SAUNDERS COMPREHENSIVE REVIEW FOR THE
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1
A 62-year-old man arrives by ambulance after sudden onset of
chest pain; he’s diaphoretic, pale, and begins to vomit. His
respiratory rate is 28/min, pulse 120, BP 86/50 mm Hg. Which
triage category and immediate nursing action are highest
priority?
A. Non-urgent — obtain a 12-lead ECG when triage room
available.
B. Urgent — place on continuous cardiac monitor and notify ED
physician immediately.
C. Emergent — apply high-flow oxygen, establish 2 large-bore
IVs, and activate STEMI protocol.
D. Emergent — give oral aspirin and place on bed rest and
observe for 30 minutes.
,Answer: C
Rationale:
• Correct — The patient shows signs of hemodynamic
instability (hypotension, tachycardia, diaphoresis) and
possible acute coronary syndrome requiring immediate,
lifesaving interventions: airway/oxygenation, IV access,
fluids/medications, and activation of STEMI/acute
coronary team. This is emergent acuity. EMSC
Improvement Center+1
• A — Wrong; non-urgent is inappropriate for unstable,
hypotensive patients.
• B — Monitor and physician notification are necessary but
insufficient as first actions; emergent interventions take
precedence.
• D — Aspirin is indicated (chewed) after initial resuscitation
steps; observation alone is unsafe given shock signs.
2
During triage using the Emergency Severity Index (ESI), which
patient would be assigned ESI level 1?
A. Adult in severe respiratory distress requiring immediate
airway intervention.
B. Patient with ankle pain after twisting, able to ambulate and
wanting radiographs.
,C. Afebrile 4-year-old with sore throat and normal vitals.
D. Adult with simple laceration requiring 2 sutures.
Answer: A
Rationale:
• Correct — ESI level 1 is for patients who require immediate
lifesaving interventions (e.g., airway support). EMSC
Improvement Center
• B — Likely ESI 3 or 4 depending on resource needs.
• C — Likely ESI 4 or 5 (non-urgent).
• D — Procedure requiring limited resources — usually ESI 4.
3
A 9-year-old in a mass-casualty incident (MCI) has respirations
34/min, radial pulse present, obeys commands. Using START
triage, what tag/priority is assigned?
A. Black (expectant)
B. Red (immediate)
C. Yellow (delayed)
D. Green (minor)
Answer: B
Rationale:
• START uses RPM (Respiration, Perfusion, Mental status).
Respirations >30/min → immediate (red) or at least
, immediate assessment/intervention. The child obeys
commands and has a pulse, but RR >30 is a red flag in
START. Thus immediate priority for airway/ventilation.
CERT-LA+1
• A — Expectant reserved for apneic despite repositioning or
unsurvivable injuries.
• C/D — Not appropriate when RR >30.
4
You’re triaging in the ED. Which client should be seen first?
A. 45-year-old with simple migraine, pain 8/10, stable vitals.
B. 70-year-old with acute stroke symptoms, last known well 45
minutes ago, slurred speech and right-sided weakness.
C. 25-year-old with uncomplicated closed mid-shaft tibia
fracture.
D. 30-year-old with sore throat & fever, can swallow liquids.
Answer: B
Rationale:
• Correct — Stroke is time-sensitive (time is brain);
immediate prioritized evaluation for thrombolysis/CTA.
This is emergent. NCSBN
• A/C/D — Urgent or non-urgent compared to acute stroke.
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1
A 62-year-old man arrives by ambulance after sudden onset of
chest pain; he’s diaphoretic, pale, and begins to vomit. His
respiratory rate is 28/min, pulse 120, BP 86/50 mm Hg. Which
triage category and immediate nursing action are highest
priority?
A. Non-urgent — obtain a 12-lead ECG when triage room
available.
B. Urgent — place on continuous cardiac monitor and notify ED
physician immediately.
C. Emergent — apply high-flow oxygen, establish 2 large-bore
IVs, and activate STEMI protocol.
D. Emergent — give oral aspirin and place on bed rest and
observe for 30 minutes.
,Answer: C
Rationale:
• Correct — The patient shows signs of hemodynamic
instability (hypotension, tachycardia, diaphoresis) and
possible acute coronary syndrome requiring immediate,
lifesaving interventions: airway/oxygenation, IV access,
fluids/medications, and activation of STEMI/acute
coronary team. This is emergent acuity. EMSC
Improvement Center+1
• A — Wrong; non-urgent is inappropriate for unstable,
hypotensive patients.
• B — Monitor and physician notification are necessary but
insufficient as first actions; emergent interventions take
precedence.
• D — Aspirin is indicated (chewed) after initial resuscitation
steps; observation alone is unsafe given shock signs.
2
During triage using the Emergency Severity Index (ESI), which
patient would be assigned ESI level 1?
A. Adult in severe respiratory distress requiring immediate
airway intervention.
B. Patient with ankle pain after twisting, able to ambulate and
wanting radiographs.
,C. Afebrile 4-year-old with sore throat and normal vitals.
D. Adult with simple laceration requiring 2 sutures.
Answer: A
Rationale:
• Correct — ESI level 1 is for patients who require immediate
lifesaving interventions (e.g., airway support). EMSC
Improvement Center
• B — Likely ESI 3 or 4 depending on resource needs.
• C — Likely ESI 4 or 5 (non-urgent).
• D — Procedure requiring limited resources — usually ESI 4.
3
A 9-year-old in a mass-casualty incident (MCI) has respirations
34/min, radial pulse present, obeys commands. Using START
triage, what tag/priority is assigned?
A. Black (expectant)
B. Red (immediate)
C. Yellow (delayed)
D. Green (minor)
Answer: B
Rationale:
• START uses RPM (Respiration, Perfusion, Mental status).
Respirations >30/min → immediate (red) or at least
, immediate assessment/intervention. The child obeys
commands and has a pulse, but RR >30 is a red flag in
START. Thus immediate priority for airway/ventilation.
CERT-LA+1
• A — Expectant reserved for apneic despite repositioning or
unsurvivable injuries.
• C/D — Not appropriate when RR >30.
4
You’re triaging in the ED. Which client should be seen first?
A. 45-year-old with simple migraine, pain 8/10, stable vitals.
B. 70-year-old with acute stroke symptoms, last known well 45
minutes ago, slurred speech and right-sided weakness.
C. 25-year-old with uncomplicated closed mid-shaft tibia
fracture.
D. 30-year-old with sore throat & fever, can swallow liquids.
Answer: B
Rationale:
• Correct — Stroke is time-sensitive (time is brain);
immediate prioritized evaluation for thrombolysis/CTA.
This is emergent. NCSBN
• A/C/D — Urgent or non-urgent compared to acute stroke.
