# The nurse performs START triage after a building collapse. Which findings require immediate follow-up? Highlight the findings that meet immediate red-tag criteria.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=556748&lang=en  
> language: en  
> subject: Standard/Transmission-Based Precautions/Surgical Asepsis  
> category: SIPC

## Question

The nurse performs START triage after a building collapse. Which findings require immediate follow-up? Highlight the findings that meet immediate red-tag criteria.

| Victim | Triage finding |
| --- | --- |
| Victim 1 | Breathing is spontaneous at 36/min after the airway is found open. |
| Victim 2 | The victim walks to the designated area with small cuts on both hands. |
| Victim 3 | Breathing is 18/min and capillary refill is 2 seconds, but the victim cannot follow commands. |
| Victim 4 | An open lower-leg fracture is present; breathing is 24/min and commands are followed. |
| Victim 5 | Breathing is 22/min, but capillary refill remains four seconds. |
| Victim 6 | Partial-thickness burns involve both arms; radial pulse is present and commands are followed. |
| Victim 7 | A closed thigh fracture is present; breathing is 26/min and the radial pulse is palpable. |
| Victim 8 | Breathing is 20/min and the radial pulse is present, but commands are not followed. |
| Victim 9 | The victim walks with an ankle sprain and correctly states name and location. |

## 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.

## In-depth explanation

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

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