A nurse on a hospice unit is planning care for 5 clients after receiving change-of-shift report.

Exhibits

For which of the following 2 clients can the nurse delegate tasks to the AP?

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.A tracheostomy dressing change is important for preventing infection but is not as urgent as a potential complication like deep vein thrombosis (DVT).
B.Discharge teaching is essential but not time-sensitive and can be safely delayed.
C.Diarrhea from enteral feedings may require adjustment of the formula, but the feeding isn’t due for 2 hours, making this less urgent.
D.A client who is 4 hr postoperative with pitting edema of the right legshould be seen first. This finding could indicate a deep vein thrombosis (DVT), a potentially life-threatening complication due to the risk of pulmonary embolism. This requires immediate assessment and intervention.