# A nurse is triaging 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=543568 > language: ko > subject: Next Gen NCLEX ## 문제 A nurse is triaging patients in the emergency department. Which patient should the nurse assess first? ## 보기 1. A 45-year-old patient with acute myocardial infarction who reports sudden onset of severe chest pain **✔ 정답** 2. A 62-year-old patient with diabetes mellitus who has a blood glucose level of 180 mg/dL and is requesting insulin 3. A 38-year-old patient post-operative day 1 from appendectomy who reports mild incisional pain rated 4/10 4. A 55-year-old patient with hypertension who has a blood pressure reading of 150/90 mmHg and is due for medication administration **정답: 1** ## 해설 The patient with acute MI and sudden severe chest pain requires immediate assessment for life-threatening cardiac complications per ABC principles. Other patients have non-urgent needs like glucose management or post-op pain. ## 심화 해설 Correct Answer: 1 Rationale: In emergency department triage, the nurse must prioritize patients based on the immediacy of the threat to life or limb. This follows the principle of assessing the patient with the most time-sensitive and potentially life-threatening condition first. The patient with an acute myocardial infarction (AMI) reporting a sudden onset of severe chest pain requires immediate assessment. This presentation indicates an active, evolving ischemic event with a high risk for hemodynamic instability, lethal dysrhythmias, and cardiac arrest. Evidence underscores that for patients with acute chest pain, the time from presentation to diagnosis and intervention is the single most critical factor in reducing mortality and disability [3]. Optimizing the initial nursing response, beginning with immediate triage and assessment, is directly linked to improved rescue success rates and a reduction in adverse reactions [2]. A continuous, evidence-based pre-examination process for acute chest pain is essential for rapid identification and management [1]. Delaying assessment for this patient directly contradicts the core objectives of emergency cardiac care. Why the Other Options Are Not the Priority: - Option 2: A blood glucose level of 180 mg/dL in a patient with diabetes is a non-critical finding. While it requires attention and the patient is requesting insulin, this hyperglycemia does not represent an immediate threat to airway, breathing, or circulation. This patient’s needs are subacute and can be safely managed after life-threatening conditions are addressed. - Option 3: A post-operative patient reporting mild incisional pain rated 4/10 is an expected finding. Pain management is an important nursing responsibility, but this level of discomfort does not signal a life-threatening complication. This patient is stable and can wait for assessment. - Option 4: A blood pressure reading of 150/90 mmHg in a patient with hypertension is moderately elevated but does not constitute a hypertensive emergency. The need for a scheduled medication is a time-sensitive task, but not one that takes precedence over a patient with an active, evolving myocardial infarction. The patient with AMI and severe chest pain has a dynamic, high-risk condition that must be assessed first. Clinical Application of the Evidence: The rationale for prioritizing the AMI patient is directly supported by research on emergency chest pain management. A foundational concept is the implementation of a specialization-green channel nursing model, which streamlines the triage and care process specifically for high-risk chest pain patients to enable faster diagnosis and intervention, thereby reducing mortality [3]. The core of this model is immediate recognition and prioritization at the point of triage. Furthermore, studies on optimizing the emergency nursing care process for acute chest pain demonstrate that a structured, rapid-response approach from the first point of contact significantly improves the success rate of rescue and lowers the incidence of adverse reactions [2]. This begins with the triage nurse’s decision to assess the patient first. The continuous improvement of the pre-examination process, grounded in evidence-based nursing, is a critical strategy for managing acute chest pain in adults, emphasizing that the initial assessment phase is where delays are most detrimental [1]. The nurse’s triage decision is the pivotal first step in this evidence-based process, directly influencing the patient’s trajectory and potential for a positive short-term outcome .References (research sources) - [1]Application of Continuous Improvement of Pre-Examination Process Based on Evidence-Based Nursing Concept in Acute Chest Pain of Adults.Research articleGan Q, Yao R. (2026) · DOI: 10.1155/emmi/8401158 - [2]Effects of optimizing emergency nursing care process on success rate of rescue and incidence of adverse reactions in patients with acute chest pain.Research articleZhu H, Ding D. (2025) · DOI: 10.3389/fmed.2025.1727151 - [3]Analysis of the application of specialization-green channel nursing model to emergency chest pain patients.Research articleMou G, Zhang W. (2025) · DOI: 10.1097/md.0000000000043195 ## 임상 시나리오 Emergency Triage for Acute Chest PainPrioritizing Life-Threatening Ischemia In triage, a patient with an acute myocardial infarction and sudden severe chest pain is the highest priority. This presentation indicates an evolving ischemic event with high risk for lethal dysrhythmias and cardiac arrest. The primary goal is to minimize myocardial damage by reducing the time from presentation to intervention. Immediate nursing assessment and continuous monitoring are critical for identifying hemodynamic instability. CautionDo not delay assessment for a patient with active chest pain to administer routine medications or treat non-critical findings. A blood pressure of 150/90 mmHg or a blood glucose of 180 mg/dL are not immediate life threats in this context. ## 핵심 개념 - **Triage** — A process of prioritizing patient treatment based on the severity of their condition to ensure those with the most life-threatening issues are seen first. - **Acute Myocardial Infarction** — A life-threatening condition caused by the sudden blockage of blood flow to the heart muscle, leading to ischemia and potential cardiac arrest. - **Hemodynamic Instability** — A state of abnormal or unstable blood pressure and perfusion that can lead to organ failure and requires immediate medical intervention. ## 같은 주제 문제 - [A nurse is caring for multiple patients on a medical-surgical unit. Which patient should t…](https://mymerci.kr/pages/nclex_q.php?qn_id=543567) - [A nurse is caring for patients in a pediatric unit. 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