effectively, often following a severe myocardial infarction, leading to hypotension and organ failure. ## 같은 주제 문제 - [A nurse is caring for multiple patients in the emergency department. Which patient should …](https://mymerci.kr/pages/nclex_q.php?qn_id=542788) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._