Everything you have learned about priority reverses in a mass casualty event, and that reversal is the whole exam item.

In the emergency department, the sickest client is seen first. In disaster triage with limited resources, the sickest client may be tagged expectant while a nurse treats someone with a better chance of survival.

That shift feels wrong, which is exactly why these items exist. The exam wants to know whether you can apply a different framework when the situation calls for it.

This guide covers the disaster triage categories, the START and JumpSTART systems, evacuation order, decontamination, bioterrorism recognition, and the preparedness concepts that appear alongside them.

Written for internationally educated nurses (IENs) and repeat test-takers.

Quick answer: In disaster triage, the goal shifts from the best outcome for one client to the greatest good for the greatest number. Red means immediate and survivable with intervention. Yellow means delayed, serious but able to wait. Green means minor, the walking wounded. Black means expectant, where survival is unlikely given available resources. Cardiopulmonary resuscitation is generally not performed during mass casualty disaster triage, which is the single biggest reversal from normal practice.

The Principle That Changes Disaster Triage

Day-to-day nursing optimizes for the individual client in front of you. Disaster triage optimizes for the population.

The governing idea: the greatest good for the greatest number, with the resources actually available.

Three consequences follow, and all three appear in items.

The most injured may not be treated first. A client with injuries unsurvivable under current conditions is tagged expectant so that resources go to clients who can be saved.

Resources, not need alone, drive the decision. The same client might be treated aggressively in a well-staffed emergency department and tagged expectant in a field with three nurses and forty casualties.

Speed matters more than thoroughness. Disaster triage assessment takes seconds per casualty, not minutes. Treatment during the sort is limited to opening an airway and controlling catastrophic bleeding.

One point worth stating plainly. The expectant category is not abandonment. Comfort care, pain relief, and dignity continue. Items that describe a nurse withdrawing all care from an expectant client describe an error.

The Four Disaster Triage Categories

The category candidates misapply most often is red. Red does not mean most injured. It means survivable and requiring immediate intervention. A casualty who will die regardless of what is done now belongs in the expectant category, not the immediate one.

Green is easier than it looks in disaster triage. If a casualty can walk, they are green at the initial sort, which is why the first instruction at a scene is to ask everyone who can walk to move to a designated area.

A note on tag names. Different systems label these differently, and some use a fifth category. The NCLEX works with the four above, and items will usually give you both the colour and the word so you are not guessing which convention is in play.

START Triage: The Adult Disaster Triage System

START stands for Simple Triage and Rapid Treatment, and it is the adult system most likely to appear. It was developed in California in 1983 and, according to the US Department of Health and Human Services CHEMM resource, remains the most commonly used mass casualty triage algorithm in the United States.

It assesses three things, remembered as RPM: Respirations, Perfusion, Mental status.

The Sequence

Step one: ask everyone who can walk to move to a designated area. Those who walk are tagged green.

Step two: assess respirations in those remaining.

• Not breathing: open the airway with a single positioning manoeuvre
• Still not breathing after that: tag expectant
• Breathing resumes: tag immediate
• Respiratory rate above 30: tag immediate

Step three: assess perfusion in those breathing at 30 or below.

• Capillary refill longer than two seconds, or absent radial pulse: tag immediate

Step four: assess mental status in those with adequate perfusion.

• Unable to follow simple commands: tag immediate
• Able to follow simple commands: tag delayed

The two interventions permitted during disaster triage. Opening an airway and controlling severe bleeding. Nothing else, because stopping to treat one casualty leaves the rest unassessed.

Why the order is fixed. You stop at the first criterion that assigns a tag and move on. Working the steps out of order, or going back to reconsider a tag on clinical instinct, is where candidates lose these items.

JumpSTART: Disaster Triage for Children

JumpSTART is the paediatric adaptation, typically used for children roughly one to eight years old, and it exists because children differ physiologically. It was developed in Miami in 1995 and is the most commonly used paediatric mass casualty algorithm in the United States.

The key difference. Children deteriorate for respiratory reasons far more often than adults. A child who is apnoeic but still has a pulse may respond to ventilation, so JumpSTART builds in an extra step.

The adapted sequence:

• Apnoeic with a palpable pulse: give rescue breaths before deciding. If breathing resumes, tag immediate. If not, tag expectant
• Respiratory rate below 15 or above 45: tag immediate
• Mental status assessed with the AVPU scale rather than command-following, since young children may not follow instructions even when uninjured

Why the exam likes this distinction. Applying the adult rule to a child produces a different and wrong answer, which makes it a clean test of whether you know there are two disaster triage systems rather than one.

The practical rule for infants and very young children. If a child cannot walk because of age rather than injury, they are carried to the green area and assessed there rather than counted as ambulatory. An item that tags a non-walking toddler as yellow purely because the child did not walk is describing an error.

The Disaster Triage Reversal That Costs Most Points

Here is the single most important contrast on this topic.

The clearest application. A casualty in cardiac arrest during a mass casualty event is tagged expectant. Cardiopulmonary resuscitation is generally not performed, because it occupies one or more rescuers for a prolonged period while many other casualties go unassessed.

In the emergency department, that same client receives immediate resuscitation.

What determines which framework applies. Whether resources are overwhelmed. An item describing an emergency department with normal staffing is asking a normal priority question. An item describing a bus crash with forty casualties and limited staff is asking a disaster triage question.

Read the stem for that signal before you answer. Our guide to what the NCLEX is looking for covers how the question stem sets the frame.

The phrases that signal disaster triage include mass casualty, multiple casualties, limited resources, field triage, scene of the incident, and any count of casualties that clearly exceeds the staff described. The phrases that signal normal priority include a named unit, a single client, and an otherwise routine shift.

Evacuation Order

Evacuation sits beside disaster triage in the same exam category, and these items follow their own rules that are straightforward once learned.

Who moves first:

1. Ambulatory clients, who can walk out with direction and need the least assistance
2. Clients needing assistance, such as those using wheelchairs
3. Non-ambulatory and bedbound clients, who require the most staff and time

Two further principles:

Those closest to the danger move first, regardless of category, since proximity determines immediate risk.

Horizontal evacuation before vertical. Move clients away from the threat on the same floor, often through fire doors into another wing, before attempting to move them down stairs. Vertical evacuation is slower, more dangerous, and used when horizontal movement is not enough.

The logic behind the order. Moving ambulatory clients first clears the area quickly and frees staff to assist those who cannot move themselves.

One fire-specific sequence worth memorizing. RACE: Rescue anyone in immediate danger, Activate the alarm, Confine the fire by closing doors, then Extinguish or Evacuate as the facility plan directs. Items will sometimes ask for the first action, and rescuing the client in immediate danger comes before pulling the alarm.

Decontamination Before Entry

Items on chemical exposure test sequence and self-protection, and they often appear in the same disaster triage case study.

The order that matters:

1. Protect yourself first. Appropriate personal protective equipment before any contact. A contaminated rescuer becomes another casualty and can contaminate the facility
2. Decontaminate before entry to the clean treatment area
3. Remove clothing, which removes a large proportion of contaminant on its own
4. Irrigate with water as the facility protocol directs
5. Contain removed clothing and runoff

The point that appears most often. Decontamination happens before the casualty enters the facility, not after. An item describing a contaminated client brought straight into the emergency department describes an error.

Why self-protection outranks the client here. It looks like a violation of everything else you have learned about priority. It is not. One contaminated nurse can shut down a treatment area and remove several staff from the response, which costs more lives than the seconds spent putting on protective equipment.

Radiation Exposure

Three principles cover most radiation items that accompany disaster triage, and they are easy to recall.

Time. Minimize the duration of exposure.

Distance. Maximize the distance from the source, since exposure falls sharply as distance increases.

Shielding. Place appropriate barriers between yourself and the source.

Staff rotation during care of a client with an internal radiation source is an application of the time principle, and it appears regularly. The federal Radiation Emergency Medical Management resource is the reference your North American colleagues are trained against.

Two specifics that show up. A pregnant nurse is not assigned to a client with an internal radiation source. And a dislodged implant is handled with long-handled forceps and placed in a lead container, never with gloved hands.

Bioterrorism Agents and the Precautions That Go With Them

Items in this area usually test one thing: which precautions go with which agent. The CDC maintains the categorised agent list that North American preparedness training uses.

The pattern. Most of these need standard precautions only, because they are not transmitted between people. Smallpox is the one that demands airborne and contact precautions together, and it is the one items most often use.

The reporting point. In a disaster triage response, a suspected bioterrorism exposure is reported through the facility chain and to public health authorities. A nurse does not make a public announcement or contact media.

Our guide to NCLEX infection control precautions covers the four precaution types in detail, and this table is simply those rules applied to agents you may not have studied outside North America.

The Four Phases of Emergency Management

Items may name these phases directly, and disaster triage belongs to only one of them.

The phase candidates underestimate is preparedness. Knowing where your facility's disaster plan is, what your assigned role is, and how the incident command structure works is itself an exam-relevant nursing responsibility.

Recovery includes staff. Critical incident debriefing and mental health support for responders sit in recovery, and an item asking what the nurse manager should arrange after a mass casualty event is usually pointing there.

Hospital Incident Command and Where Disaster Triage Fits

North American facilities operate a hospital incident command system, and a handful of items test whether you understand how you fit into it.

The structure in one sentence. A single incident commander has overall authority, section chiefs manage defined areas such as operations and logistics, and every responder reports to one person only.

What that means for a nurse at the bedside. You work within the role you are assigned. You do not self-deploy to the area that looks busiest, and you do not change assignments without going through the person you report to.

Three applications that appear in items:

Report to the designated area, not the scene. A nurse called in during a disaster goes to the labour pool or staging area named in the plan and is assigned from there.

One supervisor, one chain. If two people give conflicting instructions, the nurse clarifies through the assigned chain rather than choosing between them.

Documentation continues. Disaster triage tags, times, and interventions are recorded even when conditions are chaotic, because tracking casualties is part of the response.

Why IENs should pay attention here. Many national systems coordinate disasters differently, and an item that seems to be about clinical judgment is sometimes testing whether you know you are operating inside a defined command structure.

Surge Capacity and Who Gets Discharged

A specific item type asks which client can be discharged to free a bed during a mass casualty event.

What you are looking for: the most stable client, whose care could reasonably continue elsewhere or at home.

Typical correct answers: a client awaiting a routine procedure, a client already medically ready for discharge, a stable client whose remaining care is observational.

Typical wrong answers: anyone unstable, anyone requiring intravenous therapy that cannot continue elsewhere, anyone whose condition is still changing.

A related item type asks which clients a nurse can be assigned or which tasks may be delegated under surge conditions. The usual scope rules still apply, which sits inside Management of Care at roughly 18% of the RN exam according to the NCSBN test plans.

A Disaster Triage Decision Tree You Can Memorize

If you remember nothing else, remember this sequence.

For a child, change two things. Apnoeic with a pulse gets rescue breaths before a decision, and the respiratory range is 15 to 45 rather than up to 30.

Print this and work it by hand. Writing the steps out five times from memory does more for recall than reading the table twenty times.

A Worked Disaster Triage Example

The scenario. Following a building collapse, a nurse is triaging casualties at the scene. Four casualties remain after the walking wounded have been directed to a designated area.

• Casualty A: respiratory rate 36, radial pulse present, follows commands
• Casualty B: not breathing after the airway is opened
• Casualty C: respiratory rate 22, capillary refill four seconds
• Casualty D: respiratory rate 18, capillary refill under two seconds, follows commands

The question: how should the nurse tag each casualty?

Working through START:

Casualty A. Respiratory rate above 30 stops the assessment there. Immediate, red.

Casualty B. Not breathing after a single airway manoeuvre. Expectant, black.

Casualty C. Respiratory rate acceptable, but capillary refill longer than two seconds indicates poor perfusion. Immediate, red.

Casualty D. Respirations, perfusion, and mental status all adequate. Delayed, yellow.

Where candidates lose this. Casualty B feels like the one needing most help, and in an emergency department would receive resuscitation. Under mass casualty conditions, assigning rescuers to that casualty leaves the others unassessed.

The pattern to carry forward. Work the algorithm in order and stop at the first criterion that assigns a tag. Do not reassess from clinical instinct.

A Second Worked Example: The Child

The scenario. During the same event, a six-year-old is found not breathing, with a palpable pulse.

The adult rule would say: airway opened, still not breathing, tag expectant.

JumpSTART says otherwise. Because a child with a pulse who is apnoeic may be in respiratory rather than cardiac failure, rescue breaths are given before a decision is made.

• If breathing resumes: immediate, red
• If it does not: expectant, black

Why this matters on the exam. The same findings produce different tags depending on the client's age, which is precisely what the item is testing.

How Disaster Triage Items Appear on the Exam

As priority items. Which casualty should the nurse attend to first, where the framework depends on whether resources are overwhelmed.

As ordered response items. Placing casualties in order of treatment priority, or sequencing evacuation steps.

As matrix items. Assigning a tag colour to each of several casualties, which suits disaster triage exactly.

In case studies. An unfolding disaster scenario where casualty numbers and available resources change across items.

As delegation items. Which staff member can be assigned which casualty under surge conditions.

As select-all-that-apply items. Which actions are appropriate during the initial sort, where the trap options are treatments that go beyond airway and bleeding control.

Our guide to Next Generation NCLEX strategy covers how the newer item types are scored, which matters because a matrix item gives partial credit while a priority item does not.

Six Mistakes on Disaster Triage Items

1. Applying normal priority rules. The sickest client is not automatically first in a mass casualty event.

2. Starting cardiopulmonary resuscitation during triage. It occupies rescuers while other casualties go unassessed.

3. Treating during the sort. Only airway opening and severe bleeding control, then move on.

4. Using the adult algorithm for a young child. JumpSTART adds the rescue breath step.

5. Evacuating bedbound clients first. Ambulatory clients go first, and those closest to the danger go before others in their category.

6. Bringing a contaminated casualty inside. Decontamination precedes entry to the treatment area.

How to Study Disaster Triage

Learn the four tags with examples, not definitions. A definition will not survive an unfamiliar casualty description.

Memorize the START sequence in order. Respirations, perfusion, mental status, with the stopping criteria at each step.

Learn JumpSTART as the difference, not as a separate system. One extra step and different rate thresholds.

Drill the reversal explicitly. Write out the same casualty in two scenarios, one emergency department and one mass casualty, and note how the answer changes.

Practise tagging sets of casualties. Four or five at a time, since that is how the exam presents them.

Budget your time honestly. Disaster triage is a small share of the exam. If you have two weeks left and large gaps in pharmacology, this is not where the hours should go. It is worth one focused session and a few practice sets, not a week.

Our guide to NCLEX remediation covers how to tag misses so you can tell an algorithm error from a framework error.

Podcast and Video for Disaster Triage

Priority and delegation sit underneath most disaster triage items, so these are the episodes worth your time.

Podcast: REPEAT TEST-TAKERS, you need to hear this, Episode 78 is the episode to start with if you have tested before, and it explains what a CPR actually tells you about areas like this one.

Browse the full catalogue: NCLEX High Yield podcasts, where episodes on prioritisation, delegation, and Management of Care apply directly to disaster triage items.

YouTube: the NCLEX High Yield channel covers priority-setting frameworks and the newer case study format, both of which carry straight into this topic.

A Note for Internationally Educated Nurses

Three points deserve attention if you trained outside North America.

Triage systems vary between countries. You may have trained with a different colour scheme, a different algorithm, or a four-level emergency department scale rather than a mass casualty system. The NCLEX expects START and JumpSTART, and the four-colour categories above.

The incident command structure is specific. North American facilities use a hospital incident command system with defined roles, and knowing that a nurse works within an assigned role rather than improvising is itself an exam point.

Scope during a disaster still applies. Emergency conditions do not expand what a nurse may do independently as much as candidates often assume. Delegation and scope rules continue, which sits inside Management of Care, where many experienced IENs lose the most points.

One-on-one tutoring can help you tell clinical knowledge gaps apart from practice framework gaps, which look identical from the inside.

Frequently Asked Questions

What do the disaster triage tag colours mean?

Red means immediate, for life-threatening injuries that are survivable with prompt intervention. Yellow means delayed, for serious injuries that can wait. Green means minor, the walking wounded. Black means expectant, where survival is unlikely with available resources.

What is START triage?

Simple Triage and Rapid Treatment, an adult disaster triage system assessing respirations, perfusion, and mental status in that order. Those who can walk are tagged green first, then the remaining casualties are assessed against stopping criteria at each step.

Is CPR performed during mass casualty triage?

Generally no. A casualty in cardiac arrest during a mass casualty event is tagged expectant, because resuscitation occupies rescuers for a prolonged period while many other casualties remain unassessed.

Who is evacuated first in a hospital?

Ambulatory clients first, then those needing assistance such as wheelchair users, then non-ambulatory and bedbound clients. Those closest to the danger move first, and horizontal evacuation is used before vertical.

How does JumpSTART differ from START?

JumpSTART is the paediatric adaptation. A child who is apnoeic with a palpable pulse receives rescue breaths before a tag is assigned, the respiratory rate thresholds differ, and mental status is assessed with the AVPU scale.

How many disaster triage questions are on the NCLEX?

There is no fixed number. Disaster triage sits mainly within Safety and Infection Control and Management of Care, and because the exam is adaptive, no two candidates receive the same mix.

Learn the Disaster Triage Framework, Then Apply It

Disaster triage items are not testing compassion. They are testing whether you can apply a different framework when resources are overwhelmed, and then return to normal priorities when they are not.

If you have tested before, your Candidate Performance Report shows whether this area was genuinely weak for you, or whether your gap sits in clinical judgment more broadly. Our guide to reading your NCLEX Candidate Performance Report walks through every line.

Submit your CPR for analysis on the NCLEX High Yield website, or text us at 725-444-7551 to speak with our team.

We will tell you honestly what your report shows, including when more content study is not the answer.

You can also join our free weekly Zoom sessions, explore our NCLEX programs, or build a schedule with the NCLEX High Yield Study Planner.

CPRs must be dated within the last 12 months. Reviews are professional guidance based on experience and are not affiliated with NCSBN or a prediction of your exam result. Exam details are from NCSBN's published material and were checked in October 2026.

Disaster triage algorithms and protocols vary between systems and are periodically revised. This article is study guidance for exam preparation rather than a clinical reference, so always follow your own institution's disaster plan and current protocols in practice.