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    Ati Adn 110 Holistic Health Assessment Proctored Exam

    A nurse is assessing a client during a disaster triage. The client is not breathing, has no carotid or radial pulse, and does not respond to commands. Which of the following color tags should be attached to this client?

    Explanation & Rationale

    Rationale: A. Yellow tags are used for clients with delayed or non-life-threatening injuries. These clients need medical attention but can safely wait without immediate risk of death. Examples include stable fractures or moderate injuries. The client described—unresponsive, pulseless, and not breathing—does not fit this category. B. Red tags indicate immediate, life-threatening injuries that require urgent intervention to survive, such as severe hemorrhage, airway obstruction, or shock. Red-tagged clients have a chance of survival if treated promptly. In a mass-casualty incident, a client who is pulseless and apneic is considered unlikely to survive, even with intervention, and is therefore not tagged red. C. Black tags are assigned to deceased or expectant clients. Expectant clients have injuries that are so severe that survival is unlikely given the current resources. This allows healthcare providers to focus on clients with a higher probability of survival when resources are limited. In this case, the client’s absence of breathing, lack of pulse, and unresponsiveness classifies them as expectant. Comfort care and palliative measures are prioritized, rather than aggressive resuscitation. D. Green tags are used for minor injuries, also called “walking wounded.” These clients are stable, ambulatory, and can often assist in their own care. They are the lowest priority for immediate intervention and clearly do not match the critically ill client described.

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