Editing Management of Care – RN Practice Questions (section)

==Question 11==
A registered nurse is performing triage at the scene of a multivehicle collision with limited resources and prolonged transport times. Which client should be tagged as '''immediate (red)'''?
# A 40-year-old with an open tibia fracture who is alert with a strong radial pulse.
# A 28-year-old with severe dyspnea, absent breath sounds on the right, and tracheal deviation to the left.
# A 60-year-old with an open head injury, agonal respirations, and fixed, dilated pupils.
# A 22-year-old with multiple superficial lacerations who is walking around the scene.

'''Answer:''' 2. The 28-year-old with severe dyspnea, absent breath sounds on the right, and tracheal deviation to the left.

''Rationale:'' These findings suggest a tension pneumothorax, a life-threatening condition that is rapidly reversible with a simple intervention, which is exactly the profile of an immediate or red tag. Option 1 is a serious injury that can tolerate a short delay and is tagged delayed or yellow. Option 3 describes an injury unlikely to be survivable with available resources and is tagged expectant or black. Option 4 is a walking wounded client tagged minimal or green. The key concept is that disaster triage shifts from doing the most for each individual to achieving the greatest good for the greatest number, which reverses the usual rule that the most critically injured is treated first.