TRIAGE - NCLEX JumpSTART SYSTEM Flashcards
A 5-year-old child is not breathing. You reposition their airway, and they begin breathing spontaneously. What do you do next?
Tag as RED (Immediate). Airway repositioning was required, indicating a need for immediate care. Move to the next patient.
A 2-year-old child is found not breathing. You reposition the airway, but they remain apneic. You check for a pulse and find none. What do you do next?
Tag as BLACK (Expectant/Deceased). If no breathing and no pulse, no resuscitation is attempted in JumpSTART triage. Move on.
A 7-year-old boy is crying and walking towards you with a small forehead laceration. He is alert and obeys commands. What do you do next?
Tag as GREEN (Minor). A walking pediatric patient with stable vitals is classified as minor.
A 3-year-old girl is found lying on the ground. She is breathing at a rate of 45 breaths per minute, has a weak radial pulse, and moans in response to pain. What do you do next?
Tag as RED (Immediate). Tachypnea and altered mental status indicate the need for immediate care. Move on.
A 6-year-old boy is unconscious but has a respiratory rate of 28, a strong pulse, and withdraws to pain. What do you do next?
Tag as RED (Immediate). His altered mental status (unconscious but responding to pain) meets the criteria for immediate care. Move on.
A 4-year-old girl has an open femur fracture. She is alert, has a strong pulse, and a respiratory rate of 24. What do you do next?
Tag as YELLOW (Delayed). Serious injury but stable vitals. Continue triaging.
A 9-month-old baby is found crying and has minor bruises. What do you do next?
Tag as GREEN (Minor). A crying infant with minor injuries is considered ambulatory.
A 2-year-old child is breathing at 20 breaths per minute, has a weak pulse, and does not respond to pain. What do you do next?
Tag as RED (Immediate). Poor responsiveness and weak pulse indicate a critical condition. Move on after tagging.
A 6-year-old boy has a respiratory rate of 34, a strong radial pulse, and follows commands. What do you do next?
Tag as YELLOW (Delayed). Stable vitals but not ambulatory, so he needs further evaluation but not immediate intervention.
A 10-year-old girl is gasping for breath with a respiratory rate of 50, a weak pulse, and is unresponsive. What do you do next?
Tag as RED (Immediate). Severe respiratory distress with altered mental status requires immediate attention. Move on.
A 4-year-old child is apneic. You reposition their airway, but they still are not breathing. You check for a pulse and find one. What do you do next?
Give 5 rescue breaths. If the child starts breathing, tag as RED (Immediate). If still apneic, tag as BLACK (Expectant/Deceased).
A 2-year-old is found unresponsive and apneic. You reposition their airway, but they remain apneic. You check for a pulse and find none. What do you do next?
Tag as BLACK (Expectant/Deceased). In JumpSTART, a child with no breathing and no pulse is considered deceased.
A 6-year-old child has a fractured femur but is alert, has a respiratory rate of 24, and a strong pulse. What do you do next?
Tag as YELLOW (Delayed). The injury is serious but does not require immediate care. Move to the next patient.
A 3-year-old girl is apneic. After you reposition her airway, she still does not breathe. She has a pulse. You give 5 rescue breaths, and she starts breathing at 18 breaths per minute. What do you do next?
Tag as RED (Immediate). Any child who resumes breathing after airway repositioning or rescue breaths requires immediate intervention.
A 7-year-old boy has a respiratory rate of 15, a strong radial pulse, and is crying for his mother. What do you do next?
Tag as GREEN (Minor). He is alert, breathing normally, and ambulatory.
A 10-month-old baby is not moving and is breathing at 8 breaths per minute. He has a weak pulse and does not respond to pain. What do you do next?
Tag as RED (Immediate). Severe respiratory distress and altered mental status indicate the need for immediate care.
A 5-year-old girl has minor scrapes on her arms and is running to you, crying. What do you do next?
Tag as GREEN (Minor). She is ambulatory with stable vitals.
A 9-year-old boy is lying on the ground, not breathing. You reposition his airway, and he remains apneic. You check for a pulse and find a weak one. What do you do next?
Give 5 rescue breaths. If he starts breathing, tag as RED (Immediate). If still apneic, tag as BLACK (Expectant/Deceased).
A 2-year-old is moaning but not responding to commands. His respiratory rate is 50, and his pulse is weak. What do you do next?
Tag as RED (Immediate). Tachypnea and altered mental status require immediate intervention.
A 4-year-old child is unconscious with a respiratory rate of 32 and a strong pulse. He withdraws to pain but does not follow commands. What do you do next?
Tag as RED (Immediate). Altered mental status (not following commands) requires urgent care.
