The nurse is working in the emergency department and is receiving multiple clients from a mass casualty incident. The client arrives by ambulance and is awake, alert, and oriented, complaining of severe abdominal pain with nausea and vomiting. The client's respiratory rate is 20 and has a good radial pulse with normal capillary refill. How would you triage this client using the START triage?

Red

Yellow

Black

Green

Answer and Explanation

The Correct Answer is B

Choice A reason: The red category in the START triage system is assigned to clients who require immediate life-saving intervention. Although this client is in pain and has severe symptoms, their respiratory rate, pulse, and capillary refill are normal, indicating that they do not need immediate life-saving intervention.

Choice B reason: The yellow category is designated for clients whose condition is stable but requires observation. This client is awake, alert, and oriented, with a normal respiratory rate, good radial pulse, and normal capillary refill. While they have severe abdominal pain and nausea, their condition does not appear to be life-threatening, making yellow the appropriate triage level.

Choice C reason: The black category is used for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client is stable and responsive, so they do not fall into this category.

Choice D reason: The green category is for clients with minor injuries who can walk and do not require urgent medical attention. Since this client has severe symptoms and needs medical attention, the green category is not appropriate.

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Correct Answer is A

Explanation

Choice A reason: The sudden onset of a headache and numbness on one side of the body are potential signs of a stroke or other serious medical conditions. The most appropriate response is to assist the visitor to the emergency department for immediate evaluation and treatment. Time is critical in such scenarios, and prompt medical attention can significantly impact the outcome.

Choice B reason: While taking the visitor's blood pressure might provide some information, it is not sufficient to assess the severity of the symptoms. This action alone could delay necessary urgent care.

Choice C reason: Encouraging the visitor to lie down and see if the symptoms improve is not appropriate because it does not address the potential seriousness of the symptoms. Delaying medical evaluation could worsen the visitor's condition.

Choice D reason: Advising the visitor to call their primary care provider is not appropriate in this urgent situation. Immediate evaluation in the emergency department is necessary to rule out serious conditions like a stroke.

A. Black B. Green C. Red D. Yellow

Correct Answer is C

Explanation

Choice A reason: The black category in the START triage system is for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client is not in that category since they are conscious and breathing.

Choice B reason: The green category is for clients who are ambulatory with minor injuries and do not require urgent medical attention. This client is experiencing significant respiratory distress, which categorizes them as more urgent.

Choice C reason: The red category is for clients who need immediate life-saving intervention. This client's respiratory rate of 36 and shortness of breath indicate a severe respiratory distress that requires urgent medical attention.

Choice D reason: The yellow category is for clients who are unable to walk but have stable conditions that do not require immediate life-saving intervention. This client's condition is more severe and needs prompt intervention.

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Naxlex Comprehensive Predictor Exams

The nurse is working on the medical-surgical unit when a visiting family member reports the sudden onset of a headache and numbness on the left side of their body. The visitor asks the nurse to check their blood pressure. What is the most appropriate response by the nurse?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

The nurse is assessing a newly admitted client who appears upset and agitated. What would be the best action for the nurse to best assist this client?

The nurse is assessing a client with a diagnosis of acute emphysema. The client is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which assessment findings should be reported to the provider immediately?

The emergency department nurse is triaging clients arriving from a mass casualty incident. During the triage, the nurse confirms that each client has a disaster tag. What information should be placed on the tag for each client? (Select all that apply)

A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select All That Apply)

The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?

A school nurse is helping emergency medical services (EMS) triage students after a bus accident occurred in the school parking lot. A 10-year-old client is awake, alert, and ambulatory but reports a headache and neck pain. Using START triage, what acuity level would be assigned to this client?