Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Triage in the ED
A 34-year-old male arrives at the ED after a motor-
vehicle collision. He is conscious, complaining of
chest pain and shortness of breath. Vital signs: RR
32, HR 120, BP 88/56, SpO₂ 88% on room air. He has
obvious deformity of the left femur but no active
external bleeding. According to disaster triage
categories (immediate/urgent/delayed/minor),
which category is most appropriate?
A. Minor (green)
B. Delayed (yellow)
C. Immediate (red)
D. Expectant (black)
,Correct answer: C. Immediate (red)
Rationale — correct (stepwise):
1. Apply triage/primary survey: ABCs show
compromised airway/respirations (RR 32, SpO₂
88%) and hypotension (BP 88/56) → physiologic
instability.
2. Immediate (red) indicates life/limb-threatening
conditions that require rapid intervention to
survive (oxygenation, IV fluids, chest/airway
management).
3. Prioritize rapid assessment and treatment
(airway/oxygen, IV access, hemorrhage control,
rapid imaging).
Rationale — incorrect:
• A (Minor): Green is for ambulatory/minor
injuries; not appropriate because patient is
hemodynamically unstable.
• B (Delayed): Yellow is for stable patients who
need care but not immediately; this patient is
unstable.
, • D (Expectant): Black is for patients with
unsurvivable injuries or who will not survive
given resources; this patient is salvageable with
immediate care.
2 — Primary Survey (ABCs)
During the primary survey of a trauma patient,
which action takes highest priority?
A. Obtain a complete set of vital signs.
B. Establish and secure the airway with cervical
spine stabilization.
C. Start two large-bore IV lines.
D. Get portable chest and pelvic x-rays.
Correct answer: B. Establish and secure the airway
with cervical spine stabilization.
Rationale — correct (stepwise):
1. ABCs: Airway with cervical spine protection is
first to prevent hypoxia and secondary spinal
injury.
, 2. Secure airway (jaw thrust, suction, advanced
airway if needed) before other non-life-saving
tasks.
3. Cervical spine immobilization must be
maintained during airway maneuvers in blunt
trauma.
Rationale — incorrect:
• A: Vital signs are important but come after
airway control during primary survey.
• C: IV access is critical (circulation) but secondary
to securing airway.
• D: Imaging assists diagnosis but should not
delay airway stabilization.
3 — Burn Fluid Resuscitation (Case)
A 45-year-old male sustained 40% TBSA partial- and
full-thickness burns. The nurse is preparing fluid
resuscitation using Parkland formula (4 mL × body
weight (kg) × %TBSA burned). If the patient weighs
80 kg, how much lactated Ringer’s should be given
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Triage in the ED
A 34-year-old male arrives at the ED after a motor-
vehicle collision. He is conscious, complaining of
chest pain and shortness of breath. Vital signs: RR
32, HR 120, BP 88/56, SpO₂ 88% on room air. He has
obvious deformity of the left femur but no active
external bleeding. According to disaster triage
categories (immediate/urgent/delayed/minor),
which category is most appropriate?
A. Minor (green)
B. Delayed (yellow)
C. Immediate (red)
D. Expectant (black)
,Correct answer: C. Immediate (red)
Rationale — correct (stepwise):
1. Apply triage/primary survey: ABCs show
compromised airway/respirations (RR 32, SpO₂
88%) and hypotension (BP 88/56) → physiologic
instability.
2. Immediate (red) indicates life/limb-threatening
conditions that require rapid intervention to
survive (oxygenation, IV fluids, chest/airway
management).
3. Prioritize rapid assessment and treatment
(airway/oxygen, IV access, hemorrhage control,
rapid imaging).
Rationale — incorrect:
• A (Minor): Green is for ambulatory/minor
injuries; not appropriate because patient is
hemodynamically unstable.
• B (Delayed): Yellow is for stable patients who
need care but not immediately; this patient is
unstable.
, • D (Expectant): Black is for patients with
unsurvivable injuries or who will not survive
given resources; this patient is salvageable with
immediate care.
2 — Primary Survey (ABCs)
During the primary survey of a trauma patient,
which action takes highest priority?
A. Obtain a complete set of vital signs.
B. Establish and secure the airway with cervical
spine stabilization.
C. Start two large-bore IV lines.
D. Get portable chest and pelvic x-rays.
Correct answer: B. Establish and secure the airway
with cervical spine stabilization.
Rationale — correct (stepwise):
1. ABCs: Airway with cervical spine protection is
first to prevent hypoxia and secondary spinal
injury.
, 2. Secure airway (jaw thrust, suction, advanced
airway if needed) before other non-life-saving
tasks.
3. Cervical spine immobilization must be
maintained during airway maneuvers in blunt
trauma.
Rationale — incorrect:
• A: Vital signs are important but come after
airway control during primary survey.
• C: IV access is critical (circulation) but secondary
to securing airway.
• D: Imaging assists diagnosis but should not
delay airway stabilization.
3 — Burn Fluid Resuscitation (Case)
A 45-year-old male sustained 40% TBSA partial- and
full-thickness burns. The nurse is preparing fluid
resuscitation using Parkland formula (4 mL × body
weight (kg) × %TBSA burned). If the patient weighs
80 kg, how much lactated Ringer’s should be given
