A nurse is performing triage on several clients following a mass casualty incident. The nurse should assign a red tag to which of the following clients? (Select All that Apply.)

A client with a right ankle sprain

A client who has sustained a major burn to their upper torso and extremities

A client with agonal respirations after a traumatic brain injury

A client who has sustained a partial amputation of the left leg

A client who is deceased

Answer and Explanation

Correct Answer : B,D

A. A client with a right ankle sprain would be assigned a green tag, indicating minor injuries that can wait for treatment. A sprain is not life-threatening and does not require immediate intervention to preserve life, limb, or eyesight.
B. A client who has sustained a major burn to their upper torso and extremities should be assigned a red tag because airway compromise, fluid loss, and shock are imminent risks. Immediate, aggressive interventions are necessary to stabilize breathing and circulation in this client.
C. A client with agonal respirations after a traumatic brain injury would typically be assigned a black tag, indicating expected death. Agonal breathing reflects end-stage respiratory effort, and limited resources in a mass casualty are directed toward those with better survival chances.
D. A client who has sustained a partial amputation of the left leg should be assigned a red tag because rapid intervention is needed to control hemorrhage and preserve limb function. Without urgent treatment, this client is at high risk of death or major disability.
E. A client who is deceased is assigned a black tag in mass casualty triage. Resources are not allocated to those without signs of life, allowing responders to focus on clients who have a chance of survival with immediate care.

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Correct Answer is A

Explanation

A. A client who has renal failure, a serum potassium of 6.1 mEq/L, and is prescribed sodium polystyrene sulfonate should receive medications first because hyperkalemia is a life-threatening electrolyte imbalance. Elevated potassium levels can cause fatal cardiac arrhythmias, and immediate treatment is needed to lower serum potassium and stabilize cardiac function.
B. A client who has anemia, hemoglobin of 11 g/dL, and is prescribed epoetin alfa is stable because mild anemia at this level does not pose an immediate threat to life. While treatment is important for managing chronic anemia, it does not take precedence over urgent electrolyte correction.
C. A client who has pneumonia, a WBC count of 11,500/mm³, and is prescribed piperacillin needs prompt antibiotic therapy, but a slightly elevated WBC count suggests an active infection without immediate critical deterioration. The situation is urgent but not as acutely life-threatening as hyperkalemia.
D. A client who is post-coronary artery bypass graft (CABG) and has a total cholesterol of 318 mg/dL, prescribed atorvastatin, requires lipid management for long-term cardiovascular risk reduction. However, administering atorvastatin is not urgent compared to correcting potentially fatal electrolyte imbalances.

A. Small serosanguineous drainage from the puncture site B. Decreased temperature from baseline C. Mild discomfort at the puncture site D. Increased heart rate and respirations from baseline

Correct Answer is D

Explanation

A. Small serosanguineous drainage from the puncture site is generally expected after a thoracentesis and is not typically alarming unless the drainage becomes heavy, purulent, or continuous. Minimal drainage indicates a healing puncture site without significant complications like infection or major bleeding.
B. Decreased temperature from baseline is not commonly associated with immediate thoracentesis complications. While hypothermia can occur in critically ill patients, a slight drop in temperature is not a key warning sign for pneumothorax, hemorrhage, or respiratory distress, which are more urgent concerns after thoracentesis.
C. Mild discomfort at the puncture site is a normal finding after a thoracentesis procedure. Some soreness or aching is expected due to the needle insertion but should not be severe or worsening. Monitoring is important, but mild discomfort alone does not suggest an emergency situation.
D. Increased heart rate and respirations from baseline can indicate the development of a pneumothorax, hemothorax, or respiratory distress, all of which are serious complications of thoracentesis. Tachycardia and tachypnea reflect the body’s attempt to compensate for impaired gas exchange and should prompt immediate provider notification.

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A nurse is performing triage on several clients following a mass casualty incident. The nurse should assign a red tag to which of the following clients? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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