Examkin

Question

Difficulty: MediumEmergency Response Plan

First responders are deployed to a residential apartment complex following a severe earthquake that caused widespread structural collapse. While utilizing the Simple Triage and Rapid Treatment (START) algorithm during this mass casualty incident, which client should the nurse classify as delayed (yellow tag)?

  1. A
    A client who is spontaneously breathing 36 times per minute and appears highly agitated and confused.
  2. B
    A client with severe cranial trauma who exhibits no spontaneous respirations after the airway is manually repositioned.
  3. A client who cannot walk due to a suspected femur fracture, has a respiratory rate of 20 breaths/min, palpable radial pulses, and correctly states their name.Answer
  4. D
    A client with a bleeding laceration on the forearm who independently walked to the designated safe zone.

Answer

The client who cannot walk but has a respiratory rate of 20 breaths/min, palpable radial pulses, and correctly states their name.
According to the Simple Triage and Rapid Treatment (START) algorithm, a yellow (delayed) tag is assigned to clients whose injuries are significant and require medical care, but who are physiologically stable enough to wait for treatment without an immediate threat to life. This client is unable to walk (which excludes a green tag) but passes all three primary START assessments: their respirations are under 30/min, they have palpable radial pulses, and they can follow commands. Therefore, they are correctly prioritized as delayed.

Step-by-Step Solution

1
Assess the client's ability to walk (ambulate).
The client is unable to walk due to a suspected femur fracture.
In the START triage method, clients who can walk are immediately classified as 'walking wounded' (green tag). Inability to walk prompts further assessment.
2
Evaluate the respiratory rate.
The client's respiratory rate is 20 breaths/min.
A respiratory rate under 30 breaths/min indicates adequate breathing. A rate over 30 would require an immediate (red) tag.
3
Assess systemic perfusion.
The client has palpable radial pulses.
The presence of a radial pulse (or capillary refill under 2 seconds) indicates adequate circulation. Absent radial pulses would require an immediate (red) tag.
4
Assess mental status.
The client is able to correctly state their name (follows commands).
The ability to follow simple commands demonstrates intact neurological function. Because respirations, perfusion, and mental status are all within acceptable limits but the client cannot walk, they are classified as delayed (yellow tag).

Key Concept

Disaster Triage Principles (START Algorithm)
Rate this question

Topics

Emergency Response Plan

More questions from this topic