Free BCEN Certified Emergency Nurse (CEN) Practice Question

The START (Simple Triage and Rapid Treatment) triage system prioritizes patients based on their ability to walk, presence of spontaneous respiration, respiratory rate, perfusion, and mental status. The patient with a respiratory rate of 10 breaths per minute is breathing spontaneously and falls within the normal range of 12-20 breaths per minute, which suggests adequate perfusion and mental status, but they may need urgent care because they are not obeying commands. This patient should be tagged as 'Immediate' or red, indicating they require immediate life-saving interventions. The patient with a respiratory rate of 28 breaths per minute may be in respiratory distress and could also be tagged as 'Immediate' if they don't follow commands or don't have a peripheral pulse. The ambulatory patient and the patient with a respiratory rate of 32 breaths per minute may be tagged as 'Delayed' or yellow, indicating their condition is less severe than that of an 'Immediate' patient. The patient who is not breathing even after airway repositioning would typically be tagged as 'Deceased' or black after a quick attempt to open the airway fails to produce spontaneous breathing, indicating a very low chance of survival.