Daily prioritization follows ABCs first: a patient with an airway or breathing problem is always seen before one with a circulation or lower-priority issue.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A nurse is triaging a behavioral health emergency. Which client should be assessed first?
Answer: A. Airway, breathing, circulation, and immediate danger to self or others drive prioritization. A client who has taken an overdose has a physiological threat to life and is the priority over clients with non-life-threatening distress.
Question 2 of 5
In a mass-casualty event using START triage, which client is tagged for care FIRST?
Answer: B. Triage prioritizes those with life threats who are salvageable with quick intervention (e.g., respiratory rate >30 or absent radial pulse). A client with no pulse after airway repositioning is tagged expectant; the walking wounded are minor.
Question 3 of 5
During triage in the emergency department, which client should the nurse treat FIRST?
Answer: B. Using ABC and acuity-based triage, the client with a sucking chest wound has a compromised airway and breathing from an open pneumothorax, which is immediately life-threatening. A closed forearm fracture, a 3 cm laceration, and a sprained ankle are urgent or non-urgent but not immediately life-threatening.
Question 4 of 5
After a mass-casualty incident, the nurse uses START triage. Which client is tagged for IMMEDIATE (red) priority?
Answer: B. In START triage, IMMEDIATE (red) tags go to clients with life-threatening but survivable injuries, such as a respiratory rate over 30, who need urgent intervention. A client who is walking and can follow commands is minor (green); a client with no respirations after airway repositioning is expectant; and a client with a minor laceration is delayed.
Question 5 of 5
During a mass-casualty event using START triage, which client should be tagged RED (immediate)?
Answer: B. In START triage, RED (immediate) is assigned to clients with a life-threatening but salvageable problem, such as a respiratory rate over 30, absent radial pulse, or inability to follow commands. A respiratory rate of 36 after airway repositioning meets the RED criteria. The walking client is GREEN, the apneic client who does not breathe after repositioning is BLACK (expectant), and the client with a closed forearm fracture who follows commands is YELLOW (delayed).
Keep the streak going with more questions like these, each with a full rationale.
What is triage and prioritization?
In daily care, prioritize by ABCs (airway, breathing, circulation), then by Maslow's hierarchy (physiologic before psychosocial), then actual over potential problems and unstable over stable patients. In mass-casualty disaster triage, the goal shifts to the greatest good for the greatest number, using color-coded tags.
Key points to remember
- Daily prioritization follows ABCs first: a patient with an airway or breathing problem is always seen before one with a circulation or lower-priority issue.
- Maslow's hierarchy ranks physiologic needs above safety, and safety above love/belonging, self-esteem, and self-actualization.
- Actual problems and unstable patients generally take priority over potential problems and stable patients, and unexpected findings over expected ones.
- In standard ED triage (emergent/urgent/non-urgent), life-threatening conditions are emergent and seen immediately.
- Disaster (mass-casualty) triage reverses everyday logic: resources go to those most likely to survive, so expectant/non-salvageable patients are deprioritized.
- START tags: red = immediate life threat but salvageable, yellow = delayed/can wait, green = minor/walking wounded, black = expectant/deceased.
Nursing priorities
- Assess airway, breathing, and circulation first and treat the most immediately life-threatening problem.
- Compare patients by stability: see the unstable, deteriorating, or newly symptomatic patient before the stable one.
- Weigh actual versus potential problems and apply Maslow when no immediate ABC threat distinguishes patients.
- In a mass-casualty event, apply START principles and tag by survivability to save the most lives, not the sickest.
- Reassess continuously, as triage status changes when a patient's condition changes.
Red flags: report now
- A compromised or threatened airway always outranks all other findings; address it first.
- Sudden change such as new chest pain, dyspnea, decreased level of consciousness, or active hemorrhage moves a patient to immediate priority.
- In a disaster, do not expend scarce resources on an expectant (black-tag) patient at the expense of salvageable red-tag patients.
- Never deprioritize a deteriorating or unstable patient in favor of a stable one with a chronic complaint.
References
Clinical references for this topic
