The nurse triages victims of a hurricane who were rescued from a five-story apartment building. Which victim should be tagged as yellow?

Rationale:

A. In a mass-casualty or field triage situation, time is critical, and the priority is to rapidly identify life-threatening injuries and categorize patients for treatment, rather than performing a detailed head-to-toe assessment on every victim. Complete assessments are performed later once patients are stabilized or brought to definitive care. Spending time on a full assessment in the field could delay care for more critical victims.

B. While notifying the receiving hospital is an important step in disaster response, it is not the immediate priority during initial triage. The nurse’s first responsibility in the field is to assess and categorize patients to determine treatment priority based on the severity of injuries. Communication with the hospital is secondary and occurs after rapid triage.

C. In emergency and disaster situations, consent is implied for urgent or life-threatening injuries. Waiting to locate parents before providing care could delay treatment and put the child at unnecessary risk. Parental consent can be obtained later if needed once the child is stabilized.

D. The child has an open femur fracture, which is a serious injury that requires prompt care but is not immediately life-threatening if airway, breathing, and circulation are stable. In field triage, this type of injury is categorized as yellow (urgent/delayed). Yellow-tagged patients need care after immediate life-threatening cases (red tag) are stabilized, but before minor injuries (green tag). The tag communicates the priority

Rationale:

A. The most serious and potentially life-threatening complication after a liver biopsy is hemorrhage. Bleeding may occur either at the puncture site or internally within the abdominal cavity. Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, and cool, clammy skin. Monitoring vital signs frequently—typically every 15 minutes for the first hour and then at progressively longer intervals if stable—allows the nurse to detect bleeding early and intervene promptly. Early recognition is essential because internal bleeding may not be immediately visible, and delays can result in rapid deterioration and death. Vital signs are therefore the priority assessment immediately post-procedure.

B. This is incorrect as the primary focus, though it remains an important secondary assessment. Abdominal pain, tenderness, or distension may indicate bleeding or bile leakage, but vital signs usually change before these physical findings become apparent. Relying solely on subjective symptoms could delay recognition of serious complications.

C. Infection is a potential late complication of liver biopsy, typically developing days after the procedure. While monitoring the site for redness, swelling, or drainage is part of ongoing post-procedure care, it is not the immediate priority compared to detecting life-threatening hemorrhage.

D. This is incorrect as the primary immediate assessment. Changes in mental status may indicate severe hypovolemia, hypoxia, or hepatic encephalopathy, but they are less sensitive and later indicators than vital sign changes. By the time significant mental status changes occur, the client may already be in advanced shock, making early vital sign monitoring more critical.