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.
Question 1 — (Triage: categorical acuity)
A 56-year-old male arrives to triage with sudden, severe,
tearing chest pain radiating to his back, BP 180/110 mmHg,
respiratory rate 24/min, alert and oriented. According to
common ED 5-level triage frameworks (e.g., ESI), what triage
level is most appropriate?
A. Non-urgent (ESI 5)
B. Urgent (ESI 3)
C. Emergent — immediate attention (ESI 1)
D. Semi-urgent (ESI 4)
E. Fast-track (ESI 5 alternate)
Correct answer: C
,Rationale: Tearing chest pain with markedly elevated blood
pressure suggests possible aortic dissection — a life-threatening
condition requiring immediate, physician-level intervention. In a
five-level triage system like ESI, patients who need immediate
life-saving interventions or cannot wait are level 1 (emergent).
ESI levels 4–5 are for minor or single-resource needs; level 3 is
for patients who are stable but require multiple resources —
not appropriate for suspected dissection. (Client need:
Physiological Integrity — Reduction of Risk Potential.) EMSC
Improvement Center+1
Why other options are wrong:
A/D/E — ESI 5/fast-track and ESI 4 are for nonurgent/minor
issues and would delay essential care. B — ESI 3 underestimates
the acuity because immediate intervention may be required.
Question 2 — (Mass casualty triage: START)
At the scene of a multi-vehicle crash (mass casualty), the first
responder instructs all ambulatory victims to move to a
designated area. A 25-year-old who can walk but has an open
femur fracture is identified later. Under START triage, how
would this victim be categorized?
A. Immediate (Red)
B. Delayed (Yellow)
C. Minor (Green)
,D. Expectant (Black)
E. Not classifiable until assessed in hospital
Correct answer: C
Rationale: START (Simple Triage and Rapid Treatment) initially
uses ability to walk as the first discriminator: ambulatory
patients triage as minor/green even if they have serious injuries
that can be managed later. A walking patient with an open
femur fracture would be tagged green (minor) and moved to
the ambulatory collection area; later reassessment can escalate
priority if deterioration occurs. START is designed for speed and
initial sorting at the scene. (Disaster/mass casualty domain.)
CHEMM+1
Why others are wrong:
A — Red/immediate reserved for compromised airway,
respiratory distress, uncontrolled hemorrhage, or severely
compromised perfusion. B — Yellow/delayed is for
nonambulatory but stable patients needing care. D — Expectant
reserved for those unlikely to survive given resources. E —
START specifically classifies walking victims as minor during
initial triage.
Question 3 — (ESI level determination)
A 45-year-old female presents with fever 103°F, generalized
weakness, and a history of neutropenia from chemotherapy.
She is ambulatory but appears ill. Using ESI logic (acuity +
, anticipated resource needs), which triage level is most
appropriate?
A. ESI 5
B. ESI 4
C. ESI 3
D. ESI 2
E. ESI 1
Correct answer: D
Rationale: Despite being ambulatory, this patient has a high-
risk history (neutropenia) and a fever potentially indicating
sepsis. ESI identifies patients with dangerous vital sign
abnormalities or high risk as needing rapid attention; many
triage systems place such patients at ESI 2 (emergent) because
they may deteriorate rapidly and require timely physician
assessment. ESI 3 is for stable patients requiring multiple
resources but not at immediate risk. EMSC Improvement
Center+1
Why others are wrong:
A/B — ESI 5/4 undertriage high-risk febrile neutropenia. E — ESI
1 reserved for immediate life-saving interventions (e.g.,
cardiopulmonary arrest).
Question 4 — (Triage prioritization — NGN-style clinical
judgment)
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
Question 1 — (Triage: categorical acuity)
A 56-year-old male arrives to triage with sudden, severe,
tearing chest pain radiating to his back, BP 180/110 mmHg,
respiratory rate 24/min, alert and oriented. According to
common ED 5-level triage frameworks (e.g., ESI), what triage
level is most appropriate?
A. Non-urgent (ESI 5)
B. Urgent (ESI 3)
C. Emergent — immediate attention (ESI 1)
D. Semi-urgent (ESI 4)
E. Fast-track (ESI 5 alternate)
Correct answer: C
,Rationale: Tearing chest pain with markedly elevated blood
pressure suggests possible aortic dissection — a life-threatening
condition requiring immediate, physician-level intervention. In a
five-level triage system like ESI, patients who need immediate
life-saving interventions or cannot wait are level 1 (emergent).
ESI levels 4–5 are for minor or single-resource needs; level 3 is
for patients who are stable but require multiple resources —
not appropriate for suspected dissection. (Client need:
Physiological Integrity — Reduction of Risk Potential.) EMSC
Improvement Center+1
Why other options are wrong:
A/D/E — ESI 5/fast-track and ESI 4 are for nonurgent/minor
issues and would delay essential care. B — ESI 3 underestimates
the acuity because immediate intervention may be required.
Question 2 — (Mass casualty triage: START)
At the scene of a multi-vehicle crash (mass casualty), the first
responder instructs all ambulatory victims to move to a
designated area. A 25-year-old who can walk but has an open
femur fracture is identified later. Under START triage, how
would this victim be categorized?
A. Immediate (Red)
B. Delayed (Yellow)
C. Minor (Green)
,D. Expectant (Black)
E. Not classifiable until assessed in hospital
Correct answer: C
Rationale: START (Simple Triage and Rapid Treatment) initially
uses ability to walk as the first discriminator: ambulatory
patients triage as minor/green even if they have serious injuries
that can be managed later. A walking patient with an open
femur fracture would be tagged green (minor) and moved to
the ambulatory collection area; later reassessment can escalate
priority if deterioration occurs. START is designed for speed and
initial sorting at the scene. (Disaster/mass casualty domain.)
CHEMM+1
Why others are wrong:
A — Red/immediate reserved for compromised airway,
respiratory distress, uncontrolled hemorrhage, or severely
compromised perfusion. B — Yellow/delayed is for
nonambulatory but stable patients needing care. D — Expectant
reserved for those unlikely to survive given resources. E —
START specifically classifies walking victims as minor during
initial triage.
Question 3 — (ESI level determination)
A 45-year-old female presents with fever 103°F, generalized
weakness, and a history of neutropenia from chemotherapy.
She is ambulatory but appears ill. Using ESI logic (acuity +
, anticipated resource needs), which triage level is most
appropriate?
A. ESI 5
B. ESI 4
C. ESI 3
D. ESI 2
E. ESI 1
Correct answer: D
Rationale: Despite being ambulatory, this patient has a high-
risk history (neutropenia) and a fever potentially indicating
sepsis. ESI identifies patients with dangerous vital sign
abnormalities or high risk as needing rapid attention; many
triage systems place such patients at ESI 2 (emergent) because
they may deteriorate rapidly and require timely physician
assessment. ESI 3 is for stable patients requiring multiple
resources but not at immediate risk. EMSC Improvement
Center+1
Why others are wrong:
A/B — ESI 5/4 undertriage high-risk febrile neutropenia. E — ESI
1 reserved for immediate life-saving interventions (e.g.,
cardiopulmonary arrest).
Question 4 — (Triage prioritization — NGN-style clinical
judgment)
