Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Question 1 — Triage Priority (single best answer)
A 56-year-old man arrives to triage after a high-speed motor
vehicle collision. He is conscious but agitated, has a respiratory
rate of 10 breaths/min, shallow respirations, and diminished
breath sounds on the left. Which action should the emergency
nurse perform first?
A. Apply high-flow oxygen via nonrebreather and obtain a chest
x-ray.
B. Perform a rapid primary survey and prepare for immediate
needle decompression if indicated.
C. Start two large-bore IVs and obtain blood for type and
crossmatch.
D. Administer intravenous morphine for pain control and
anxiolysis.
Correct answer: B
Rationale (stepwise):
, 1. Immediate priorities in trauma follow the primary survey
(Airway, Breathing, Circulation—ABCs) to identify life-
threatening issues quickly; diminished breath sounds with
shallow respirations raise concern for a tension or massive
hemothorax requiring urgent decompression. ACS+1
2. Applying high-flow oxygen (A) is appropriate but secondary
to rapidly assessing and treating a potentially life-
threatening breathing problem (needle decompression).
Chest x-ray should not delay immediate intervention.
3. Establishing IV access and labs (C) is important but comes
after securing airway/breathing in the primary survey.
4. IV morphine (D) is inappropriate as initial priority because
it can depress respiratory drive and mask deterioration;
analgesia follows stabilization.
Why B is best: It aligns with ATLS/primary survey
principles—rapid assessment and immediate intervention
for life-threatening chest injuries. ACS
Question 2 — Prioritization (Maslow/ABCs)
An older adult with advanced COPD is admitted to the ED with
shortness of breath and confusion. Which nursing goal takes
highest priority based on Maslow and ABCs?
A. Promote social interaction to reduce anxiety.
B. Maintain effective airway and oxygenation.
,C. Administer scheduled bronchodilator doses.
D. Provide information about discharge planning.
Correct answer: B
Rationale:
• Maslow’s hierarchy and ABCs prioritize physiological needs
(airway and breathing) above psychosocial or long-term
planning. Ensuring airway and oxygenation prevents
imminent harm and is therefore the highest priority.
• Options A, C, and D are important but secondary:
bronchodilators (C) are part of management, but the
overarching goal is to maintain effective oxygenation (B).
Support: Primary physiologic priorities are foundational in
emergency care/triage. NCBI
Question 3 — START Triage (mass casualty)
During a mass-casualty incident, the triage nurse uses START.
Which patient is tagged Immediate (Red)?
A. Able to walk, complaining of leg pain only.
B. Respiratory rate 30/min, absent radial pulse, unable to follow
commands.
C. Respiratory rate 10/min, controlled hemorrhage, alert.
D. Not breathing unless airway repositioned; starts breathing
after head tilt.
Correct answer: B
, Rationale:
• START identifies immediate (red) tags for patients with life-
threatening conditions who need rapid intervention (e.g.,
RR > 30, absent radial pulse, inability to follow commands).
CHEMM+1
• A (walking wounded) = Minor (Green). C has stable RR and
alertness—may be Delayed (Yellow). D who begins to
breathe after repositioning but with other stable signs
often becomes Immediate depending on perfusion/mental
status; however, B demonstrates multiple criteria for
Immediate.
Why B is best: Multiple START triggers (high RR, poor
perfusion, altered mental status) indicate high mortality
risk without rapid care. CHEMM
Question 4 — Shock Recognition
A client in the ED has cool, clammy skin; weak, thready pulse;
hypotension; and delayed capillary refill after a perforated
diverticulum with intra-abdominal bleeding. Which type of
shock is most likely?
A. Cardiogenic shock
B. Hypovolemic shock
C. Distributive (septic) shock
D. Obstructive shock
Correct answer: B
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Question 1 — Triage Priority (single best answer)
A 56-year-old man arrives to triage after a high-speed motor
vehicle collision. He is conscious but agitated, has a respiratory
rate of 10 breaths/min, shallow respirations, and diminished
breath sounds on the left. Which action should the emergency
nurse perform first?
A. Apply high-flow oxygen via nonrebreather and obtain a chest
x-ray.
B. Perform a rapid primary survey and prepare for immediate
needle decompression if indicated.
C. Start two large-bore IVs and obtain blood for type and
crossmatch.
D. Administer intravenous morphine for pain control and
anxiolysis.
Correct answer: B
Rationale (stepwise):
, 1. Immediate priorities in trauma follow the primary survey
(Airway, Breathing, Circulation—ABCs) to identify life-
threatening issues quickly; diminished breath sounds with
shallow respirations raise concern for a tension or massive
hemothorax requiring urgent decompression. ACS+1
2. Applying high-flow oxygen (A) is appropriate but secondary
to rapidly assessing and treating a potentially life-
threatening breathing problem (needle decompression).
Chest x-ray should not delay immediate intervention.
3. Establishing IV access and labs (C) is important but comes
after securing airway/breathing in the primary survey.
4. IV morphine (D) is inappropriate as initial priority because
it can depress respiratory drive and mask deterioration;
analgesia follows stabilization.
Why B is best: It aligns with ATLS/primary survey
principles—rapid assessment and immediate intervention
for life-threatening chest injuries. ACS
Question 2 — Prioritization (Maslow/ABCs)
An older adult with advanced COPD is admitted to the ED with
shortness of breath and confusion. Which nursing goal takes
highest priority based on Maslow and ABCs?
A. Promote social interaction to reduce anxiety.
B. Maintain effective airway and oxygenation.
,C. Administer scheduled bronchodilator doses.
D. Provide information about discharge planning.
Correct answer: B
Rationale:
• Maslow’s hierarchy and ABCs prioritize physiological needs
(airway and breathing) above psychosocial or long-term
planning. Ensuring airway and oxygenation prevents
imminent harm and is therefore the highest priority.
• Options A, C, and D are important but secondary:
bronchodilators (C) are part of management, but the
overarching goal is to maintain effective oxygenation (B).
Support: Primary physiologic priorities are foundational in
emergency care/triage. NCBI
Question 3 — START Triage (mass casualty)
During a mass-casualty incident, the triage nurse uses START.
Which patient is tagged Immediate (Red)?
A. Able to walk, complaining of leg pain only.
B. Respiratory rate 30/min, absent radial pulse, unable to follow
commands.
C. Respiratory rate 10/min, controlled hemorrhage, alert.
D. Not breathing unless airway repositioned; starts breathing
after head tilt.
Correct answer: B
, Rationale:
• START identifies immediate (red) tags for patients with life-
threatening conditions who need rapid intervention (e.g.,
RR > 30, absent radial pulse, inability to follow commands).
CHEMM+1
• A (walking wounded) = Minor (Green). C has stable RR and
alertness—may be Delayed (Yellow). D who begins to
breathe after repositioning but with other stable signs
often becomes Immediate depending on perfusion/mental
status; however, B demonstrates multiple criteria for
Immediate.
Why B is best: Multiple START triggers (high RR, poor
perfusion, altered mental status) indicate high mortality
risk without rapid care. CHEMM
Question 4 — Shock Recognition
A client in the ED has cool, clammy skin; weak, thready pulse;
hypotension; and delayed capillary refill after a perforated
diverticulum with intra-abdominal bleeding. Which type of
shock is most likely?
A. Cardiogenic shock
B. Hypovolemic shock
C. Distributive (septic) shock
D. Obstructive shock
Correct answer: B
