Difficulty: Medium
Average Score: 87%
Simulated
Passage / Scenario
Client has a compromised airway; Client experienced a brief loss of consciousness; Client has fixed pupils; Client has major burns covering 70% of their body.A nurse in an emergency department is triaging four clients following a mass casualty event. To which of the clients should the nurse assign a red tag?
Correct answer
A
Rationale
The correct answer is A: A client who has a compromised airway. Assigning a red tag signifies the highest priority for immediate medical attention. A compromised airway is a life-threatening emergency that requires immediate intervention to ensure the client can breathe. This client is at the greatest risk of deteriorating rapidly if not treated promptly. Choices B, C, and D do not present an immediate threat to life like a compromised airway does. B, experiencing a brief loss of consciousness, may indicate a potential head injury but does not require immediate life-saving interventions. C, fixed pupils, suggest a neurological issue but may not be immediately life-threatening. D, major burns covering 70% of the body, while serious, does not pose an immediate threat to the client's airway and breathing.