# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617296&lang=en  
> language: en  
> subject: Establishing Priorities  
> category: MOC

## Question

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.

1

A 24-year-old with hives and lip swelling after a bee sting; clear voice, BP 122/78 mm Hg

2

A 34-year-old with asthma, drowsy and speaking 1 to 2 words; SpO2 88%, RR 34/min

3

A 20-year-old after heroin use, drowsy but answers to voice; RR 14/min, SpO2 96%

4

A 22-year-old with hives and stridor after a bee sting; BP 104/68 mm Hg, SpO2 95%

5

A 36-year-old with asthma, alert and speaking in short phrases; SpO2 93%, RR 28/min

6

A 19-year-old after heroin use who responds only to pain; RR 8/min, SpO2 91%

## Explanation

ESI level 1 means an immediate life-saving intervention is needed now. Stridor after a sting means the airway is closing and needs epinephrine now, whereas hives and lip swelling with a clear voice and normal BP is high-risk ESI 2. The drowsy asthma client speaking 1 to 2 words with SpO2 88% is heading toward respiratory arrest, while the alert client in short phrases at 93% is ESI 2. Responding only to pain with RR 8 needs airway support or naloxone now; drowsy but answering to voice with RR 14 is ESI 2.

## In-depth explanation

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.

References
1Emergency Nurses Association (ENA)Emergency Severity Index triage criteria, including level 1 life-saving interventions
2AHRQ — Emergency Severity Index (ESI)ESI algorithm and decision point A for immediate life-saving intervention

## Clinical scenario

Scenario
Six simultaneous ED arrivals in three look-alike pairs (bee-sting reaction, asthma, heroin use); within each pair one client needs an immediate life-saving intervention.

## Key concepts

- **Emergency Severity Index (ESI)** — A five-level ED triage algorithm based on acuity and expected resource needs.
- **Life-saving intervention** — An immediate airway, breathing, circulation, or emergency medication action required to prevent death.
- **Stridor** — A high-pitched inspiratory sound signaling upper airway obstruction.

## Related questions

- [A nurse in a busy emergency department is triaging five clients who arrive simultaneously.…](https://mymerci.kr/pages/nclex_q.php?qn_id=368320&lang=en)
- [At shift change, a charge nurse receives six postoperative reports. Classify the timing of…](https://mymerci.kr/pages/nclex_q.php?qn_id=393410&lang=en)
- [Review the nurse's escalation timeline for a postoperative client whose condition is deter…](https://mymerci.kr/pages/nclex_q.php?qn_id=393500&lang=en)
- [The nurse receives report on four clients. Which client should the nurse assess first?](https://mymerci.kr/pages/nclex_q.php?qn_id=393675&lang=en)
- [Four hours after open reduction and internal fixation of a fractured tibia, a client repor…](https://mymerci.kr/pages/nclex_q.php?qn_id=394047&lang=en)
- [The nurse receives reports on four clients. Which client should the nurse assess first?](https://mymerci.kr/pages/nclex_q.php?qn_id=394076&lang=en)
- [During a mass casualty incident, which client should be assigned a delayed priority rather…](https://mymerci.kr/pages/nclex_q.php?qn_id=394136&lang=en)
- [During disaster triage, a client is not breathing after the airway is opened and repositio…](https://mymerci.kr/pages/nclex_q.php?qn_id=394166&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617296&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617296&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617296&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617296&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617296&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._