RN Nursing · Emergency Preparedness and Disaster Response · Practice question
A community health nurse is triaging clients following a worksite explosion. Select the 2 clients that the nurse should identify as requiring immediate care.
Client 1
0800:
Client sustained laceration to left shin. Wound edges well approximated. Bandage placed over laceration. Client alert and oriented, gait steady. Heart rate 88/min, respiratory rate 20/min.
0815:
Scant amount of serosanguinous drainage visible through client's bandage
Client 2
0800:
Client sustained deep partial thickness burns over 10% of total body surface area. Client alert and oriented. Heart rate 102/min, respiratory rate 22/min, blood pressure 110/70 mm Hg.
0805:
Client states "I need something for this pain, it's unbearable." Client diaphoretic, heart rate 115/min, respiratory rate 26/min, blood pressure 98/62 mm Hg.
Client 3
0800:
Client sustained blunt force injury to forehead. Edema present over left side of forehead, tender to touch, skin intact. Client is alert and oriented. Heart rate 90/min, respiratory rate 18/min.
0810:
Client is alert and oriented. Client reports mild headache over frontal region of forehead. Pupils equal, round, reactive to light, accommodate. Heart rate 88/min, respiratory rate 19/min.
Client 4
0800:
Client sustained severe injury to head and cervical spine. Client is unconscious, pupils fixed, respirations are shallow.
0805:
Client remains unconscious, pupils fixed, decorticate posturing present, respirations irregular and shallow.
Client 5
0800:
Client has open fracture of left forearm. Client is alert and oriented. Radial pulses 2+ bilaterally. Heart rate 95/min, respiratory rate 17/min.
0810:
Client reports a pain level of 8 on a 0 to 10 pain scale.
Client 6
0800:
Client states "I inhaled a lot of smoke during the explosion." Client is seated upright. Lungs clear to auscultation bilaterally. Heart rate 97/min, respiratory rate 21/min.
0815:
Client seated in tripod position, appears anxious. Breath sounds diminished, intercostal retractions visible. Heart rate 102/min, respiratory rate 27/min.
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Client 1
-
✓
Client 2
-
Client 3
-
Client 4
-
Client 5
-
✓
Client 6
Answer & explanation
Correct: Client 2 · Client 6
In mass casualty triage, clients requiring immediate care (red tag) are those with life-threatening but survivable conditions who need rapid intervention. Client 2 sustained deep partial-thickness burns over 10% of total body surface area and is showing signs of hemodynamic instability — heart rate rising to 115/min, respiratory rate increasing to 26/min, and blood pressure dropping to 98/62 mm Hg — indicating early hypovolemic shock from fluid loss associated with burns. This client requires immediate fluid resuscitation and pain management. Client 6 inhaled smoke and is now showing progressive respiratory compromise: tripod positioning, intercostal retractions, diminished breath sounds, rising heart rate of 102/min, and respiratory rate of 27/min. These findings indicate impending airway obstruction or severe bronchospasm requiring immediate airway intervention. Client 1 has a minor laceration with minimal drainage and stable vitals — this client is delayed or minor. Client 3 has a blunt forehead injury with a mild headache but stable and reassuring neurological findings, making them a delayed priority. Client 4, with fixed pupils, unconsciousness, and decorticate posturing, represents a black-tag expectant client with unsurvivable injuries given resource constraints. Client 5 has an open forearm fracture with intact distal pulses and pain — serious but not immediately life-threatening, placing this client in the delayed category.
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