Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1 — Triage prioritization (START/ESI concept)
A triage nurse arrives at a mass-casualty incident. A conscious
adult is breathing 28/min, has a radial pulse, and can follow
commands. According to START principles, what triage category
should the nurse assign?
A. Minor (green)
B. Immediate (red)
C. Delayed (yellow)
D. Expectant (black)
Correct answer: C. Delayed (yellow)
Rationale (stepwise):
• START: assess breathing, respirations >30 → immediate;
here RR 28 (<30).
• Perfusion: radial pulse present → suggests adequate
perfusion.
, • Mental status: follows commands → not unresponsive.
• Patient does not meet Immediate criteria but has injuries
needing attention; this fits Delayed/Yellow.
Why others are wrong: A (Minor) is for walking wounded /
minimal injuries; this patient’s RR 28 and need for
evaluation exceed “minor.” B (Immediate) would require
RR >30, absent pulse, or inability to follow commands. D
(Expectant) is for those unlikely to survive even with care.
2 — ABC prioritization (airway)
A patient arrives after facial trauma and is conscious but hoarse
and drooling. Which action is the highest priority?
A. Obtain IV access and start fluids.
B. Prepare equipment for intubation and call anesthesia/ENT.
C. Apply high-flow oxygen by non-rebreather.
D. Assess skin integrity for burns.
Correct answer: B. Prepare equipment for intubation and call
anesthesia/ENT.
Rationale:
• Airway is top priority (A in ABCs). Hoarseness and drooling
indicate potential airway compromise from
edema/bleeding — airway may rapidly deteriorate.
Immediate preparation for definitive airway and expert
assistance is essential.
, • A (IV fluids) and C (oxygen) are important but come after
securing/predicting airway problems. Oxygen alone
doesn’t protect a threatened airway. D is low priority here.
3 — Maslow & prioritizing care
During triage, which patient should be seen first based on
Maslow’s hierarchy and immediate safety needs?
A. A patient with a laceration requiring sutures (bleeding
controlled).
B. A patient with suicidal ideation and active plan but physically
stable.
C. A patient with severe shortness of breath and oxygen
saturation 82%.
D. A patient requesting pain medication for chronic back pain.
Correct answer: C. Severe shortness of breath and SpO₂ 82%
Rationale:
• Maslow: physiological needs (airway/respiration) take
precedence. SpO₂ 82% indicates life-threatening
hypoxemia and needs immediate intervention.
• B (suicidal ideation) requires urgent psychiatric safety
evaluation but immediate physiological threat is higher for
C. A and D are lower priority.
4 — Shock recognition (hypovolemic vs distributive)
, A patient with suspected hypovolemic shock has cool, pale skin;
tachycardia; hypotension; and decreased urine output. Which
initial nursing intervention is highest priority?
A. Rapid infusion of isotonic crystalloid (e.g., normal saline).
B. Administer broad-spectrum antibiotics.
C. Give high-dose vasopressors immediately.
D. Place patient in Trendelenburg position.
Correct answer: A. Rapid infusion of isotonic crystalloid
(normal saline).
Rationale:
• Hypovolemic shock = decreased intravascular volume →
restore circulating volume with isotonic crystalloids as first-
line emergency treatment.
• B (antibiotics) is for septic/distributive shock, not first for
hypovolemia. C (vasopressors) may be used if fluid
resuscitation fails; vasopressors without volume can
worsen ischemia. D (Trendelenburg) is not recommended
as standard therapy.
5 — Burn injury triage and fluid resuscitation
A 35-year-old with partial- and full-thickness burns to the
anterior chest and both anterior thighs after a house fire is in
triage. Which action is most important initially?
A. Calculate %TBSA and begin Parkland formula fluids.
B. Apply antibacterial ointment and occlusive dressing.
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1 — Triage prioritization (START/ESI concept)
A triage nurse arrives at a mass-casualty incident. A conscious
adult is breathing 28/min, has a radial pulse, and can follow
commands. According to START principles, what triage category
should the nurse assign?
A. Minor (green)
B. Immediate (red)
C. Delayed (yellow)
D. Expectant (black)
Correct answer: C. Delayed (yellow)
Rationale (stepwise):
• START: assess breathing, respirations >30 → immediate;
here RR 28 (<30).
• Perfusion: radial pulse present → suggests adequate
perfusion.
, • Mental status: follows commands → not unresponsive.
• Patient does not meet Immediate criteria but has injuries
needing attention; this fits Delayed/Yellow.
Why others are wrong: A (Minor) is for walking wounded /
minimal injuries; this patient’s RR 28 and need for
evaluation exceed “minor.” B (Immediate) would require
RR >30, absent pulse, or inability to follow commands. D
(Expectant) is for those unlikely to survive even with care.
2 — ABC prioritization (airway)
A patient arrives after facial trauma and is conscious but hoarse
and drooling. Which action is the highest priority?
A. Obtain IV access and start fluids.
B. Prepare equipment for intubation and call anesthesia/ENT.
C. Apply high-flow oxygen by non-rebreather.
D. Assess skin integrity for burns.
Correct answer: B. Prepare equipment for intubation and call
anesthesia/ENT.
Rationale:
• Airway is top priority (A in ABCs). Hoarseness and drooling
indicate potential airway compromise from
edema/bleeding — airway may rapidly deteriorate.
Immediate preparation for definitive airway and expert
assistance is essential.
, • A (IV fluids) and C (oxygen) are important but come after
securing/predicting airway problems. Oxygen alone
doesn’t protect a threatened airway. D is low priority here.
3 — Maslow & prioritizing care
During triage, which patient should be seen first based on
Maslow’s hierarchy and immediate safety needs?
A. A patient with a laceration requiring sutures (bleeding
controlled).
B. A patient with suicidal ideation and active plan but physically
stable.
C. A patient with severe shortness of breath and oxygen
saturation 82%.
D. A patient requesting pain medication for chronic back pain.
Correct answer: C. Severe shortness of breath and SpO₂ 82%
Rationale:
• Maslow: physiological needs (airway/respiration) take
precedence. SpO₂ 82% indicates life-threatening
hypoxemia and needs immediate intervention.
• B (suicidal ideation) requires urgent psychiatric safety
evaluation but immediate physiological threat is higher for
C. A and D are lower priority.
4 — Shock recognition (hypovolemic vs distributive)
, A patient with suspected hypovolemic shock has cool, pale skin;
tachycardia; hypotension; and decreased urine output. Which
initial nursing intervention is highest priority?
A. Rapid infusion of isotonic crystalloid (e.g., normal saline).
B. Administer broad-spectrum antibiotics.
C. Give high-dose vasopressors immediately.
D. Place patient in Trendelenburg position.
Correct answer: A. Rapid infusion of isotonic crystalloid
(normal saline).
Rationale:
• Hypovolemic shock = decreased intravascular volume →
restore circulating volume with isotonic crystalloids as first-
line emergency treatment.
• B (antibiotics) is for septic/distributive shock, not first for
hypovolemia. C (vasopressors) may be used if fluid
resuscitation fails; vasopressors without volume can
worsen ischemia. D (Trendelenburg) is not recommended
as standard therapy.
5 — Burn injury triage and fluid resuscitation
A 35-year-old with partial- and full-thickness burns to the
anterior chest and both anterior thighs after a house fire is in
triage. Which action is most important initially?
A. Calculate %TBSA and begin Parkland formula fluids.
B. Apply antibacterial ointment and occlusive dressing.
