Question

A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag?

a) A client who is alert and has a 2.5 cm (1 in) laceration on the forehead
Rationale:
- Green Tag

b) A client who has significant head trauma and agonal respirations

c) A client who has an open fracture of the right forearm
Rational:
- yellow tag

d) A client who is unconscious and has a rapid, thready radial pulse
Rationale:
- Red tag

Answer 1

A black tag should be placed on a client with significant head trauma and agonal respirations during triage. O negative blood is used for urgent transfusions without known blood type. Increased redness, swelling, and pain after bandaging may indicate an infection.

Step-by-step explanation:

A community health nurse should place a black tag on a client who has significant head trauma and agonal respirations. This indicates that the patient is not expected to survive because agonal respirations are irregular, gasping breaths that signal severe trauma or significant brain injury, typically occurring just before death. The black tag is used in triage to denote that the patient is either deceased or mortally injured and that death is imminent, allowing resources to be focused on patients with a better chance of survival.

In emergency scenarios where there is severe bleeding and a patient's blood type cannot be determined, type O negative blood is transfused because it is the universal donor type, which means it is compatible with any blood type.

A significant increase in redness, swelling, and pain after a cut or abrasion has been cleaned and bandaged may indicate an infection, which requires prompt attention to prevent further complications.