Nurses are expected to understand the principles of triage when caring for multiple clients. The ICU charge nurse is reviewing assignments. Based on the principles of triage, to which client would the charge nurse give priority for treatment?

Select all that apply.
  • a client on a ventilator who has an alarm sounding
  • a client who has just returned from an open appendectomy
  • a client ready to transfer to the floor after the nurse calls report
  • a client who has been talking with family and is now unresponsive
  • a client receiving a new antibiotic who complains of tingling in the mouth
  • a client who has not eaten yet and is a type 2 diabetic with a morning blood sugar of 90
Numbers 1, 2, 4, and 5 are correct.
Principles of triage include treating the least stable clients first. In this scenario, there are four clients requiring immediate attention. When a piece of equipment alarms, the first course of action is to check the client, and then troubleshoot the alarm. The nurse should never ignore any alarm for any reason. Clients who have just returned from surgery, especially an open surgical approach, are at risk for loss of airway due to anesthesia, bleeding from the site, and other potential surgery-specific risks. A sudden change in level of consciousness requires immediate action to determine the cause. Tingling in the mouth is a sign of a possibly serious allergic reaction and may occur if the client receives a new medication for the first time. This client is at high risk of anaphylactic shock. A client who is ready to transfer to the floor is stable and therefore not a priority situation. The client with diabetes who has a blood sugar of 90 is within a safe range and does not require emergent treatment or monitoring.