Emergency Nursing & Triage Q 13

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A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can’t move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to?

  

    A. Red

    B. Black

    C. Yellow

    D. Green

    E. White

    

Correct Answer: C. Yellow

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The client is possibly suffering from a spinal injury but otherwise, has a stable status and can communicate so the appropriate tag is yellow. If individuals can breathe spontaneously, follow simple commands, and have distal pulses with a normal capillary refill, they are tagged delayed and given the code yellow.

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Option A: Red tags are for people with life-threatening conditions who need immediate emergency treatment. The rest of the individuals who have poor respirations or cannot protect their airway, have absent or decreased peripheral pulses, and are unable to follow simple commands are tagged immediately and given the color red.

Option B: Black tags are for deceased people and for those who are not expected to survive due to extensive injuries. Once the “minor” injuries are out of the area, responders should begin to move and triage patients with the RPM acronym; respirations, perfusion, and mental status. This includes making sure the individual has a manual respiration rate that is roughly greater than 30 breaths a minute, peripheral pulses are present with a capillary refill of fewer than 2 seconds, and can follow commands. If a patient has none of these, the patient is declared deceased, given a black tag, and moved to the black-coded area.

Option D: Green tags are for those people with non-urgent cases and can wait for their turn for assessment and treatment. Anyone who can follow these commands and walk to this area is designated as “minor” and given a green tag to signify minor injury status.

Option E: White tags are for those with minor injuries that don’t require any medical care. With this method, providers can quickly rule in and rule out individuals who require immediate medical attention, who can wait, and who nothing can be done for.

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