Question

The nurse is assessing clients at the site of a community disaster. Using the color-code system for triage, which client should the nurse tag with a red code?

A. A client with a large head injury that is bleeding, and open chest wound, cyanotic skin, no capillary refill, and agonal respirations
B. A client with bruising and swelling of the right forearm, assorted lacerations to the face and neck, dry skin, normal capillary refill, and a respiratory rate of 18
C. A client with scratches and scrapes to the head and face who is limping and helping other clients at the scene
D. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiration rate 32, who is moaning

Answer 1

D. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiration rate 32, who is moaning Client D should be tagged with a red code in a triage situation due to the serious nature of their injuries and vital signs indicating immediate medical attention is required.

Step-by-step explanation:

Using the color-code system for triage in disaster situations, the client who should be tagged with a red code is D. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiration rate 32, who is moaning. This client's symptoms indicate that they are in immediate need of medical attention due to significant injuries that compromise their circulation and breathing, which could potentially be life-threatening if not treated promptly. In contrast, the other scenarios have clients with less critical injuries or more stable vital signs, suggesting that they could wait for medical attention without immediate risk to their lives.

The nurse should tag the client described in option A with a red code. This client presents with a large head injury that is bleeding, an open chest wound, cyanotic skin, no capillary refill, and agonal respirations. These signs and symptoms indicate a life-threatening condition and require immediate medical attention.