Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1. A 45-year-old man arrives to the ED after a motor
vehicle crash. He is somnolent, breathing at 10
breaths/min, and has shallow chest rise. His pulse is
110 bpm and blood pressure is 98/64 mm Hg.
Which action should the nurse perform first?
A. Insert two large-bore IVs and begin fluid
resuscitation.
B. Apply a cervical spine immobilization collar and
stabilize the head.
C. Prepare for immediate endotracheal intubation.
D. Obtain portable chest x-ray.
Correct answer: C
Stepwise rationale (prioritization & ABCs):
,1. Recognize cues: Somnolence, respiratory rate
10, shallow respirations → potential
compromised airway/ventilation and decreased
level of consciousness.
2. Analyze/Prioritize: Airway with cervical spine
protection is first (A of ABCs). Because the
patient has decreased consciousness and
inadequate ventilation, securing the airway
(intubation) is the highest priority.
3. Why others are incorrect:
• A (IVs/fluids): Important for circulation but
secondary to securing airway/oxygenation when
ventilatory compromise exists.
• B (collar): Cervical spine immobilization should
be done concurrently with airway management
(manual in-line stabilization during intubation),
but immobilization alone does not correct
hypoventilation.
• D (CXR): Diagnostic testing is lower priority until
airway/ventilation and circulation are stabilized.
,2. During triage in a busy ED, which patient should
be assigned “immediate (red)” triage priority?
A. A 7-year-old with a fever of 39.2°C and moderate
dehydration.
B. A 58-year-old with crushing chest pain,
diaphoresis, and hypotension.
C. A 23-year-old with a small laceration to the
forearm with active but controllable bleeding.
D. A 34-year-old with an ankle sprain who can
ambulate.
Correct answer: B
Stepwise rationale (triage categories):
1. Recognize cues: Crushing chest pain +
diaphoresis + hypotension → signs of possible
acute myocardial ischemia and hemodynamic
instability.
2. Analyze: Immediate (red) is for life- or limb-
threatening conditions requiring rapid
intervention.
, 3. Why others are incorrect:
• A: Moderate dehydration is urgent but not
immediate if airway/breathing/circulation
stable.
• C: Controllable bleeding and minor laceration →
delayed/urgent but not immediate.
• D: Nonurgent (green/minor).
3. A patient in the ED develops sudden generalized
urticaria, facial swelling, and difficulty breathing
after receiving IV penicillin. The nurse’s first action
should be:
A. Stop the IV infusion and remove the medication.
B. Administer high-flow oxygen and call for
epinephrine per protocol.
C. Begin a rapid infusion of normal saline.
D. Give intravenous diphenhydramine.
Correct answer: B
Stepwise rationale (anaphylaxis management):
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1. A 45-year-old man arrives to the ED after a motor
vehicle crash. He is somnolent, breathing at 10
breaths/min, and has shallow chest rise. His pulse is
110 bpm and blood pressure is 98/64 mm Hg.
Which action should the nurse perform first?
A. Insert two large-bore IVs and begin fluid
resuscitation.
B. Apply a cervical spine immobilization collar and
stabilize the head.
C. Prepare for immediate endotracheal intubation.
D. Obtain portable chest x-ray.
Correct answer: C
Stepwise rationale (prioritization & ABCs):
,1. Recognize cues: Somnolence, respiratory rate
10, shallow respirations → potential
compromised airway/ventilation and decreased
level of consciousness.
2. Analyze/Prioritize: Airway with cervical spine
protection is first (A of ABCs). Because the
patient has decreased consciousness and
inadequate ventilation, securing the airway
(intubation) is the highest priority.
3. Why others are incorrect:
• A (IVs/fluids): Important for circulation but
secondary to securing airway/oxygenation when
ventilatory compromise exists.
• B (collar): Cervical spine immobilization should
be done concurrently with airway management
(manual in-line stabilization during intubation),
but immobilization alone does not correct
hypoventilation.
• D (CXR): Diagnostic testing is lower priority until
airway/ventilation and circulation are stabilized.
,2. During triage in a busy ED, which patient should
be assigned “immediate (red)” triage priority?
A. A 7-year-old with a fever of 39.2°C and moderate
dehydration.
B. A 58-year-old with crushing chest pain,
diaphoresis, and hypotension.
C. A 23-year-old with a small laceration to the
forearm with active but controllable bleeding.
D. A 34-year-old with an ankle sprain who can
ambulate.
Correct answer: B
Stepwise rationale (triage categories):
1. Recognize cues: Crushing chest pain +
diaphoresis + hypotension → signs of possible
acute myocardial ischemia and hemodynamic
instability.
2. Analyze: Immediate (red) is for life- or limb-
threatening conditions requiring rapid
intervention.
, 3. Why others are incorrect:
• A: Moderate dehydration is urgent but not
immediate if airway/breathing/circulation
stable.
• C: Controllable bleeding and minor laceration →
delayed/urgent but not immediate.
• D: Nonurgent (green/minor).
3. A patient in the ED develops sudden generalized
urticaria, facial swelling, and difficulty breathing
after receiving IV penicillin. The nurse’s first action
should be:
A. Stop the IV infusion and remove the medication.
B. Administer high-flow oxygen and call for
epinephrine per protocol.
C. Begin a rapid infusion of normal saline.
D. Give intravenous diphenhydramine.
Correct answer: B
Stepwise rationale (anaphylaxis management):
