A nurse is triaging clients injured during a tornado. The nurse assesses a client who has an open fracture of his arm. Which of the following actions should the nurse take?
Explanation & Rationale
A. Place a red tag on the client's upper body: Red (Emergent) tags are for clients with immediately life-threatening injuries who can be saved with quick intervention (e.g., compromised airway, uncontrolled hemorrhage, shock). An open fracture without evidence of severe bleeding or shock does not meet this criterion. B. Have the client's wife drive him to the hospital: This is unsafe. During a disaster, traffic control is vital, and the client requires stabilization and monitoring that a layperson cannot provide during transport. C. Perform a rapid head-to-toe assessment: During a Mass Casualty Incident (MCI), nurses perform a triage assessment (checking Respirations, Perfusion, and Mental Status - RPM), which takes less than 60 seconds per person. A full head-to-toe assessment takes too long and delays care for others. D. Place a yellow tag on the client's upper body: Yellow (Urgent) tags are for clients with significant injuries who require medical attention but can wait a short time (30 minutes to 2 hours) without loss of life. An open fracture requires surgery and antibiotics but is not immediately fatal, fitting the Yellow category.