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Difficulty: MediumEmergency Response Plan

A localized chemical explosion at a manufacturing plant produces multiple casualties. A nurse on the emergency response team assesses an adult victim found sitting on the ground outside the main blast zone. The client states they are unable to stand up due to severe back pain. The nurse notes a palpable radial pulse, a capillary refill time of 1.5 seconds, and a respiratory rate of 34 breaths per minute. The client is alert and accurately states their name. Based on the START (Simple Triage and Rapid Treatment) algorithm, which triage category should the nurse assign to this client?

  1. Immediate priority category (Red)Answer
  2. B
    Delayed priority category (Yellow)
  3. C
    Minimal priority category (Green)
  4. D
    Expectant priority category (Black)

Answer

The correct category is the Immediate priority category (Red).
Under the START (Simple Triage and Rapid Treatment) algorithm for adults, victims who are unable to walk are first assessed for their respiratory rate. A respiratory rate exceeding 30 breaths per minute indicates severe distress or impending shock, which mandates an Immediate priority (Red) categorization. Because this respiratory threshold is met, the nurse does not need to consider the intact perfusion (pulse/capillary refill) or the alert mental status when determining the final triage level.

Step-by-Step Solution

1
Evaluate the client's ability to walk.
The client cannot stand or walk due to severe back pain.
This rules out the Minimal priority category (Green), which is reserved for clients who can safely walk away from the immediate scene.
2
Evaluate the client's breathing and respiratory rate.
The client is breathing spontaneously at a rate of 34 breaths per minute.
According to the START algorithm, a respiratory rate greater than 30 breaths per minute is a critical indicator of impending shock or respiratory failure.
3
Determine the triage classification based on the first critical deviation.
The client is assigned to the Immediate priority category (Red).
Once the respiratory rate exceeds the threshold of 30, the assessment stops, and the client is categorized as Immediate, regardless of their normal pulse, capillary refill, and mental status.

Key Concept

Disaster Triage Prioritization (START Algorithm)
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Topics

Emergency Response Plan

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