Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
Test bank: 20 NCLEX/NGN-style items —
Emergency Nursing & Triage
1. (Prioritization — single best answer)
A 58-year-old male arrives to the ED after a motor-
vehicle collision. He is conscious but anxious. Vital
signs: HR 124, BP 86/52, RR 28, SpO₂ 92% on room
air. He has active external bleeding from the left
thigh, which is soaking the dressing. Which action
should the ED nurse perform first?
A. Apply a pressure dressing to the thigh wound.
B. Give 1 L normal saline bolus via large-bore IV.
C. Administer high-flow oxygen via nonrebreather
,mask.
D. Obtain a focused history using SAMPLE.
Answer: A. Apply a pressure dressing to the thigh
wound.
Rationale (stepwise):
1. Immediate external hemorrhage that is life-
threatening must be controlled first —
uncontrolled bleeding is an immediate threat to
circulation (C in ABCs). Direct
pressure/tourniquet to stop hemorrhage is the
priority.
2. After bleeding control, airway and oxygenation
interventions (C) are next; oxygen is important
but will not stop rapid hemorrhagic shock.
3. IV fluid resuscitation (B) is appropriate after
hemorrhage control and establishing IV access.
4. Focused history (D) is important but secondary
to immediate life-saving interventions.
Why other options are wrong: Oxygen and fluids
are crucial but cannot stop exsanguination; history
,takes lower priority. (ABCs: control life-threatening
airway/bleeding first.)
2. (Triage — single best answer / ESI)
A pediatric patient with fever and mild cough
presents to triage. He is alert, breathing
comfortably, and has no signs of respiratory distress.
Triage nurse expects that the patient will likely
require only a single resource (rapid strep test) and
discharge home. According to ESI principles, which
triage level is most appropriate?
A. ESI level 1
B. ESI level 2
C. ESI level 3
D. ESI level 5
Answer: D. ESI level 5.
Rationale:
• ESI level 5: non-urgent, requires no resources
(or only minor resources — but in most ESI
frameworks, level 5 = requires no resources;
level 4 usually = one resource). Given the
, scenario (mild symptoms, likely minimal
testing), level 5 is most appropriate.
• ESI levels escalate with acuity and expected
resource use; level 1 = immediate life-saving
intervention, level 2 = high risk or severe
distress, level 3 = many resources and not
immediately life-threatening. Use of ESI is the
standard ED triage tool. California Emergency
Nurses Association+1
Why others are wrong: Level 1 & 2 are for
unstable/high-risk patients; level 3 implies multiple
ED resources and more urgency.
3. (NGN case scenario — clinical judgment /
multiple-choice)
Case: A 47-year-old female with history of
hypertension presents with chest pain and dyspnea.
Triage EKG reveals ST-segment elevation in leads
V2–V4. She is pale and diaphoretic. Which action
should the triage nurse prioritize to improve patient
outcomes?
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
Test bank: 20 NCLEX/NGN-style items —
Emergency Nursing & Triage
1. (Prioritization — single best answer)
A 58-year-old male arrives to the ED after a motor-
vehicle collision. He is conscious but anxious. Vital
signs: HR 124, BP 86/52, RR 28, SpO₂ 92% on room
air. He has active external bleeding from the left
thigh, which is soaking the dressing. Which action
should the ED nurse perform first?
A. Apply a pressure dressing to the thigh wound.
B. Give 1 L normal saline bolus via large-bore IV.
C. Administer high-flow oxygen via nonrebreather
,mask.
D. Obtain a focused history using SAMPLE.
Answer: A. Apply a pressure dressing to the thigh
wound.
Rationale (stepwise):
1. Immediate external hemorrhage that is life-
threatening must be controlled first —
uncontrolled bleeding is an immediate threat to
circulation (C in ABCs). Direct
pressure/tourniquet to stop hemorrhage is the
priority.
2. After bleeding control, airway and oxygenation
interventions (C) are next; oxygen is important
but will not stop rapid hemorrhagic shock.
3. IV fluid resuscitation (B) is appropriate after
hemorrhage control and establishing IV access.
4. Focused history (D) is important but secondary
to immediate life-saving interventions.
Why other options are wrong: Oxygen and fluids
are crucial but cannot stop exsanguination; history
,takes lower priority. (ABCs: control life-threatening
airway/bleeding first.)
2. (Triage — single best answer / ESI)
A pediatric patient with fever and mild cough
presents to triage. He is alert, breathing
comfortably, and has no signs of respiratory distress.
Triage nurse expects that the patient will likely
require only a single resource (rapid strep test) and
discharge home. According to ESI principles, which
triage level is most appropriate?
A. ESI level 1
B. ESI level 2
C. ESI level 3
D. ESI level 5
Answer: D. ESI level 5.
Rationale:
• ESI level 5: non-urgent, requires no resources
(or only minor resources — but in most ESI
frameworks, level 5 = requires no resources;
level 4 usually = one resource). Given the
, scenario (mild symptoms, likely minimal
testing), level 5 is most appropriate.
• ESI levels escalate with acuity and expected
resource use; level 1 = immediate life-saving
intervention, level 2 = high risk or severe
distress, level 3 = many resources and not
immediately life-threatening. Use of ESI is the
standard ED triage tool. California Emergency
Nurses Association+1
Why others are wrong: Level 1 & 2 are for
unstable/high-risk patients; level 3 implies multiple
ED resources and more urgency.
3. (NGN case scenario — clinical judgment /
multiple-choice)
Case: A 47-year-old female with history of
hypertension presents with chest pain and dyspnea.
Triage EKG reveals ST-segment elevation in leads
V2–V4. She is pale and diaphoretic. Which action
should the triage nurse prioritize to improve patient
outcomes?
