In a disaster scenario, which action would warrant immediate intervention by the nurse when a client is Priority 2, color yellow?

In a disaster scenario, which action would warrant immediate intervention by the nurse when a client is Priority 2, color yellow?

• A. The American Red Cross (ARC) volunteer documents the tag number in the disaster log.
• B. The licensed practical nurse (LPN) documents the client's vital signs on the tag.
• C. The health care professional removes the tag to examine the client's injured right leg.
• D. The unlicensed assistive personnel (UAP) attaches the tag to the client's foot.

Answer: (C)

In mass casualty triage, the triage tag stays with the patient to communicate their current priority and help guide ongoing reassessment and transport. A yellow tag means the patient is delayed but not yet requiring immediate life-saving intervention, so care continues with monitoring and planned re-evaluation. Removing the triage tag to examine the injured leg would disrupt the tracking of the patient’s status and could lead to misclassification or delays in care. The nurse must intervene immediately to prevent removal of the tag and to ensure the leg exam is performed without compromising the patient’s assigned priority. The tag can stay in place while assessment and treatment proceed, so the patient remains categorized as delayed (yellow) and is reevaluated as resources allow. Keeping the tag in place preserves accurate information for the entire care continuum, while other documentation tasks and correct tagging practices support proper triage workflow.

In mass casualty triage, the triage tag stays with the patient to communicate their current priority and help guide ongoing reassessment and transport. A yellow tag means the patient is delayed but not yet requiring immediate life-saving intervention, so care continues with monitoring and planned re-evaluation.

Removing the triage tag to examine the injured leg would disrupt the tracking of the patient’s status and could lead to misclassification or delays in care. The nurse must intervene immediately to prevent removal of the tag and to ensure the leg exam is performed without compromising the patient’s assigned priority. The tag can stay in place while assessment and treatment proceed, so the patient remains categorized as delayed (yellow) and is reevaluated as resources allow.

Keeping the tag in place preserves accurate information for the entire care continuum, while other documentation tasks and correct tagging practices support proper triage workflow.