A charge nurse is implementing the START (Simple Triage and Rapid Treatment) system during a mass casualty incident at a local hospital. Which patient should receive the highest priority for immediate treatment?
1A 45-year-old male who is walking and complaining of severe back pain, with stable vital signs
2A 30-year-old female who is unconscious, not breathing, and has no palpable pulse
3A 25-year-old male with multiple lacerations who is alert and oriented but bleeding moderately
4A 35-year-old female with compromised airway, rapid breathing at 35/min, and weak pulse✓ 정답
해설
In START triage, the patient with compromised airway, rapid respirations (35/min), and weak pulse is immediate (red) due to severe respiratory distress requiring urgent airway management. Other patients have lower priority: walking wounded (green/minor), unconscious/apneic (black/expectant), or moderate bleeding (yellow/delayed).
Core Nursing ExplanationKey Concept Analysis: This question tests the application of the START (Simple Triage and Rapid Treatment) system, a standardized method used in mass casualty incidents (MCIs) to quickly categorize patients based on the severity of their injuries and the urgency of their need for care. The core principle is to do the greatest good for the greatest number of people by prioritizing limited resources. Triage categories are: Immediate (Red), Delayed (Yellow), Minor (Green), and Expectant (Black).
Answer Rationale: The patient in option 4, with a compromised airway, tachypnea (35 breaths/min), and a weak pulse, is the highest priority. In the START system, the primary assessment follows the Key Point!ABC (Airway, Breathing, Circulation) mnemonic. A compromised airway is a life-threatening condition that can lead to death within minutes if not corrected. Rapid breathing indicates severe respiratory distress or compensation for shock, and a weak pulse suggests poor perfusion. This patient fits the Immediate (Red) category perfectly, as they have treatable, life-threatening injuries requiring urgent intervention.
Distractor Analysis:
Watch out for confusion! Option 1 (walking, severe back pain, stable vitals): This patient is ambulatory and would be tagged as Minor (Green). "Walking wounded" are the lowest priority in initial triage.
Watch out for confusion! Option 2 (unconscious, not breathing, no pulse): This patient, after a quick check of breathing and pulse, would be triaged as Expectant (Black) in a mass casualty setting. Resources are not allocated to those with obviously non-survivable injuries or who are deceased, to focus on saving those who can be saved.
Watch out for confusion! Option 3 (alert, oriented, moderate bleeding): This patient is stable and responsive. Moderate bleeding can typically be controlled with direct pressure. This patient fits the Delayed (Yellow) category—they need medical care, but it can be safely postponed.
Related Concepts: Understanding START triage requires knowing the rapid assessment algorithm: 1) Ability to walk? If yes → Green (Minor). 2) If no, assess Breathing. If not breathing → open airway. If still not breathing → Black (Expectant). If breathing resumes → Red (Immediate). 3) If breathing, assess Respiratory Rate. If >30/min → Red (Immediate). 4) If RR <30/min, assess Perfusion (Capillary Refill or Pulse). If capillary refill >2 seconds or no radial pulse → Red (Immediate). 5) If perfusion is adequate, assess Mental Status. Cannot follow simple commands → Red (Immediate). Can follow commands → Yellow (Delayed).
Concept Summary
Triage Category (Color)
Description & Priority
Example Patient Presentation
Immediate (Red)
Highest priority. Life-threatening but treatable conditions requiring intervention within minutes.
Compromised airway, severe respiratory distress, uncontrolled hemorrhage, shock.
Delayed (Yellow)
Second priority. Serious injuries but stable enough that treatment can be delayed for hours.
Stable open fractures, major burns without airway issue, controlled bleeding.
Minor (Green)
Third priority. "Walking wounded" with minor injuries.
Minor lacerations, sprains, contusions.
Expectant (Black)
Lowest priority (or comfort care). Deceased or injuries so severe survival is unlikely given resource constraints.
Unresponsive, apneic, pulseless; catastrophic head injury.
Side-by-Side Comparison!
Assessment Step
Normal / Negative Finding
Abnormal / Positive Finding (Triggers RED tag)
Nursing Action
1. Ambulation
Patient can walk.
N/A (Walkers are tagged GREEN).
Direct to minor treatment area.
2. Breathing
Present.
Absent. After positioning airway, still absent.
Tag BLACK. Move to next patient.
3. Respiratory Rate
<30 breaths/min
>30 breaths/min
Tag RED IMMEDIATELY.
4. Perfusion (Pulse/Cap Refill)
Radial pulse present. Cap refill < 2 seconds.
No radial pulse (only carotid). Cap refill > 2 seconds.
Tag RED IMMEDIATELY.
5. Mental Status
Can follow simple commands (e.g., "Squeeze my hand").
Cannot follow simple commands.
Tag RED.
Anatomy, Physiology & Pharmacology Points
The triage decision for the correct answer hinges on airway patency and respiratory physiology. A compromised airway obstructs gas exchange, leading to hypoxemia (low blood oxygen) and hypercapnia (high blood CO2). Tachypnea (>30/min) is a compensatory mechanism but is inefficient and leads to fatigue. A weak pulse indicates poor cardiac output and impending shock. Immediate interventions would focus on securing the airway (e.g., jaw-thrust, insertion of an oropharyngeal airway, preparation for intubation) and supporting breathing and circulation.
Memory TipsMnemonic for START order: "Ready (Red/Immediate) When? You (Yellow/Delayed) Get (Green/Minor) Back (Black/Expectant)."
Quick Think: In mass casualty, think "Treat the living, not the dying." The Black tag is the hardest but most crucial concept for resource allocation.
High-Frequency NCLEX Topics
Triage, especially START and disaster nursing principles, is a Core NCLEX topic. You must know the color codes, the order of assessment steps (walking → breathing → RR → perfusion → mental status), and be able to apply them to a scenario. NCLEX often tests your ability to prioritize care in emergency situations.
Watch Out for Question Variations!
The same concept can be tested by: 1) Asking which patient the nurse should tag with a specific color (e.g., "Which patient receives a Yellow tag?"). 2) Presenting a list of 5 patients and asking you to sequence the order of treatment. 3) Testing the reverse logic: "A patient is tagged Red (Immediate). Which finding would the nurse most likely have assessed?" The answer would be something like "Respiratory rate of 40/min."Nursing Clinical Practice GuideClinical Scenario: You are the first nurse to respond to the emergency department lobby after a reported bus crash. Multiple injured people are arriving by private vehicle. You have a triage tag kit (Red, Yellow, Green, Black tags) and must quickly sort patients.
Nursing Intervention Strategy:
1. Scene Safety & Announcement: First, ensure your own safety and that of responders. Loudly announce, "If you can hear me and are able to walk, please move to the designated green area (e.g., waiting room chairs)." This instantly identifies all Minor (Green) patients.
2. Systematic Rapid Assessment: Move to the non-ambulatory patients. Spend no more than 30-60 seconds per patient.
For the unconscious patient (Option 2): Check for breathing. If none, perform a jaw-thrust to open the airway. If still not breathing, check for a carotid pulse (quickly). If absent, tag Black. This is a difficult but necessary decision.
For the patient in respiratory distress (Option 4): You note stridor (high-pitched sound) indicating airway obstruction, rapid chest movements, and a thready radial pulse. This is an ABC emergency. Tag Red and call for immediate airway management support (e.g., respiratory therapist, physician for possible intubation).
For the alert patient with bleeding (Option 3): Apply direct pressure with a trauma dressing to the wound while you assess. The bleeding slows. The patient is alert and follows commands. Tag Yellow and instruct them to hold pressure.
3. Communication & Re-triage: Clearly communicate the triage category to the treatment team. In a real MCI, patients' conditions can change, necessitating re-triage.
Patient Safety and Precautions:
Contraindication: Do not spend time starting IV lines or providing detailed care during the initial triage phase. Your sole job is to sort and tag.
Key Monitoring: After tagging, monitor for deterioration, especially in Yellow and Green patients who are waiting.
Nursing Procedure & Medication Flow
In the Immediate (Red) treatment area, care for the patient with a compromised airway would follow this sequence:
1. Primary Survey (ABCDE): A (Airway with C-spine control) – Perform head-tilt/chin-lift or jaw-thrust. Suction if needed. Consider advanced airway (endotracheal tube). B (Breathing) – Provide oxygen via bag-valve-mask. C (Circulation) – Establish IV access, control external bleeding, administer IV fluids for shock. D (Disability) – Quick neuro check (AVPU). E (Exposure/Environment) – Fully expose to find injuries, prevent hypothermia.
2. Medication: Medications may be needed for rapid sequence intubation (RSI) – sedatives (e.g., etomidate) and paralytics (e.g., succinylcholine). Nurses must know dosages, indications, and monitor for side effects like hypotension.
A Word from Your Senior Nurse
"Triage in a disaster is one of the most challenging but vital skills a nurse can have. It goes against our every instinct to 'do everything' for one patient. Remember, in that moment, you are making decisions for the entire community of patients. Your calm, systematic approach using START can save countless lives. On the NCLEX, they are testing your judgment under pressure. Don't get emotionally hooked by one graphic description; stick to the algorithm: Can they walk? Are they breathing? How fast? What's their pulse? Can they obey commands? That's the disciplined thinking that saves lives."
START Triage — Simple Triage and Rapid Treatment; a rapid casualty sorting method used in mass casualty incidents based on breathing, perfusion, and mental status.
Immediate (Red Tag) — Highest priority category for patients with life-threatening but treatable injuries (e.g., airway obstruction, shock) requiring care within minutes.
Expectant (Black Tag) — Lowest priority category for patients who are deceased or have injuries so severe that survival is unlikely given available resources.
Mass Casualty Incident — An event that generates more patients than available local resources can manage using routine procedures, requiring activation of special protocols.
Primary Survey — A systematic initial assessment sequence: Airway with C-spine control, Breathing, Circulation with hemorrhage control, Disability (neurological status), Exposure/Environment.