Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1. (Prioritization — ABCs)
A 54-year-old man arrives to the ED after a motor
vehicle crash. He is conscious but speaking in short
sentences, has bruising across his chest, and a
respiratory rate of 34/min with use of accessory
muscles. Which action should the nurse perform
first?
A. Apply high-flow oxygen via nonrebreather mask.
B. Obtain a portable chest x-ray.
C. Start two large-bore IVs and begin fluid
resuscitation.
D. Perform a focused neurologic assessment.
E. Obtain baseline blood work and type and cross.
Correct answer: A
,Rationale (stepwise):
1. Airway and breathing have highest immediate
priority—patient is tachypneic with increased
work of breathing; delivering high-flow oxygen
addresses hypoxia and reduces immediate risk.
(ABC principle).
2. Chest x-ray (B) and IV access (C) are important
but come after stabilizing oxygenation.
3. Focused neuro (D) and labs (E) can be done
after immediate stabilization.
Why other options are incorrect: B delays
oxygenation; C is important for shock risk but
not the first step if patient is hypoxic; D and E
are lower priority in a potentially compromised
airway/breathing situation.
2. (Triage categories — mass-casualty vignette)
During a mass-casualty incident, the triage nurse
applies START triage to a walking, alert adult who
has an open femur fracture but is able to follow
,commands and has a radial pulse. Into which triage
category should the nurse place this patient?
A. Immediate (Red)
B. Delayed (Yellow)
C. Minor (Green)
D. Expectant (Black)
E. Deceased
Correct answer: B
Rationale:
1. START triage identifies immediate life-
threatening conditions (absent breathing,
uncontrolled hemorrhage, inability to follow
commands) for Red. This patient is walking but
has a serious limb injury without imminent
airway or perfusion compromise—Delayed
(Yellow) is appropriate. REMM
2. Minor (Green) is for minor injuries;
expectant/black is for those unlikely to survive
even with resources. Deceased is reserved for
no signs of life.
, 3. (Maslow’s hierarchy + prioritization)
A 68-year-old postoperative abdominal surgery
patient in the ED reports severe shortness of breath
and is pale with a SpO₂ of 85% on room air. Which
nursing action reflects correct use of Maslow’s
hierarchy and clinical priority?
A. Sit with the patient to provide emotional support.
B. Administer prescribed PRN opioid for pain.
C. Raise the head of the bed and apply
supplemental oxygen.
D. Call the hospital chaplain for spiritual support.
E. Offer warm blankets for comfort.
Correct answer: C
Rationale:
1. Maslow and clinical triage require physiological
needs first—airway/oxygenation must be
addressed before psychosocial interventions.
Raising the head of bed and applying oxygen
addresses physiologic threat.
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1. (Prioritization — ABCs)
A 54-year-old man arrives to the ED after a motor
vehicle crash. He is conscious but speaking in short
sentences, has bruising across his chest, and a
respiratory rate of 34/min with use of accessory
muscles. Which action should the nurse perform
first?
A. Apply high-flow oxygen via nonrebreather mask.
B. Obtain a portable chest x-ray.
C. Start two large-bore IVs and begin fluid
resuscitation.
D. Perform a focused neurologic assessment.
E. Obtain baseline blood work and type and cross.
Correct answer: A
,Rationale (stepwise):
1. Airway and breathing have highest immediate
priority—patient is tachypneic with increased
work of breathing; delivering high-flow oxygen
addresses hypoxia and reduces immediate risk.
(ABC principle).
2. Chest x-ray (B) and IV access (C) are important
but come after stabilizing oxygenation.
3. Focused neuro (D) and labs (E) can be done
after immediate stabilization.
Why other options are incorrect: B delays
oxygenation; C is important for shock risk but
not the first step if patient is hypoxic; D and E
are lower priority in a potentially compromised
airway/breathing situation.
2. (Triage categories — mass-casualty vignette)
During a mass-casualty incident, the triage nurse
applies START triage to a walking, alert adult who
has an open femur fracture but is able to follow
,commands and has a radial pulse. Into which triage
category should the nurse place this patient?
A. Immediate (Red)
B. Delayed (Yellow)
C. Minor (Green)
D. Expectant (Black)
E. Deceased
Correct answer: B
Rationale:
1. START triage identifies immediate life-
threatening conditions (absent breathing,
uncontrolled hemorrhage, inability to follow
commands) for Red. This patient is walking but
has a serious limb injury without imminent
airway or perfusion compromise—Delayed
(Yellow) is appropriate. REMM
2. Minor (Green) is for minor injuries;
expectant/black is for those unlikely to survive
even with resources. Deceased is reserved for
no signs of life.
, 3. (Maslow’s hierarchy + prioritization)
A 68-year-old postoperative abdominal surgery
patient in the ED reports severe shortness of breath
and is pale with a SpO₂ of 85% on room air. Which
nursing action reflects correct use of Maslow’s
hierarchy and clinical priority?
A. Sit with the patient to provide emotional support.
B. Administer prescribed PRN opioid for pain.
C. Raise the head of the bed and apply
supplemental oxygen.
D. Call the hospital chaplain for spiritual support.
E. Offer warm blankets for comfort.
Correct answer: C
Rationale:
1. Maslow and clinical triage require physiological
needs first—airway/oxygenation must be
addressed before psychosocial interventions.
Raising the head of bed and applying oxygen
addresses physiologic threat.
