After a train accident, the nurse is assigned to triage the injured. Based upon the triage protocol, which individual should be seen last?

  1. 66-year-old male with no visible injuries, but who is experiencing tachycardia and seems confused
  2. 16-year-old female with fixed, dilated pupils who is unresponsive and has clear fluid draining from right ear
  3. 25-year-old female with an abrasion to left eye and a swollen ankle, who is unable to put weight on right leg
  4. 80-year-old male with chest pains and shortness of breath
Number 2 is correct.
Rationale: The 16-year-old female is not likely to survive her injuries. Fixed, dilated pupils, unresponsiveness, and probable severe head trauma are indicators of a very poor prognosis. Clients who are not expected to survive, even with treatment and intervention, are not the triage priority. Triage should prioritize critical clients who have a chance of survival if treated quickly, and then should see clients with less serious injuries.