A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?
Red tag
Black tag
Green tag
Yellow tag
The Correct Answer is A
Choice A: Red tag
A red tag is assigned to patients who require immediate medical attention and intervention to survive. These patients have life-threatening injuries but have a high chance of survival if treated promptly. In this scenario, the client has a respiratory rate of 38, a weak and rapid pulse, and uncontrolled bleeding. These symptoms indicate severe physiological distress and potential shock, necessitating immediate intervention to prevent death. According to NATO triage guidelines, such critical conditions warrant a red tag to prioritize urgent care1.
Choice B: Black tag
A black tag is used for patients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. This category is also known as “expectant” and is used to allocate resources to those with a higher chance of survival. The client in this scenario, despite having severe symptoms, is not described as being beyond the possibility of survival, thus a black tag would not be appropriate1.
Choice C: Green tag
A green tag is assigned to patients with minor injuries who can wait for medical treatment without immediate risk to life. These patients are often referred to as “walking wounded.” The client’s symptoms of a high respiratory rate, weak and rapid pulse, and uncontrolled bleeding are far too severe to be classified under this category. Assigning a green tag would delay critical care, potentially leading to fatal outcomes1.
Choice D: Yellow tag
A yellow tag is for patients who have serious injuries but whose treatment can be delayed without immediate risk to life. These patients need medical attention but are stable enough to wait for a short period. Given the client’s symptoms, particularly the uncontrolled bleeding and signs of shock, delaying treatment could result in rapid deterioration. Therefore, a yellow tag would not be suitable in this case1.
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Correct Answer is B
Explanation
Choice A reason:
Assisting a client with a bed bath who has a history of falls is important for maintaining hygiene and preventing skin breakdown. However, this task does not address an immediate physiological need. While it is essential to ensure the safety of clients with a history of falls, this task can be scheduled after more urgent needs are met. The priority in nursing care is to address tasks that have the most immediate impact on a client’s health and safety.
Choice B reason:
Providing a snack to a diabetic client who is feeling lightheaded is the most urgent task. Lightheadedness in a diabetic client can be a sign of hypoglycemia, which requires immediate intervention to prevent serious complications such as loss of consciousness or seizures. Hypoglycemia occurs when blood sugar levels drop too low, and providing a quick source of glucose can help stabilize the client’s condition. This task addresses an immediate physiological need and is critical for the client’s safety and well-being.
Choice C reason:
Feeding a client who has bilateral casts due to upper arm fractures is necessary to ensure the client receives adequate nutrition. However, this task does not address an immediate threat to the client’s health. While it is important to assist clients who are unable to feed themselves, this task can be performed after more urgent needs are addressed. Prioritizing tasks that address immediate physiological needs is essential in nursing care.
Choice D reason:
Ambulating a postoperative client for the first time is important for preventing complications such as deep vein thrombosis, pneumonia, and muscle weakness. Early ambulation is a key component of postoperative care and helps promote recovery. However, this task can be scheduled after addressing more immediate physiological needs. Ensuring the safety and stability of clients with urgent conditions takes precedence over routine postoperative care activities.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason:
Assigning the client to a private room is not the priority action in this scenario. The focus should be on decontamination and preventing the spread of the unknown substance to others in the emergency department. Isolation measures can be considered after initial decontamination.
Choice B reason:
Removing the client and transport crew from the Emergency department is a priority action to prevent contamination of the area and exposure to other patients and staff. This step helps contain the potential hazard and ensures the safety of everyone in the department.
Choice C reason:
Contacting the decontamination team is essential for managing the situation. The decontamination team has the expertise and equipment to safely remove the unknown substance from the client and transport crew, reducing the risk of further exposure and contamination.
Choice D reason:
Calling the scene to identify the chemical can be helpful, but it is not the immediate priority. The focus should be on decontamination and ensuring the safety of the client and others. Identifying the chemical can be done concurrently or after initial decontamination efforts.
Choice E reason:
Immediately removing the saturated clothing from the client is a critical step in the decontamination process. Removing contaminated clothing helps reduce the client’s exposure to the substance and prevents further absorption through the skin.