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    Ati Adn 110 Holistic Health Assessment Proctored Exam

    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

    Rationale: A. Having the client transported by a family member is unsafe in a mass-casualty situation because the client may require immediate medical intervention. Professional triage and emergency transport ensure safety and priority care. B. Performing a rapid head-to-toe assessment is part of initial triage evaluation, but once the injury type and severity are identified (an open fracture without life-threatening compromise), the triage decision should be made promptly to categorize the client appropriately. A full head-to-toe assessment is done after priority care is established. C. A yellow tag is used for clients with urgent but non-life-threatening injuries. An open fracture requires care but does not immediately threaten life if there is no uncontrolled bleeding, airway compromise, or shock. The yellow tag indicates that the client should receive treatment after red-tagged clients with life-threatening injuries. D. A red tag is reserved for immediate life-threatening injuries that require urgent intervention to save the client’s life, such as airway obstruction, severe bleeding, or compromised circulation. An isolated open arm fracture without major complications does not meet this criterion.

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