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Difficulty: EasyEmergency Response Plan

An external mass casualty incident occurs, and the hospital activates its emergency response plan. The nurse is performing disaster triage in the emergency department. Which of the following clients should the nurse assign a "red tag" (immediate priority)?

  1. A
    A client with partial-thickness burns on the forearms who is walking around crying.
  2. A client with an open femur fracture, absent radial pulses, and a respiratory rate of 34 breaths per minute.Answer
  3. C
    A client with a closed wrist fracture who reports severe pain but has stable vital signs.
  4. D
    A client with a severe crush injury to the head who remains apneic even after the airway is repositioned.

Answer

The client with an open femur fracture, absent radial pulses, and a respiratory rate of 34 breaths per minute should be assigned a red tag.
In disaster triage, a red tag (immediate) is assigned to clients with life-threatening injuries who have a high probability of survival if treated rapidly. Key indicators include a respiratory rate greater than 30 breaths per minute, absent radial pulses indicating shock, or an inability to follow simple commands. The client with the open femur fracture meets these criteria.

Step-by-Step Solution

1
Recall the categories of the disaster triage system.
Green is for the walking wounded, yellow is for delayed care, red is for immediate life-threatening but treatable conditions, and black is for expectant (deceased or unsalvageable).
Applying the correct triage criteria is essential during a mass casualty incident to do the greatest good for the greatest number of people.
2
Evaluate each client's presentation against the criteria for a red tag (Immediate).
Red tag criteria include an altered mental status, absent radial pulses (capillary refill > 2 seconds), or a respiratory rate > 30 breaths per minute.
Identifying clients who meet the red tag criteria ensures those with life-threatening, salvageable conditions receive prioritized care.
3
Identify the client who meets the immediate criteria.
The client with the open femur fracture has absent radial pulses and a respiratory rate over 30, meeting the criteria for a red tag.
This client has an immediate threat to life (shock and respiratory distress) but can potentially be saved with rapid intervention.

Key Concept

Disaster Triage Prioritization (START Method)
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Topics

Emergency Response Plan

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