A nurse is assisting in performing triage on several clients following a mass casualty event. The nurse should assign a red tag to which of the following clients?
A client who has a sprained left ankle.
A client who has an open traumatic brain injury and agonal breaths.
A client who has sustained a partial amputation of the right leg.
A client who is deceased.
A client who has sustained a major burn to the upper torso and extremities.
The Correct Answer is B
A. A client who has a sprained left ankle is typically categorized as a lower priority in triage.
B. A client who has an open traumatic brain injury and agonal breaths should be assigned a red tag and indicates immediate or emergent care; this client requires immediate attention.
C. A client who has sustained a partial amputation of the right leg requires urgent care but may not be as immediately life-threatening as option B.
D. A client who is deceased typically does not receive further medical intervention in a mass casualty situation.
E. While serious, the severity may not necessitate immediate intervention compared to option B.
F. This is typically categorized as a lower priority in triage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Explanation
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Correct Answer is ["B","D","E"]
Explanation
A. Drawing legs up into a fetal position may indicate discomfort or agitation.
B. Facial muscle relaxation is indicative of a therapeutic response to the massage.
C. An increased respiratory rate may suggest distress or discomfort.
D. Drooping shoulders suggest relaxation and a positive response to the massage.
E. Maintaining an expected pulse rate indicates that the massage is not causing undue stress or discomfort.
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