Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Basic triage prioritization (single best answer)
A 46-year-old man arrives at the ED after a motor
vehicle collision. He is talking, has a respiratory rate
of 10/min, oxygen saturation 92% on room air, a
systolic BP of 84 mm Hg, and a bleeding laceration
to the left thigh that is controlled with pressure.
Using ABC prioritization, what should the nurse
address first?
A. Apply high-flow oxygen via nonrebreather mask.
B. Start two large-bore IVs and begin fluid
resuscitation.
C. Obtain an immediate portable chest x-ray.
D. Reassure the patient and complete primary
survey documentation.
,Correct answer: B. Start two large-bore IVs and
begin fluid resuscitation.
Rationale (stepwise):
1. Apply ABCs: Airway is patent (talking). Breathing
is present though SpO₂ 92%—not immediately
life-threatening. Circulation shows hypotension
(SBP 84 mm Hg), representing immediate threat
to perfusion → address circulation first.
2. Rapid vascular access and fluid resuscitation (or
blood if indicated) is the priority to restore
perfusion and prevent shock. This follows
emergency nursing/surgical trauma priorities
(resuscitate circulation after ensuring airway).
cpr.heart.org+1
Why other options are incorrect:
A. Oxygen is reasonable, but circulation
(hypotension) is immediately life-threatening and
takes precedence over oxygen at this moment.
C. Chest x-ray is diagnostic and delays resuscitation
— not prioritized over restoring circulation in
hypotension.
,D. Reassurance/documentation are low priority
when the patient is hypotensive.
2 — Triage color/category (single best answer)
During a mass casualty incident implementing
START triage, a victim is found breathing
spontaneously only after repositioning the airway,
has absent radial pulses, and cannot follow
commands. Using START, which triage category is
appropriate?
A. Immediate (Red)
B. Delayed (Yellow)
C. Minor (Green)
D. Expectant/Deceased (Black)
Correct answer: A. Immediate (Red).
Rationale (stepwise):
1. START uses simple assessments: breathing,
respirations, perfusion (radial pulse/cap refill),
and mental status.
, 2. This victim breathes after airway repositioning
(so not dead), has no radial pulse (poor
perfusion), and cannot follow commands
(altered mental status) — these indicate a high-
priority, salvageable patient who needs
immediate intervention → Red.
remm.hhs.gov+1
Why other options are incorrect:
B. Delayed (Yellow) are those who are stable for a
few hours — not applicable with absent perfusion.
C. Minor (Green) are walking wounded; clearly not
this case.
D. Expectant/Black is for those without respirations
after repositioning or injuries incompatible with life
— not applicable here.
3 — Anaphylaxis immediate action (case-based)
A 28-year-old with known peanut allergy presents
with sudden facial swelling, audible wheeze, stridor,
hypotension (BP 78/40), and urticaria after eating.
Which is the nurse’s highest priority action?
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Basic triage prioritization (single best answer)
A 46-year-old man arrives at the ED after a motor
vehicle collision. He is talking, has a respiratory rate
of 10/min, oxygen saturation 92% on room air, a
systolic BP of 84 mm Hg, and a bleeding laceration
to the left thigh that is controlled with pressure.
Using ABC prioritization, what should the nurse
address first?
A. Apply high-flow oxygen via nonrebreather mask.
B. Start two large-bore IVs and begin fluid
resuscitation.
C. Obtain an immediate portable chest x-ray.
D. Reassure the patient and complete primary
survey documentation.
,Correct answer: B. Start two large-bore IVs and
begin fluid resuscitation.
Rationale (stepwise):
1. Apply ABCs: Airway is patent (talking). Breathing
is present though SpO₂ 92%—not immediately
life-threatening. Circulation shows hypotension
(SBP 84 mm Hg), representing immediate threat
to perfusion → address circulation first.
2. Rapid vascular access and fluid resuscitation (or
blood if indicated) is the priority to restore
perfusion and prevent shock. This follows
emergency nursing/surgical trauma priorities
(resuscitate circulation after ensuring airway).
cpr.heart.org+1
Why other options are incorrect:
A. Oxygen is reasonable, but circulation
(hypotension) is immediately life-threatening and
takes precedence over oxygen at this moment.
C. Chest x-ray is diagnostic and delays resuscitation
— not prioritized over restoring circulation in
hypotension.
,D. Reassurance/documentation are low priority
when the patient is hypotensive.
2 — Triage color/category (single best answer)
During a mass casualty incident implementing
START triage, a victim is found breathing
spontaneously only after repositioning the airway,
has absent radial pulses, and cannot follow
commands. Using START, which triage category is
appropriate?
A. Immediate (Red)
B. Delayed (Yellow)
C. Minor (Green)
D. Expectant/Deceased (Black)
Correct answer: A. Immediate (Red).
Rationale (stepwise):
1. START uses simple assessments: breathing,
respirations, perfusion (radial pulse/cap refill),
and mental status.
, 2. This victim breathes after airway repositioning
(so not dead), has no radial pulse (poor
perfusion), and cannot follow commands
(altered mental status) — these indicate a high-
priority, salvageable patient who needs
immediate intervention → Red.
remm.hhs.gov+1
Why other options are incorrect:
B. Delayed (Yellow) are those who are stable for a
few hours — not applicable with absent perfusion.
C. Minor (Green) are walking wounded; clearly not
this case.
D. Expectant/Black is for those without respirations
after repositioning or injuries incompatible with life
— not applicable here.
3 — Anaphylaxis immediate action (case-based)
A 28-year-old with known peanut allergy presents
with sudden facial swelling, audible wheeze, stridor,
hypotension (BP 78/40), and urticaria after eating.
Which is the nurse’s highest priority action?
