Relias ED RN A
1. A 58-year-old male presents to the ED with chest pain radiating to the left arm.
What is the nurse's priority action?
A. Obtain a complete medical history
B. Administer morphine for pain
C. Apply oxygen and obtain vital signs
D. Perform a 12-lead ECG and alert the provider
✅ Correct Answer: D. Perform a 12-lead ECG and alert the provider
Rationale: The priority in suspected myocardial infarction is early ECG to detect ST
elevation and initiate treatment quickly.
,2. Which of the following patients should be prioritized for treatment using the
Emergency Severity Index (ESI) triage system?
A. A 45-year-old with mild abdominal pain
B. A 19-year-old with a twisted ankle
C. A 67-year-old with shortness of breath and low oxygen saturation
D. A 5-year-old with a low-grade fever
✅ Correct Answer: C. A 67-year-old with shortness of breath and low oxygen
saturation
Rationale: Airway and breathing issues are high-priority and may indicate life-
threatening conditions needing immediate intervention.
3. A patient presents with signs of stroke. Which assessment is the most critical
during triage?
A. Blood glucose level
B. Full medication history
C. Pain rating
D. Respiratory rate
✅ Correct Answer: A. Blood glucose level
Rationale: Hypoglycemia can mimic stroke symptoms and must be ruled out
immediately before stroke protocols are initiated.
4. What is the first intervention for a trauma patient with a GCS score of 6?
A. Start an IV line
B. Provide pain medication
C. Secure the airway
D. Assess pupil response
✅ Correct Answer: C. Secure the airway
Rationale: A GCS score ≤ 8 indicates a need for airway protection to prevent
aspiration or hypoxia.
, 5. During a disaster, which patient should be treated last under START triage?
A. A patient who is pulseless and apneic despite airway repositioning
B. A patient with a femur fracture
C. A patient walking with a bleeding scalp laceration
D. A patient with burns over 15% of body surface area
✅ Correct Answer: A. A patient who is pulseless and apneic despite airway
repositioning
Rationale: In mass casualty triage (START), individuals who are not breathing even
after airway repositioning are classified as deceased.
6. A patient arrives by EMS with a suspected spinal cord injury after a fall. What is
the nurse’s initial priority?
A. Log-roll the patient to assess the back
B. Immobilize the cervical spine
C. Establish IV access
D. Monitor for signs of shock
✅ Correct Answer: B. Immobilize the cervical spine
Rationale: Protecting the cervical spine is the first step in trauma patients until injury
is ruled out.
7. In the case of suspected sepsis, which order should the nurse implement first?
A. Administer broad-spectrum antibiotics
B. Draw blood cultures
C. Start IV fluids
D. Measure lactate levels
✅ Correct Answer: B. Draw blood cultures
Rationale: Blood cultures must be obtained before starting antibiotics to identify the
causative organism.8. A 32-year-old female arrives complaining of shortness of
1. A 58-year-old male presents to the ED with chest pain radiating to the left arm.
What is the nurse's priority action?
A. Obtain a complete medical history
B. Administer morphine for pain
C. Apply oxygen and obtain vital signs
D. Perform a 12-lead ECG and alert the provider
✅ Correct Answer: D. Perform a 12-lead ECG and alert the provider
Rationale: The priority in suspected myocardial infarction is early ECG to detect ST
elevation and initiate treatment quickly.
,2. Which of the following patients should be prioritized for treatment using the
Emergency Severity Index (ESI) triage system?
A. A 45-year-old with mild abdominal pain
B. A 19-year-old with a twisted ankle
C. A 67-year-old with shortness of breath and low oxygen saturation
D. A 5-year-old with a low-grade fever
✅ Correct Answer: C. A 67-year-old with shortness of breath and low oxygen
saturation
Rationale: Airway and breathing issues are high-priority and may indicate life-
threatening conditions needing immediate intervention.
3. A patient presents with signs of stroke. Which assessment is the most critical
during triage?
A. Blood glucose level
B. Full medication history
C. Pain rating
D. Respiratory rate
✅ Correct Answer: A. Blood glucose level
Rationale: Hypoglycemia can mimic stroke symptoms and must be ruled out
immediately before stroke protocols are initiated.
4. What is the first intervention for a trauma patient with a GCS score of 6?
A. Start an IV line
B. Provide pain medication
C. Secure the airway
D. Assess pupil response
✅ Correct Answer: C. Secure the airway
Rationale: A GCS score ≤ 8 indicates a need for airway protection to prevent
aspiration or hypoxia.
, 5. During a disaster, which patient should be treated last under START triage?
A. A patient who is pulseless and apneic despite airway repositioning
B. A patient with a femur fracture
C. A patient walking with a bleeding scalp laceration
D. A patient with burns over 15% of body surface area
✅ Correct Answer: A. A patient who is pulseless and apneic despite airway
repositioning
Rationale: In mass casualty triage (START), individuals who are not breathing even
after airway repositioning are classified as deceased.
6. A patient arrives by EMS with a suspected spinal cord injury after a fall. What is
the nurse’s initial priority?
A. Log-roll the patient to assess the back
B. Immobilize the cervical spine
C. Establish IV access
D. Monitor for signs of shock
✅ Correct Answer: B. Immobilize the cervical spine
Rationale: Protecting the cervical spine is the first step in trauma patients until injury
is ruled out.
7. In the case of suspected sepsis, which order should the nurse implement first?
A. Administer broad-spectrum antibiotics
B. Draw blood cultures
C. Start IV fluids
D. Measure lactate levels
✅ Correct Answer: B. Draw blood cultures
Rationale: Blood cultures must be obtained before starting antibiotics to identify the
causative organism.8. A 32-year-old female arrives complaining of shortness of
