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RN Nursing · Priority Setting and Time Management · Practice question

A charge nurse is assisting in triaging clients following a mass casualty event in the community. Complete the following sentence by using the lists of options. The nurse should apply a red tag to ____ due to their ____

1200, Client 1:

Open head trauma, actively dying.

1205, Client 2:

Sucking chest wound with difficulty breathing and wheezing.

Heart rate 119/min

Blood pressure 97/65 mm Hg

Respiratory rate 40/min

Oxygen saturation 85%

1210, Client 3:

Right ankle sprain and abrasions on legs bilaterally.

1215, Client 4:

Right leg with partial amputation, tourniquet in place to upper

leg, no active bleeding noted.

Thready pulse 99/min

Blood pressure 98/53 mm Hg

Answer & explanation

Correct:

In mass-casualty triage using the START system, color tags indicate priority: green (minor), yellow (delayed), red (immediate), and black (expectant/deceased). A red tag is applied to clients who have life-threatening injuries but a high possibility of survival with immediate intervention. Client 1 has open head trauma and is actively dying — this client would receive a black tag as expectant, with no reasonable chance of survival given resource constraints. Client 2 has a sucking chest wound with severely compromised breathing (respiratory rate 40/min, oxygen saturation 85%), along with hemodynamic compromise — this is a life-threatening injury that is potentially survivable with immediate intervention such as sealing the wound and airway support, making a red tag appropriate. Client 3 has an ankle sprain and abrasions — this is a minor injury warranting a green tag. Client 4 has a partial amputation with a tourniquet in place and no active bleeding, but has a thready pulse and hypotension suggesting hemorrhagic shock; this client could also be red-tagged, but based on the scenario pairing options, Client 2 most clearly matches the red tag criterion of a life-threatening injury with a high possibility of survival if treated immediately. Therefore, the nurse should apply a red tag to Client 2 due to their life-threatening injury with a high possibility of survival.

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