A nurse is caring for a client who has a pressure injury. Which of the following findings indicates the need for a referral to a wound care specialist?

In mass casualty triage, clients are categorized using a color-coded tagging system to prioritize care based on the severity of injuries and the likelihood of survival with immediate treatment. The red tagis assigned to clients who have life-threatening but survivable injuriesand require immediate medical attention.

Rationale

• Client 1: Open head trauma, actively dying.
  ➤This client is in the expectant (black tag)category. Although the injury is critical, the chance of survival is minimal even with treatment. Resources should be conserved for those more likely to survive.
• Client 2: Sucking chest wound, difficulty breathing, HR 119, BP 97/65, RR 40, O2 sat 85%.
  ➤This client has compromised airway and breathing, and is in respiratory distressbut has a chance of survival with immediate intervention(e.g., chest seal, oxygen). This qualifies them for a red tag—immediate priority.
• Client 3: Right ankle sprain and leg abrasions.
  ➤Minor injuries, stable condition. This client would receive a green tag(walking wounded, delayed care).
• Client 4: Partial leg amputation with tourniquet, thready pulse, low BP.
  ➤This client is in shockbut currently has no active bleedingdue to a tourniquet. Though critical, they are more stable than Client 2. They may qualify for a yellow tag(delayed), unless signs of decompensation appear.

A. Petroleum jelly is not recommended for tracheostomy care because it can be aspirated and cause airway obstruction.

B. An obturator is essential to have on hand in case the tracheostomy tube becomes dislodged. It allows for safe reinsertion of the tube and is a critical emergency supply.

C. An oxygen tank may be necessary if the client requires supplemental oxygen therapy at home, depending on their respiratory status.

D. Cotton balls are not recommended for tracheostomy care because fibers can be aspirated and cause airway obstruction.

E. Pipe cleaners are unsafe for tracheostomy care because they can break or leave fragments in the airway. Proper tracheostomy cleaning supplies include sterile swabs or suction catheters.