Several clients arrive after a building collapse. Which client should the triage nurse classify as needing immediate treatment?
1A client with absent respirations after airway repositioning.
2A client walking and reporting anxiety and minor abrasions.
3A client with severe respiratory distress and capillary refill of 4 seconds.✓ Correct answer
4A client with an open forearm fracture and palpable radial pulse.
Explanation
In disaster triage, immediate treatment is prioritized for clients with life-threatening but potentially survivable airway, breathing, or circulation problems. Severe respiratory distress with delayed perfusion requires immediate intervention. A client who remains apneic after airway repositioning is categorized as expectant in many disaster triage systems.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Mass casualty triage.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical Practice GuideFor Mass casualty triage, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
Disaster Triage — Rapid sorting of clients during a mass casualty event to maximize survival.
Immediate Category — A triage priority for life-threatening but treatable problems.
Capillary Refill — A quick assessment of peripheral perfusion.