Disaster Triage And Mass Casualty Principles - NCLEX Rn

1. What does the green triage tag indicate in START triage?

   Minor: "walking wounded". Green tags mark patients with minor injuries who can ambulate and self-care, freeing resources for higher-priority cases.

2. What does the yellow triage tag indicate in START triage?

   Delayed: serious injuries, treatment can wait. Yellow tags denote patients who can tolerate delayed care without immediate risk, allowing focus on more critical victims first.

3. What does the black triage tag indicate in START triage?

   Expectant/deceased: unlikely to survive with resources. Black tags are assigned to victims with unsurvivable injuries or no vital signs, conserving resources for those with better prognoses.

4. In START triage, identify the tag for respirations $35$/min with spontaneous breathing.

   Red (immediate). Spontaneous respirations above $30$ per minute indicate instability, requiring prompt treatment to stabilize the patient.

5. Which disaster response action should the nurse take first when personal safety is uncertain at the scene?

   Ensure scene safety and use appropriate PPE before care. Prioritizing personal safety prevents responder casualties, maintaining operational capacity in hazardous mass casualty environments.

6. Which triage system uses color tags red, yellow, green, and black?

   START (Simple Triage and Rapid Treatment). START employs a rapid assessment method categorizing victims by urgency using these color codes to prioritize treatment in disasters.

7. In START triage, how do you categorize a victim who is not breathing after airway repositioning?

   Black (deceased/expectant). Absence of breathing post-intervention indicates unsurvivable status, prioritizing resources for viable patients in scarcity.

8. In START triage, identify the tag for a patient who follows commands and has stable breathing and perfusion.

   Yellow (delayed). Stable vital signs with inability to ambulate indicate serious but non-immediate needs, allowing deferred treatment.

9. In START triage, what respiratory rate threshold makes a patient red (immediate)?

   Respiratory rate $> 30$ breaths/min. A rate exceeding $30$ breaths per minute signals respiratory distress, necessitating immediate intervention to prevent deterioration.

10. In JumpSTART, categorize a child who is apneic with a pulse and remains apneic after $5$ breaths.

    Black (deceased/expectant). Persistent apnea despite intervention signals unsurvivable injury, directing resources to more viable pediatric patients.

11. What is the highest priority nursing intervention for severe external hemorrhage during MCI triage?

    Control bleeding immediately (direct pressure or tourniquet). Uncontrolled hemorrhage leads to rapid exsanguination, making hemostasis critical to preserve life in mass casualty settings.

12. What is the first action in START triage when arriving at an MCI scene?

    Direct ambulatory victims to a designated area (green). Instructing able-bodied victims to move separates minimal-injury patients quickly, enabling focus on non-ambulatory assessments.

13. What does the red triage tag indicate in START triage?

    Immediate: life-threatening but treatable now. Red tags identify patients requiring urgent interventions to prevent death, aligning with resource allocation for salvageable cases.

14. In START triage, what perfusion finding indicates red (immediate)?

    No radial pulse or capillary refill $> 2$ seconds. These signs reflect poor perfusion, indicating shock or hemorrhage that demands urgent corrective measures.

15. What is the primary goal of disaster triage in a mass casualty incident?

    Do the greatest good for the greatest number of people. This utilitarian approach maximizes overall survival by allocating limited resources efficiently during overwhelming mass casualty incidents.

16. In JumpSTART, what is the first action for a non-ambulatory child who is apneic with a pulse?

    Give $5$ rescue breaths. Providing rescue breaths attempts to reverse apnea in children with pulses, accounting for their higher resilience to hypoxia.

17. In JumpSTART, what respiratory rate range is considered adequate for pediatric triage?

    $15$ to $45$ breaths/min. This range reflects normal pediatric respiratory physiology, guiding triage to identify deviations requiring urgent intervention.

18. In START triage, what is the immediate next step after sorting walkers?

    Assess non-ambulatory victims for breathing. Evaluating breathing in remaining victims initiates the RPM (respiration, perfusion, mental status) sequence for rapid categorization.

19. Which triage principle best describes reassessing and changing categories as conditions evolve?

    Continuous triage (dynamic re-triage). Ongoing reassessment accounts for changing patient conditions, ensuring dynamic resource allocation in evolving disaster scenarios.

20. In START triage, what mental status finding indicates red (immediate)?

    Cannot follow simple commands. Inability to follow commands implies altered mental status, often due to hypoxia or trauma, requiring urgent evaluation.

21. In JumpSTART, identify the tag for a child with respirations $10$/min after airway opening.

    Red (immediate). Rates below $15$ per minute signify respiratory failure, demanding immediate categorization for prompt stabilization.

22. In JumpSTART, categorize a child who is apneic with a pulse and breathes after $5$ breaths.

    Red (immediate). Resumption of breathing post-breaths indicates a reversible airway issue, necessitating immediate advanced care in children.

23. Which triage approach is used for children and replaces "walking" with an age-appropriate check?

    JumpSTART pediatric triage. JumpSTART adapts adult protocols for pediatric physiology, using AVPU for mental status in non-verbal children instead of walking ability.

24. In START triage, identify the tag for capillary refill $> 2$ seconds after breathing is adequate.

    Red (immediate). Delayed capillary refill suggests circulatory compromise, warranting immediate categorization after confirming adequate breathing.

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