Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1. (Triage / Prioritization — ESI concept)
A 67-year-old male arrives with sudden onset chest
pain, dyspnea, diaphoresis, and hypotension (BP
86/52 mmHg). According to the Emergency Severity
Index (ESI) approach, what triage level is most
appropriate?
A. ESI 1 — immediate life-saving intervention
required
B. ESI 2 — high risk but not immediate life-saving
intervention
C. ESI 3 — multiple resources required but stable
D. ESI 4 — one resource required
Correct answer: A
,Rationale — correct (A): The patient is
hemodynamically unstable (hypotension) with
possible acute coronary syndrome and requires
immediate, life-saving interventions (IV access,
monitoring, rapid resuscitation, possible immediate
ECG/PCI activation). ESI level 1 is for patients who
need immediate life-saving care. EMSC
Improvement Center
Rationales — incorrect:
B — ESI 2 applies to potentially high-risk situations
that are not currently requiring immediate life-
saving interventions (e.g., severe pain but stable
vitals).
C — ESI 3 is for stable patients requiring multiple
resources but not immediate life-saving care.
D — ESI 4 is for patients predicted to need only one
resource.
2. (ABCs / Prioritization — NGN style)
You are assigned to three ED patients. Which should
you see first?
, 1. A 24-year-old with bronchiolitis, RR 28, SpO₂
88% on room air.
2. A 52-year-old with chest pain, RR 20, SpO₂ 96%
on room air.
3. A 70-year-old with cellulitis and temperature
38.5°C, SpO₂ 98%.
A. Patient 1
B. Patient 2
C. Patient 3
D. Assess patients in order of arrival
Correct answer: A
Rationale — correct (A): Prioritize airway and
breathing threats first; SpO₂ of 88% represents
hypoxemia needing immediate assessment
(supplemental O₂, airway support). ABCs
(Airway/Breathing/Circulation) take precedence
over chest pain that currently has stable
oxygenation.
Rationales — incorrect:
B — Chest pain is high priority but the patient’s
, oxygenation is adequate; patient 1 has immediate
hypoxia.
C — Cellulitis is lower acuity compared with
immediate hypoxia.
D — Order of arrival is not used for clinical
prioritization when life-threatening conditions are
present.
3. (Shock recognition / initial management)
A patient with suspected hypovolemic shock after a
motor vehicle crash arrives with tachycardia, cool
clammy skin, and narrowed pulse pressure. Which is
the nurse’s immediate priority?
A. Start aggressive IV fluid resuscitation with
isotonic crystalloids and obtain two large-bore IVs.
B. Administer broad-spectrum antibiotics
immediately.
C. Prepare for urgent chest tube placement.
D. Apply warming blanket and bed rest.
Correct answer: A
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1. (Triage / Prioritization — ESI concept)
A 67-year-old male arrives with sudden onset chest
pain, dyspnea, diaphoresis, and hypotension (BP
86/52 mmHg). According to the Emergency Severity
Index (ESI) approach, what triage level is most
appropriate?
A. ESI 1 — immediate life-saving intervention
required
B. ESI 2 — high risk but not immediate life-saving
intervention
C. ESI 3 — multiple resources required but stable
D. ESI 4 — one resource required
Correct answer: A
,Rationale — correct (A): The patient is
hemodynamically unstable (hypotension) with
possible acute coronary syndrome and requires
immediate, life-saving interventions (IV access,
monitoring, rapid resuscitation, possible immediate
ECG/PCI activation). ESI level 1 is for patients who
need immediate life-saving care. EMSC
Improvement Center
Rationales — incorrect:
B — ESI 2 applies to potentially high-risk situations
that are not currently requiring immediate life-
saving interventions (e.g., severe pain but stable
vitals).
C — ESI 3 is for stable patients requiring multiple
resources but not immediate life-saving care.
D — ESI 4 is for patients predicted to need only one
resource.
2. (ABCs / Prioritization — NGN style)
You are assigned to three ED patients. Which should
you see first?
, 1. A 24-year-old with bronchiolitis, RR 28, SpO₂
88% on room air.
2. A 52-year-old with chest pain, RR 20, SpO₂ 96%
on room air.
3. A 70-year-old with cellulitis and temperature
38.5°C, SpO₂ 98%.
A. Patient 1
B. Patient 2
C. Patient 3
D. Assess patients in order of arrival
Correct answer: A
Rationale — correct (A): Prioritize airway and
breathing threats first; SpO₂ of 88% represents
hypoxemia needing immediate assessment
(supplemental O₂, airway support). ABCs
(Airway/Breathing/Circulation) take precedence
over chest pain that currently has stable
oxygenation.
Rationales — incorrect:
B — Chest pain is high priority but the patient’s
, oxygenation is adequate; patient 1 has immediate
hypoxia.
C — Cellulitis is lower acuity compared with
immediate hypoxia.
D — Order of arrival is not used for clinical
prioritization when life-threatening conditions are
present.
3. (Shock recognition / initial management)
A patient with suspected hypovolemic shock after a
motor vehicle crash arrives with tachycardia, cool
clammy skin, and narrowed pulse pressure. Which is
the nurse’s immediate priority?
A. Start aggressive IV fluid resuscitation with
isotonic crystalloids and obtain two large-bore IVs.
B. Administer broad-spectrum antibiotics
immediately.
C. Prepare for urgent chest tube placement.
D. Apply warming blanket and bed rest.
Correct answer: A
