TRIAGE - NCLEX START SYSTEM Flashcards
A 40-year-old male is lying on the ground, unconscious. He is breathing at a rate of 35 breaths per minute. What do you do next?
Tag as RED (Immediate). Rapid breathing indicates possible shock or airway compromise. Move to the next patient after tagging.
A 55-year-old female has an open femur fracture. She is alert, her respiratory rate is 24, capillary refill is 1 second, and she follows commands. What do you do next?
Tag as YELLOW (Delayed). She has a serious injury but stable vital signs. Continue triaging others.
A 70-year-old man is sitting on the ground. His respiratory rate is 10, his radial pulse is weak, and he responds to verbal commands with confusion. What do you do next?
Tag as RED (Immediate). His weak pulse and altered mental status indicate possible shock. Move to the next patient after tagging.
A 30-year-old female is found unconscious. You reposition her airway, and she starts breathing at a rate of 26 per minute. What do you do next?
Tag as RED (Immediate). Airway intervention was required, which meets the criteria for immediate care. Move to the next patient.
A 25-year-old male is walking around, holding his arm, which has a deep laceration. He has a strong radial pulse and is alert. What do you do next?
Tag as GREEN (Minor). He can walk and has stable vitals. Direct him to the minor treatment area.
A 50-year-old female is lying on the ground, not breathing. After repositioning her airway, she is still not breathing. What do you do next?
Tag as BLACK (Expectant/Deceased). No spontaneous breathing after airway repositioning means no resuscitation is attempted in START triage. Move on.
A 60-year-old male has a penetrating chest wound. He is breathing at 30 breaths per minute, has a weak radial pulse, and is struggling to speak. What do you do next?
Tag as RED (Immediate). He has abnormal respirations and signs of shock. Move on after tagging.
A 45-year-old female has a suspected pelvic fracture. She has a strong radial pulse, a respiratory rate of 20, and follows commands. What do you do next?
Tag as YELLOW (Delayed). She is stable but has a serious injury requiring hospital care. Continue triaging.
A 35-year-old male is lying motionless. His respiratory rate is 12, his pulse is strong, and he does not respond to verbal commands but withdraws to pain. What do you do next?
Tag as RED (Immediate). His altered mental status (not following commands) indicates a neurological issue. Move on after tagging.
A 28-year-old pregnant woman has minor abrasions and is able to walk. What do you do next?
Tag as GREEN (Minor). Walking patients with minor injuries are considered ambulatory and do not need immediate care.
A 38-year-old male is lying on the ground unconscious. He is not breathing, but after you reposition his airway, he starts breathing at 24 breaths per minute. What do you do next?
Tag as RED (Immediate). Opening the airway led to spontaneous breathing, indicating airway compromise. Move to the next patient.
A 50-year-old female is not breathing after repositioning her airway. You check for a radial pulse and find it is absent. What do you do next?
Tag as BLACK (Expectant/Deceased). No breathing and no pulse in START triage mean no resuscitation. Move on.
A 42-year-old male is found sitting on the ground with a deformed left forearm. He is alert, follows commands, and has a respiratory rate of 22. What do you do next?
Tag as GREEN (Minor). He is ambulatory, alert, and stable, meaning he does not require immediate attention.
A 63-year-old female is found on the ground with no movement. She has a respiratory rate of 12, a weak radial pulse, and moans when you apply pain stimulus. What do you do next?
Tag as RED (Immediate). Altered mental status (not following commands) and weak pulse suggest a critical condition. Move on.
A 29-year-old male is breathing at a rate of 32, has a strong pulse, and is yelling in pain due to an abdominal wound. What do you do next?
Tag as RED (Immediate). Tachypnea (>30 breaths per minute) indicates possible shock or distress. Move to the next patient.
A 75-year-old man is found unconscious with agonal breathing at 8 breaths per minute. His radial pulse is weak, and he does not respond to pain. What do you do next?
Tag as RED (Immediate). Altered mental status, abnormal breathing, and weak pulse indicate a critical condition. Move on.
A 55-year-old woman has a deep scalp laceration but is walking and talking. What do you do next?
Tag as GREEN (Minor). Walking patients with controlled bleeding and stable vitals are considered minor.
A 34-year-old male has a penetrating neck wound. He is breathing at 28 breaths per minute, his pulse is weak, and he is struggling to speak. What do you do next?
Tag as RED (Immediate). Signs of airway compromise and weak circulation indicate the need for immediate care.
A 48-year-old female has no visible injuries but is hyperventilating and crying. She has a strong radial pulse, capillary refill of less than 2 seconds, and follows commands. What do you do next?
Tag as GREEN (Minor). Emotional distress without significant injury does not require urgent intervention.
A 60-year-old male is lying down, not moving. He has a respiratory rate of 24, a weak radial pulse, and responds to verbal commands sluggishly. What do you do next?
Tag as RED (Immediate). His weak pulse and altered mental status suggest possible shock. Move on.
