Question

A nurse on the scene following a mass casualty explosion is triaging a client who has a large, open occipital wound and the following findings:

Respirations 22/min
Blood pressure 120/80 mmHg
Capillary refill less than 2 seconds
Glasgow Coma Scale (GCS) score of 14
Which triage category should the nurse assign to this client?
A. Immediate (Red)
B. Delayed (Yellow)
C. Minimal (Green)
D. Expectant (Black)

Answer 1

The patient with a large, open occipital wound and vital signs within normal limits but a slightly reduced GCS score should be assigned to the Immediate (Red) category for prompt medical attention.

Step-by-step explanation:

A nurse triaging a client following a mass casualty explosion must quickly determine the severity of injuries and prioritize care due to the large number of victims. The client in question has a large, open occipital wound and is exhibiting vital signs and a Glasgow Coma Scale (GCS) score that helps the nurse in the decision-making process. Specifically:

• Respirations are 22/min, which is within normal limits.
• Blood pressure is 120/80 mmHg, suggesting the patient is hemodynamically stable.
• Capillary refill is less than 2 seconds, indicating good peripheral perfusion.
• A GCS score of 14 suggests the patient is alert and may have a minor decrease in consciousness or confusion but is not deeply unconscious.

In a mass casualty situation, this patient would be categorized for triage based on the severity of the injury, vital signs, and level of consciousness. The nurse should assign this client a triage category of Immediate (Red) due to the significant head wound that, while not immediately life-threatening considering the stable vital signs, needs prompt attention to prevent complications.