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.
Questions
1
A 46-year-old male arrives by ambulance after a motor-vehicle
collision. He is conscious but pale, complains of chest pain and
shortness of breath, respirations 28/min and shallow, heart rate
128 bpm, BP 86/54 mm Hg, O2 sat 88% on room air. According
to emergency triage classification (ESI/triage principles), which
category should the triage nurse assign and why?
A. Non-urgent — patient is stable enough for delayed care.
B. Urgent — needs assessment within 30–60 minutes.
C. Emergent (immediate) — needs immediate life-saving
intervention and rapid placement.
D. Fast-track — can be treated in a low-acuity area.
,Answer: C — Emergent (immediate).
Rationale: The patient shows hypotension (BP 86/54),
tachycardia, hypoxia, and signs consistent with potential
thoracic injury/hemorrhage — unstable physiology requiring
immediate assessment and life-saving interventions
(airway/oxygenation, hemorrhage control, rapid transport to
trauma bay). ESI/triage frameworks prioritize patients with
unstable vital signs and high risk of deterioration as
immediate/emergent. Non-urgent or fast-track are
inappropriate given hemodynamic instability; “urgent” is for
risk but not immediate life-threatening compromise. California
Emergency Nurses Association+1
2
During a mass casualty incident (MCI), an EMT brings in a
patient who is breathing at 36/min, is not obeying commands,
and has weak radial pulses. Using START triage, what color tag
should be assigned initially?
A. Green (minor)
B. Yellow (delayed)
C. Red (immediate)
D. Black (deceased/expectant)
Answer: C — Red (immediate).
Rationale: START triage focuses on respiration, perfusion, and
mental status. Respirations >30, altered mental status (not
,following commands), and weak pulses indicate high acuity.
These patients require immediate life-saving interventions and
rapid transport. Green/yellow are for ambulating/minor or
stable delayed patients; black is for dead/expectant when no
respirations after airway repositioning or not salvageable in
resource-scarce situations. CHEMM+1
3
A patient exposed to an unknown chemical arrives with burning
eyes, drooling, bronchospasm, and twitching muscles. The
nurse’s first action at triage is to:
A. Place the patient in the main ED waiting room and contact
poison control.
B. Remove contaminated clothing and begin gross
decontamination, then move to a decontamination corridor.
C. Start IV fluids and administer broad-spectrum antibiotics.
D. Perform a detailed history before any interventions.
Answer: B — Remove contaminated clothing and begin gross
decontamination, then move to a decontamination corridor.
Rationale: Suspected chemical exposure with cholinergic signs
(salivation, bronchospasm, muscle twitching) requires
immediate removal of clothing and gross decontamination to
prevent ongoing dermal/secondary contamination of
staff/patients. Rapid decontamination and appropriate PPE are
critical before detailed history or routine ED placement.
, Immediate supportive care (airway/breathing) is simultaneous,
but environmental control comes first to protect staff and other
patients. Refer to CHEMM and CDC chemical emergency
guidance. Options A and D risk cross-contamination and delay
life-safety measures; C is incorrect (antibiotics not first step for
chemical exposures). CHEMM+1
4
A 68-year-old with sudden collapse is found pulseless and
apneic in the ED. The team begins CPR. According to AHA 2025
guidance, what is the most important immediate action for the
team leader once high-quality chest compressions are in
progress?
A. Continue uninterrupted compressions and delay rhythm
analysis indefinitely.
B. Pause compressions every 15 seconds to check for
spontaneous pulse.
C. Coordinate timely defibrillation when a shockable rhythm is
identified and minimize pauses.
D. Intubate immediately before any defibrillation attempt.
Answer: C — Coordinate timely defibrillation when a shockable
rhythm is identified and minimize pauses.
Rationale: AHA guidance emphasizes high-quality chest
compressions with minimal interruptions and rapid
defibrillation for shockable rhythms (VF/pulseless VT). The team
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
Questions
1
A 46-year-old male arrives by ambulance after a motor-vehicle
collision. He is conscious but pale, complains of chest pain and
shortness of breath, respirations 28/min and shallow, heart rate
128 bpm, BP 86/54 mm Hg, O2 sat 88% on room air. According
to emergency triage classification (ESI/triage principles), which
category should the triage nurse assign and why?
A. Non-urgent — patient is stable enough for delayed care.
B. Urgent — needs assessment within 30–60 minutes.
C. Emergent (immediate) — needs immediate life-saving
intervention and rapid placement.
D. Fast-track — can be treated in a low-acuity area.
,Answer: C — Emergent (immediate).
Rationale: The patient shows hypotension (BP 86/54),
tachycardia, hypoxia, and signs consistent with potential
thoracic injury/hemorrhage — unstable physiology requiring
immediate assessment and life-saving interventions
(airway/oxygenation, hemorrhage control, rapid transport to
trauma bay). ESI/triage frameworks prioritize patients with
unstable vital signs and high risk of deterioration as
immediate/emergent. Non-urgent or fast-track are
inappropriate given hemodynamic instability; “urgent” is for
risk but not immediate life-threatening compromise. California
Emergency Nurses Association+1
2
During a mass casualty incident (MCI), an EMT brings in a
patient who is breathing at 36/min, is not obeying commands,
and has weak radial pulses. Using START triage, what color tag
should be assigned initially?
A. Green (minor)
B. Yellow (delayed)
C. Red (immediate)
D. Black (deceased/expectant)
Answer: C — Red (immediate).
Rationale: START triage focuses on respiration, perfusion, and
mental status. Respirations >30, altered mental status (not
,following commands), and weak pulses indicate high acuity.
These patients require immediate life-saving interventions and
rapid transport. Green/yellow are for ambulating/minor or
stable delayed patients; black is for dead/expectant when no
respirations after airway repositioning or not salvageable in
resource-scarce situations. CHEMM+1
3
A patient exposed to an unknown chemical arrives with burning
eyes, drooling, bronchospasm, and twitching muscles. The
nurse’s first action at triage is to:
A. Place the patient in the main ED waiting room and contact
poison control.
B. Remove contaminated clothing and begin gross
decontamination, then move to a decontamination corridor.
C. Start IV fluids and administer broad-spectrum antibiotics.
D. Perform a detailed history before any interventions.
Answer: B — Remove contaminated clothing and begin gross
decontamination, then move to a decontamination corridor.
Rationale: Suspected chemical exposure with cholinergic signs
(salivation, bronchospasm, muscle twitching) requires
immediate removal of clothing and gross decontamination to
prevent ongoing dermal/secondary contamination of
staff/patients. Rapid decontamination and appropriate PPE are
critical before detailed history or routine ED placement.
, Immediate supportive care (airway/breathing) is simultaneous,
but environmental control comes first to protect staff and other
patients. Refer to CHEMM and CDC chemical emergency
guidance. Options A and D risk cross-contamination and delay
life-safety measures; C is incorrect (antibiotics not first step for
chemical exposures). CHEMM+1
4
A 68-year-old with sudden collapse is found pulseless and
apneic in the ED. The team begins CPR. According to AHA 2025
guidance, what is the most important immediate action for the
team leader once high-quality chest compressions are in
progress?
A. Continue uninterrupted compressions and delay rhythm
analysis indefinitely.
B. Pause compressions every 15 seconds to check for
spontaneous pulse.
C. Coordinate timely defibrillation when a shockable rhythm is
identified and minimize pauses.
D. Intubate immediately before any defibrillation attempt.
Answer: C — Coordinate timely defibrillation when a shockable
rhythm is identified and minimize pauses.
Rationale: AHA guidance emphasizes high-quality chest
compressions with minimal interruptions and rapid
defibrillation for shockable rhythms (VF/pulseless VT). The team
