Triage (color coded)

a) red

A nurse who is working as part of a disaster response team is performing triage at a mass casualty incident. One of the victims has a sucking chest wound. The nurse would triage this client using which color-coded tag?

a) Red

b) Black

c) Yellow

d) Green

A. minor and treatment can be delayed hours to days

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injuries?

a) Minor and treatment can be delayed hours to days

b) Significant and require medical care, but can wait hours without threat to life or limb

c) Extensive and chances of survival are unlikely even with definitive care

d) Life-threatening but survivable with minimal intervention

Chest pain with diaphoresis

The client having chest pain with diaphoresis should be classified as emergent. The "emergent" category indicates that the client has a condition that poses immediate threat to life or limb. The client with severe abdominal pain and multiple soft tissue injuries are classified as "urgent" indicating that the client needs to be treated quickly but an immediate threat to life does not exist at the moment. A client with strains and sprains is classified as "nonurgent" indicating that the client could wait for several hours without a significant risk for deterioration.

The triage nurse is assessing the acuity level of clients rushed to the emergency department. What sign or symptom reported by the client prompts the nurse to classify the client as emergent?

1.Chest pain with diaphoresis

2.Severe abdominal pain

3.Multiple soft tissue injuries

4.Strains and sprains

C. yellow

Following a disaster, a client's condition is serious, but she is stable enough to survive if treatment is delayed 6 to 8 hours. What category of triage would the nurse place this client?

a) Red

b) Green

c) Yellow

d) Black

Woman bleeding heavily

The woman critically injured with trauma or an active hemorrhage is prioritized as emergent. The emergent triage category implies that a condition exists that poses an immediate threat to life or limb and should be treated immediately. Although the child with an open fracture of the arm, the man with a contusion of the head, and the teenager with a closed fracture of the leg are urgent, they are not emergent and can wait for a short time

There has been an explosion at a local refinery. Numerous serious and life-threatening injuries have occurred. The following clients arrive from the scene by private vehicle. Which client is considered a priority for treatment?

1Child with an open fracture of the arm

2Man with a contusion on the head

3Teenager with a closed fracture of the leg

4Woman bleeding heavily

D . Sucking chest wound

(This casualty is a red tag, or emergent, because it can be quickly resolved until further help can be given.)

During a mass casualty, which injury receives care first?

a. Abdominal evisceration

b. Open fracture of the left forearm

c. Sprained ankle

d. Sucking chest wound

DA client who is unconscious and has massive aortic bleeding from the chest

(This client is unlikely to survive owing to massive thoracic bleeding and would be "black-tagged" and assigned to a nursing assistant.)

The emergency department charge nurse is making client assignments and delegating care after a mass casualty event. Care for which of these clients could be delegated to a nursing assistant?

a. A client who has multiple left rib fractures and is complaining of dyspnea

b. A client who is complaining of severe left anterior chest pain

c. A client who has a femoral fracture with palpable distal pulses

d. A client who is unconscious and has massive aortic bleeding from the chest

4. Client with see-saw chest movement with respirations

There has been a major disaster with the collapse of a large building. Hundreds of victims are expected. The emergency department nurse is sent to triage victims. Which client should the nurse tag "red" and send to the hospital first?

1. Client at 8 weeks gestation with spotting; pulse of 90/min

2. Client with bone piercing skin on leg with oozing laceration; pulse of 88/min

3. Client with fixed and dilated pupils and no spontaneous respirations

4. Client with see-saw chest movement with respirations

C: Red.

The red tag indicates the patient must be seen first because they have life-threatening injuries, but could survive if treated quickly. The patient is still alive but there is a severe alteration in their breathing, circulation, or mental status that requires immediate medical attention.

You're working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first?

A. Green

B. Yellow

C. Red

D. Black

C: Green tags are for patients who have MINOR injuries.

If the patient can walk around they are tagged as green. Sometimes they are referred to as the "walking wounded"

A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital's disaster plan is activated and the wounded are brought to the hospital. You're helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor?

A. Red

B. Yellow

C. Green

D. Black

The answer is A.

This statement is INCORRECT. It should say: A survivor with this tag color is seen after patients with the RED (not green) tag color.

Which statement below is INCORRECT about the yellow triage tag color in regards to a disaster situation?

A. A survivor with this tag color is seen after patients with the green tag color.

B. A survivor with this tag color can have treatment delayed for an hour or less.

C. A survivor with this tag color has serious injuries that could eventually lead to the compromise of breathing, circulation, or mental status, especially if treatment is delayed more than an hour or so.

D. A survivor with this tag color has second priority for treatment of injuries.

B. Red

The wounded victim is unable to walk, has respiratory rate of 40, capillary refill is 6 seconds, and can't follow simple commands. The wounded victim is assigned what tag color?

A. Green

B. Red

C. Yellow

D. Black

The answer is D: Black

.The black tag is placed on the wounded that are dying or have expired. The injuries are so severe that death is imminent. There is severe alteration or absence of breathing, circulation, and neuro status.

While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned?

A. Green

B. Red

C. Yellow

D. Black

B: Red.

The wounded victim is unable to walk, has respiratory rate of 12, capillary refill is 8 seconds, and is unresponsive. The wounded victim is assigned what tag color?

A. Green

B. Red

C. Yellow

D. Black

C: Yellow.

The wounded victim is unable to walk, has respiratory rate of 19, capillary refill of one second, and is able to obey your commands. The wounded victim is assigned what tag color?

A. Green

B. Red

C. Yellow

D. Black

B: Red.

The wounded victim is unable to walk, respiratory rate is absent but when airway is repositioned breathing is noted. The wounded victim is assigned what tag color?

A. Green

B. Red

C. Yellow

D. Black

D: Black.

The wounded victim is unable to walk, respiratory rate is absent and when airway is repositioned breathing is still absent. The wounded victim is assigned what tag color?

A. Green

B. Red

C. Yellow

D. Black

A: Green.

The wounded victim is able to walk and obey commands. The wounded victim is assigned what tag color?

A. Green

B. Red

C. Yellow

D. Black

D. Yellow.

The client is possibly suffering from a spinal injury but otherwise, has a stable status and can communicate so the appropriate tag is YELLOW

A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can't move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to?

A.Black.

B.Green.

C.Red.

D.Yellow.

4. A 25-year-old with a sucking chest wound.

During a disaster, the nurse must make difficult decisions about which persons to treat first. The guidelines for triage offer general priorities for immediate, delayed, minimal, and expectant care. The client with a sucking chest wound needs immediate attention and will likely survive.

Thirty people are injured in a train derailment. Which client should be transported to the hospital first?

1. A 20-year-old who is unresponsive and has a high injury to his spinal cord.

2. An 80-year-old who has a compound fracture of the arm.

3. A 10-year-old with a laceration on his leg.

4. A 25-year-old with a sucking chest wound.

. A 49-year-old male with crushing chest pain radiating to the jaw, is diaphoretic, nauseated, and has an open fracture of the left wrist.

3. A 75-year-old female with obvious fracture of the femur, absent pedal pulses on the affected side; heart rate 110, respirations 34, skin diaphoretic; awake/alert, states pain is 10 on a scale of 1 to 10.

The nurse is triaging victims of an earthquake who were removed from a building when the earthquake occurred. Which of the following victims should be classified as red? Select all that apply.

1. A 10-year-old male with crushing chest wound, tachypnea with labored breathing, unconscious, impaled object in forehead.

2. A 49-year-old male with crushing chest pain radiating to the jaw, is diaphoretic, nauseated, and has an open fracture of the left wrist.

3. A 75-year-old female with obvious fracture of the femur, absent pedal pulses on the affected side; heart rate 110, respirations 34, skin diaphoretic; awake/alert, states pain is 10 on a scale of 1 to 10.

4. A 32-year-old female who is unconscious,3-inch (7.6-cm) laceration to her forehead, ecchymosis behind the ears, respiratory rate10/shallow; radial pulse is weak/thread/rapid; no breath sounds on the right side.