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 — START triage in mass casualty
A violent explosion brings multiple casualties to the ED. Using
the START triage system, which client should be tagged
IMMEDIATE (red) and seen first?
A. Resp 30, absent radial pulse, altered mental status.
B. Resp 18, radial pulse present, obeys commands.
C. Resp 8, apneic but starts breathing after head tilt and chin
lift.
D. Resp 24, crying and walking wounded.
Correct answer: A
Rationale — correct (A): START tags immediate (red) clients
who have RR > 30, absent or weak perfusion (absent radial
pulse), and altered mental status — signs of compromised
,airway/perfusion requiring immediate life-saving interventions.
(START = Simple Triage And Rapid Treatment)
Rationale — incorrect (B): Resp 18, pulses present, follows
commands → MINOR (green) or DELAYED (yellow) depending;
not immediate.
Rationale — incorrect (C): If apneic and starts breathing after
repositioning, assess perfusion and mental status; if breathing
and perfusion adequate, may be DELAYED (yellow); initial apnea
that becomes respirating is not automatically immediate if
perfusion and mental status are OK.
Rationale — incorrect (D): Walking wounded are MINOR
(green).
2 — Emergent vs urgent triage classification
A 62-year-old with chest pain, diaphoresis, and hypotension
arrives. How should the nurse triage this patient?
A. Emergent (must be seen immediately)
B. Urgent (seen within 1–2 hours)
C. Non-urgent (can wait several hours)
D. Fast-track (treat and discharge)
Correct answer: A
Rationale — correct (A): Chest pain with diaphoresis and
hypotension are signs of potential life-threatening myocardial
,ischemia or cardiogenic shock; the patient requires immediate
evaluation and stabilization (emergent).
Rationale — incorrect (B): Urgent is for serious but not
immediate life-threatening conditions; hypotension with chest
pain is more critical.
Rationale — incorrect (C): Non-urgent inappropriate; potential
MI must not wait.
Rationale — incorrect (D): Fast-track reserved for minor
complaints suitable for rapid care and discharge.
3 — Chemical exposure decontamination
An ambulance arrives with a patient exposed to an unknown
industrial chemical. Which is the first nursing action on arrival
outside the ED decontamination area?
A. Remove the patient's clothing and place them in a sealed
bag.
B. Begin IV fluids and administer oxygen.
C. Perform secondary survey (head-to-toe) to identify injuries.
D. Transport directly to the ED bed to expedite care.
Correct answer: A
Rationale — correct (A): For chemical exposures, immediate
removal of clothing and containment (sealed bags) reduces
ongoing dermal absorption and secondary contamination of
, staff/facilities. Decontamination occurs before definitive
treatment whenever contamination is suspected.
Rationale — incorrect (B): IV fluids/oxygen are important but
should follow decontamination to avoid contaminating
treatment areas/staff and to prevent further exposure.
Rationale — incorrect (C): Secondary survey is deferred until
after primary life-saving measures and decontamination when
chemical exposure is suspected.
Rationale — incorrect (D): Transporting directly into ED without
decontamination risks secondary contamination of
staff/facilities.
4 — Adult cardiac arrest algorithm (BLS/ALS)
During an adult witnessed cardiac arrest, single rescuer starts
CPR. Which statement is correct per current resuscitation
priorities?
A. Start chest compressions immediately; check pulse for up to
10 seconds first.
B. Provide 30 compressions : 2 ventilations until an advanced
airway is placed.
C. Deliver a shock immediately without CPR if witness says
collapse was sudden.
D. Give naloxone before starting CPR.
Correct answer: B
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1 — START triage in mass casualty
A violent explosion brings multiple casualties to the ED. Using
the START triage system, which client should be tagged
IMMEDIATE (red) and seen first?
A. Resp 30, absent radial pulse, altered mental status.
B. Resp 18, radial pulse present, obeys commands.
C. Resp 8, apneic but starts breathing after head tilt and chin
lift.
D. Resp 24, crying and walking wounded.
Correct answer: A
Rationale — correct (A): START tags immediate (red) clients
who have RR > 30, absent or weak perfusion (absent radial
pulse), and altered mental status — signs of compromised
,airway/perfusion requiring immediate life-saving interventions.
(START = Simple Triage And Rapid Treatment)
Rationale — incorrect (B): Resp 18, pulses present, follows
commands → MINOR (green) or DELAYED (yellow) depending;
not immediate.
Rationale — incorrect (C): If apneic and starts breathing after
repositioning, assess perfusion and mental status; if breathing
and perfusion adequate, may be DELAYED (yellow); initial apnea
that becomes respirating is not automatically immediate if
perfusion and mental status are OK.
Rationale — incorrect (D): Walking wounded are MINOR
(green).
2 — Emergent vs urgent triage classification
A 62-year-old with chest pain, diaphoresis, and hypotension
arrives. How should the nurse triage this patient?
A. Emergent (must be seen immediately)
B. Urgent (seen within 1–2 hours)
C. Non-urgent (can wait several hours)
D. Fast-track (treat and discharge)
Correct answer: A
Rationale — correct (A): Chest pain with diaphoresis and
hypotension are signs of potential life-threatening myocardial
,ischemia or cardiogenic shock; the patient requires immediate
evaluation and stabilization (emergent).
Rationale — incorrect (B): Urgent is for serious but not
immediate life-threatening conditions; hypotension with chest
pain is more critical.
Rationale — incorrect (C): Non-urgent inappropriate; potential
MI must not wait.
Rationale — incorrect (D): Fast-track reserved for minor
complaints suitable for rapid care and discharge.
3 — Chemical exposure decontamination
An ambulance arrives with a patient exposed to an unknown
industrial chemical. Which is the first nursing action on arrival
outside the ED decontamination area?
A. Remove the patient's clothing and place them in a sealed
bag.
B. Begin IV fluids and administer oxygen.
C. Perform secondary survey (head-to-toe) to identify injuries.
D. Transport directly to the ED bed to expedite care.
Correct answer: A
Rationale — correct (A): For chemical exposures, immediate
removal of clothing and containment (sealed bags) reduces
ongoing dermal absorption and secondary contamination of
, staff/facilities. Decontamination occurs before definitive
treatment whenever contamination is suspected.
Rationale — incorrect (B): IV fluids/oxygen are important but
should follow decontamination to avoid contaminating
treatment areas/staff and to prevent further exposure.
Rationale — incorrect (C): Secondary survey is deferred until
after primary life-saving measures and decontamination when
chemical exposure is suspected.
Rationale — incorrect (D): Transporting directly into ED without
decontamination risks secondary contamination of
staff/facilities.
4 — Adult cardiac arrest algorithm (BLS/ALS)
During an adult witnessed cardiac arrest, single rescuer starts
CPR. Which statement is correct per current resuscitation
priorities?
A. Start chest compressions immediately; check pulse for up to
10 seconds first.
B. Provide 30 compressions : 2 ventilations until an advanced
airway is placed.
C. Deliver a shock immediately without CPR if witness says
collapse was sudden.
D. Give naloxone before starting CPR.
Correct answer: B
