Which tag color represents the wounded who have the highest priority of being treated first?

Triage WS.docx - 1. You’re working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded,

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• Page graphics illustrate 2 concepts:
  • 4 distinct clinical triage categories for mass casualty patients, with each category assigned a distinct name and color
  • One algorithm suggesting how to triage patients into these 4 categories
• How this information would be used in a mass casualty event:
  • Emergency first clinical responders would follow the clinical algorithm to evaluate each patient and assign a triage category and color based on various clinical parameters. The information would be noted on the triage tag attached to the mass casualty victim.
  • Rescuers following after the triage officer would view the color and text of the triage tag and take appropriate action.
• Clinical parameters used to evaluate patients include:
  • Ability to walk
  • Presence or absence of spontaneous breathing
  • Respiratory rate greater or less than 30 per minute
  • Perfusion assessment using either the palpable radial pulse or visible capillary refill rate
  • Mental status as assessed by ability to obey commands.
• The 4 Triage Categories are:
  • Minor: Green Triage Tag Color
    • Victim with relatively minor injuries
    • Status unlikely to deteriorate over days
    • May be able to assist in own care: also known as "walking wounded"
  • Delayed: Yellow Triage Tag Color
    • Victim's transport can be delayed
    • Includes serious and potentially life-threatening injuries, but status not expected to deteriorate significantly over several hours
  • Immediate: Red Triage Tag Color
    • Victim can be helped by immediate intervention and transport
    • Requires medical attention within minutes for survival (up to 60 minutes)
    • Includes compromise to patient's airway, breathing, and circulation (the ABC's of initial resuscitation)
  • Expectant: Black Triage Tag Color
    • Victim unlikely to survive given severity of injuries, level of available care, or both
    • Palliative care and pain relief should be provided

Disaster triage nursing NCLEX questions!

This quiz is part of a nursing leadership and management review that will test your ability on how to use the color code tagging system and START method for nursing disaster triage management.

The color tagging system and START method helps the medical team group the wounded based on if they need immediate treatment versus if they can have treatment delayed. This will help utilize resources wisely, especially during a disaster situation.

Don’t forget to watch the lecture on nursing disaster triage before taking the quiz.

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1.      You’re working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first?

A.     Green

B.     Yellow

C.     Red

D.     Black

The answer is C: Red. The red tag indicates the patient must be seen first because they have life-threatening injuries, but could survive if treated quickly. The patient is still alive but there is a severe alteration in their breathing, circulation, or mental status that requires immediate medical attention.

2.      A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital’s disaster plan is activated and the wounded are brought to the hospital. You’re helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor?

A.     Red

B.     Yellow

C.     Green

D.     Black

The answer is C: Green tags are for patients who have MINOR injuries. If the patient can walk around they are tagged as green. Sometimes they are referred to as the “walking wounded”.

3.      Which statement below is INCORRECT about the yellow triage tag color in regards to a disaster situation?

A.     A survivor with this tag color is seen after patients with the green tag color.

B.     A survivor with this tag color can have treatment delayed for an hour or less.

C.     A survivor with this tag color has serious injuries that could eventually lead to the compromise of breathing, circulation, or mental status, especially if treatment is delayed more than an hour or so.

D.     A survivor with this tag color has second priority for treatment of injuries.

The answer is A. This statement is INCORRECT. It should say: A survivor with this tag color is seen after patients with the RED (not green) tag color.

4.      For the next 7 questions, use the START method for adults to help triage the wounded that have been involved in a disaster situation. Each question will give you details on what you have assessed and you will need to use those details to help you assign a color tag to the individual:  The wounded victim is unable to walk, has respiratory rate of 40, capillary refill is 6 seconds, and can’t follow simple commands. The wounded victim is assigned what tag color?

A.     Green

B.     Red

C.     Yellow

D.     Black

The answer is B: Red.

5.      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?

A.     Green

B.     Red

C.     Yellow

D.     Black

The answer is D: Black. The black tag is placed on the wounded that are dying or have expired. The injuries are so severe that death is imminent. There is severe alteration or absence of breathing, circulation, and neuro status.

6.      The wounded victim is unable to walk, has respiratory rate of 12, capillary refill is 8 seconds, and is unresponsive. The wounded victim is assigned what tag color?

A.     Green

B.     Red

C.     Yellow

D.     Black

The answer is B: Red.

7.      The wounded victim is unable to walk, has respiratory rate of 19, capillary refill of one second, and is able to obey your commands. The wounded victim is assigned what tag color?

A.     Green

B.     Red

C.     Yellow

D.     Black

The answer is C: Yellow.

8.      The wounded victim is unable to walk, respiratory rate is absent but when airway is repositioned breathing is noted. The wounded victim is assigned what tag color?

A.     Green

B.     Red

C.     Yellow

D.     Black

The answer is B: Red.

9.      The wounded victim is unable to walk, respiratory rate is absent and when airway is repositioned breathing is still absent. The wounded victim is assigned what tag color?

A.     Green

B.     Red

C.     Yellow

D.     Black

The answer is D: Black.

10.   The wounded victim is able to walk and obey commands. The wounded victim is assigned what tag color?

A.     Green

B.     Red

C.     Yellow

D.     Black

The answer is A: Green.

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