While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned?

Low oxygen saturation: Low oxygen saturation indicates a potential respiratory compromise and should be addressed promptly to ensure adequate oxygenation and prevent further deterioration.

Previous injection drug user and alcohol misuse: Past injection drug use and alcohol misuse can have significant implications for the patient's health, including increased risk of infections, compromised immune function, and potential withdrawal symptoms. It is crucial for the nurse to be aware of these factors in order to provide appropriate care and support. Has productive cough severe enough to keep her awake: A severe productive cough that disrupts the patient's sleep suggests respiratory distress or possible worsening of the underlying condition. The nurse should assess the patient's respiratory status and implement interventions to alleviate the cough and improve rest.

Elevated temperature, pulse, and respiratory rate: An elevation in vital signs, including temperature, pulse, and respiratory rate, can indicate an infectious or inflammatory process. This warrants further assessment and intervention to manage the underlying condition. Diagnosis pneumonia: The diagnosis of pneumonia indicates a respiratory infection that requires close monitoring and appropriate treatment. The nurse should assess the patient's respiratory status, administer prescribed medications, and implement respiratory hygiene measures.

The following options are not immediate concerns or relevant assessment information:

Appointment the next day: While follow-up appointments are important, they do not require immediate attention upon receiving a hand-off report.

Marital status: Marital status is not typically an immediate concern for the nurse's assessment and care planning.

Daughter's name: The patient's family member's name is not an immediate concern or relevant assessment information for the nurse's immediate care.

Fever is present: While a fever is a symptom of an underlying condition, it is not the most critical concern.

Muscle rigidity is a hallmark sign of malignant hyperthermia. It commonly affects the muscles of the jaw and upper chest.

Malignant hyperthermia can lead to rapid and shallow breathing, resulting in tachypnea. Malignant hyperthermia is characterized by a significant increase in body temperature, often exceeding 38.8°C (101.8°F).

Malignant hyperthermia can cause irregular heart rhythms or dysrhythmias, including tachycardia or arrhythmias.

The manifestations of hypertension and skin mottling are not typically associated with malignant hyperthermia. Hypertension (high blood pressure) is more commonly seen in conditions such as hypertensive emergencies or certain cardiovascular disorders. Skin mottling, which refers to irregular or patchy skin coloration, is not a specific manifestation of malignant hyperthermia.