The nurse performs START triage after a building collapse. Which findings require immediate follow-up? Highlight the findings that meet immediate red-tag criteria.
Highlight in Table
Choose your responses, then check the answer.
Explanation
A respiratory rate above 30/min, poor perfusion, or inability to follow commands after basic assessment meets START immediate criteria. Walking clients and stable serious injuries receive different tags.
Quick answer Red-tag the victim breathing 36/min, the victim with capillary refill of four seconds, and the victim who cannot follow commands. Each meets an immediate START criterion.
Why this is correct START first considers walking, then breathing, perfusion, and mental status. Respirations above 30/min, inadequate perfusion, or inability to obey commands leads to an immediate red tag.[1] The method seeks the greatest benefit with limited resources.
Easy analogy or mental picture After separating walking clients, check three gates in order. The first gate is breathing, the second is blood flow, and the third is brain response. Failing any gate sends the victim to red. The checkpoint is a triage tool, not a full trauma examination.
Memory hook START red: respirations over 30, refill over 2, or cannot follow.
NCLEX decision rule When resources are limited after a mass-casualty event, think RPM: respirations, perfusion, mental status; check the START threshold in order and stop when an immediate criterion is met.
Why the other choices are wrong Walking victims are minor, absent breathing after airway repositioning is expectant, and stable nonwalking victims who pass the RPM checks are delayed. Serious-looking wounds alone do not automatically make a victim red.
References
[1]
HHS CHEMM: START Adult Triage AlgorithmU.S. Department of Health and Human Services
[2]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing