Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
Question 1 — Triage Category (Case)
A 45-year-old man arrives at the ED after a
motorcycle crash. He is awake but confused, has
obvious deformity of the left femur, respiratory rate
28/min, shallow, and complains of chest pain. On
exam you note diminished breath sounds on the left
and tracheal deviation to the right. According to
standard disaster triage principles
(emergency/urgent/less urgent/minor), what triage
category is most appropriate?
A. Minor (green)
B. Urgent (yellow)
C. Emergent (red)
D. Expectant (black)
,Correct answer: C. Emergent (red)
Rationale — correct (C):
Tracheal deviation and diminished breath sounds
with respiratory distress suggest a tension
pneumothorax (an immediate life-threatening
condition). Per triage/rapid-sorting rules, patients
needing immediate lifesaving intervention are
"emergent" (red). The priority is airway/breathing
interventions (needle decompression/chest tube)
and advanced trauma care.
Rationale — incorrect:
A. Minor: Green is for ambulatory/minor injuries —
not appropriate for respiratory compromise.
B. Urgent: Yellow is for serious but not immediately
life-threatening injuries; this patient needs
immediate intervention.
D. Expectant: Black is for unsurvivable injuries when
resources are limited — not applicable here since
the condition is potentially reversible.
Question 2 — Prioritization: ABCs vs Maslow
,Which statement best describes how nurses use
ABC prioritization together with Maslow’s hierarchy
during emergency care?
A. Use ABCs for immediate physiologic threats; use
Maslow to address long-term psychosocial needs
after stabilization.
B. Use Maslow exclusively for triage decisions; ABCs
are used only in critical care units.
C. ABCs replace Maslow in all emergency situations
because physiologic needs are always first.
D. Maslow’s hierarchy dictates medication
administration order, while ABCs determine
discharge planning.
Correct answer: A.
Rationale — correct (A):
ABCs (airway, breathing, circulation) identify
immediate physiologic threats and guide acute
interventions. Maslow complements this by
informing broader priorities (safety, belonging,
esteem) after stabilization or concurrently for
, psychosocial needs; both frameworks are used
appropriately in sequence or together.
Rationale — incorrect:
B. Maslow is not used exclusively for triage; it’s a
broader human-needs framework.
C. ABCs don’t “replace” Maslow; they are applied
first for physiologic stability, but Maslow remains
relevant.
D. Maslow doesn’t dictate medication order; this
option misrepresents both frameworks.
Question 3 — Shock Recognition
A patient presents with cool, pale skin; hypotension
(BP 82/48 mm Hg); tachycardia (HR 128); and
absent urine output for 2 hours. Which type of
shock is most likely, and the nurse should prioritize
which initial intervention?
A. Cardiogenic shock — start inotropic agents
immediately.
B. Hypovolemic shock — initiate rapid IV isotonic
crystalloid bolus.
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
Question 1 — Triage Category (Case)
A 45-year-old man arrives at the ED after a
motorcycle crash. He is awake but confused, has
obvious deformity of the left femur, respiratory rate
28/min, shallow, and complains of chest pain. On
exam you note diminished breath sounds on the left
and tracheal deviation to the right. According to
standard disaster triage principles
(emergency/urgent/less urgent/minor), what triage
category is most appropriate?
A. Minor (green)
B. Urgent (yellow)
C. Emergent (red)
D. Expectant (black)
,Correct answer: C. Emergent (red)
Rationale — correct (C):
Tracheal deviation and diminished breath sounds
with respiratory distress suggest a tension
pneumothorax (an immediate life-threatening
condition). Per triage/rapid-sorting rules, patients
needing immediate lifesaving intervention are
"emergent" (red). The priority is airway/breathing
interventions (needle decompression/chest tube)
and advanced trauma care.
Rationale — incorrect:
A. Minor: Green is for ambulatory/minor injuries —
not appropriate for respiratory compromise.
B. Urgent: Yellow is for serious but not immediately
life-threatening injuries; this patient needs
immediate intervention.
D. Expectant: Black is for unsurvivable injuries when
resources are limited — not applicable here since
the condition is potentially reversible.
Question 2 — Prioritization: ABCs vs Maslow
,Which statement best describes how nurses use
ABC prioritization together with Maslow’s hierarchy
during emergency care?
A. Use ABCs for immediate physiologic threats; use
Maslow to address long-term psychosocial needs
after stabilization.
B. Use Maslow exclusively for triage decisions; ABCs
are used only in critical care units.
C. ABCs replace Maslow in all emergency situations
because physiologic needs are always first.
D. Maslow’s hierarchy dictates medication
administration order, while ABCs determine
discharge planning.
Correct answer: A.
Rationale — correct (A):
ABCs (airway, breathing, circulation) identify
immediate physiologic threats and guide acute
interventions. Maslow complements this by
informing broader priorities (safety, belonging,
esteem) after stabilization or concurrently for
, psychosocial needs; both frameworks are used
appropriately in sequence or together.
Rationale — incorrect:
B. Maslow is not used exclusively for triage; it’s a
broader human-needs framework.
C. ABCs don’t “replace” Maslow; they are applied
first for physiologic stability, but Maslow remains
relevant.
D. Maslow doesn’t dictate medication order; this
option misrepresents both frameworks.
Question 3 — Shock Recognition
A patient presents with cool, pale skin; hypotension
(BP 82/48 mm Hg); tachycardia (HR 128); and
absent urine output for 2 hours. Which type of
shock is most likely, and the nurse should prioritize
which initial intervention?
A. Cardiogenic shock — start inotropic agents
immediately.
B. Hypovolemic shock — initiate rapid IV isotonic
crystalloid bolus.
