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 — Single best answer (Triage acuity / ESI)
A 54-year-old male arrives by private vehicle to the ED
complaining of sudden, severe substernal chest pain radiating
to his left arm. He is diaphoretic, pale, and anxious. Vital signs:
BP 86/52 mmHg, HR 120 bpm, RR 24, SpO₂ 92% on room air.
Which triage category/ESI level should the nurse assign?
A. Non-urgent / ESI 5
B. Urgent / ESI 4
C. Emergent / ESI 2
D. Immediate / ESI 1
Correct answer: D. Immediate / ESI 1
Rationale (correct): This client shows signs of shock
(hypotension, tachycardia) and possible acute coronary
,occlusion with hemodynamic instability. ESI level 1 is for
patients requiring immediate life-saving interventions (airway,
breathing, circulation support, immediate meds, or
resuscitation). Immediate activation for resuscitation and rapid
team response is required. EMSC Improvement Center
Rationale (incorrect options):
A & B (ESI 5/4) are for stable patients with minimal or no
resources required — inappropriate for
hypotension/tachycardia.
C (ESI 2) is for high-risk/emergent patients who are not
requiring immediate life-saving intervention; because this
patient is hemodynamically unstable (BP 86/52) and needs
immediate interventions, ESI 1 is correct.
Question 2 — Single best answer (Mass casualty triage —
START)
During a mass-casualty incident, the triage nurse assesses an
adult victim who is lying supine and does not appear to be
breathing. The rescuer repositions the airway and checks again
— still not breathing. According to START triage, how should
this patient be categorized?
A. Immediate (Red)
B. Delayed (Yellow)
C. Minor (Green)
D. Deceased / Expectant (Black)
,Correct answer: D. Deceased / Expectant (Black)
Rationale (correct): In the START algorithm, if an adult is not
breathing after opening the airway, they are tagged as
deceased/expectant (black) in a resource-limited mass-casualty
setting because immediate lifesaving resources are prioritized
for those with survivable injuries. START is designed for rapid
sorting in prehospital MCI. NCBI+1
Rationale (incorrect options):
A (Immediate) and B (Delayed) imply potential for life-saving
intervention with reasonable resource allocation — but non-
breathing after airway reposition is categorized as expectant in
START during MCI. C (Minor) is for ambulatory/walking
wounded.
Question 3 — Single best answer (Chemical exposure /
decontamination)
A patient exposed to a chlorine gas leak presents with coughing,
eye irritation, and mild dyspnea. Which of the following is the
nurse’s highest priority immediate action in the ED?
A. Administer nebulized albuterol immediately.
B. Remove the patient’s clothing and irrigate exposed skin/eyes
with water.
C. Start intravenous corticosteroids.
D. Obtain an arterial blood gas (ABG).
, Correct answer: B. Remove the patient’s clothing and irrigate
exposed skin/eyes with water.
Rationale (correct): For chemical exposures, immediate
decontamination (remove contaminated clothing, irrigate
skin/eyes with copious water) reduces ongoing absorption and
further injury; protect staff with appropriate PPE. This is the
first, time-sensitive step before many treatments. CDC/CHEMM
guidance emphasizes decontamination and PPE for responders.
CDC+1
Rationale (incorrect options):
A (nebulized albuterol) may be indicated after assessment, but
decontamination comes first to prevent continued exposure.
C (IV corticosteroids) are not first-line immediate measures for
acute inhalation irritant exposure.
D (ABG) may be useful for severity assessment but is secondary
to stopping further exposure.
Question 4 — Single best answer (CPR — AHA 2025 adult BLS)
An adult collapses and is unresponsive. A bystander calls 911
and notes the patient is not breathing normally. What is the
nurse’s immediate action according to current AHA adult BLS
guidance?
A. Open the airway, check pulse for up to 10 seconds, if no
pulse start CPR.
B. Deliver 2 rescue breaths, then check for a pulse.
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
Question 1 — Single best answer (Triage acuity / ESI)
A 54-year-old male arrives by private vehicle to the ED
complaining of sudden, severe substernal chest pain radiating
to his left arm. He is diaphoretic, pale, and anxious. Vital signs:
BP 86/52 mmHg, HR 120 bpm, RR 24, SpO₂ 92% on room air.
Which triage category/ESI level should the nurse assign?
A. Non-urgent / ESI 5
B. Urgent / ESI 4
C. Emergent / ESI 2
D. Immediate / ESI 1
Correct answer: D. Immediate / ESI 1
Rationale (correct): This client shows signs of shock
(hypotension, tachycardia) and possible acute coronary
,occlusion with hemodynamic instability. ESI level 1 is for
patients requiring immediate life-saving interventions (airway,
breathing, circulation support, immediate meds, or
resuscitation). Immediate activation for resuscitation and rapid
team response is required. EMSC Improvement Center
Rationale (incorrect options):
A & B (ESI 5/4) are for stable patients with minimal or no
resources required — inappropriate for
hypotension/tachycardia.
C (ESI 2) is for high-risk/emergent patients who are not
requiring immediate life-saving intervention; because this
patient is hemodynamically unstable (BP 86/52) and needs
immediate interventions, ESI 1 is correct.
Question 2 — Single best answer (Mass casualty triage —
START)
During a mass-casualty incident, the triage nurse assesses an
adult victim who is lying supine and does not appear to be
breathing. The rescuer repositions the airway and checks again
— still not breathing. According to START triage, how should
this patient be categorized?
A. Immediate (Red)
B. Delayed (Yellow)
C. Minor (Green)
D. Deceased / Expectant (Black)
,Correct answer: D. Deceased / Expectant (Black)
Rationale (correct): In the START algorithm, if an adult is not
breathing after opening the airway, they are tagged as
deceased/expectant (black) in a resource-limited mass-casualty
setting because immediate lifesaving resources are prioritized
for those with survivable injuries. START is designed for rapid
sorting in prehospital MCI. NCBI+1
Rationale (incorrect options):
A (Immediate) and B (Delayed) imply potential for life-saving
intervention with reasonable resource allocation — but non-
breathing after airway reposition is categorized as expectant in
START during MCI. C (Minor) is for ambulatory/walking
wounded.
Question 3 — Single best answer (Chemical exposure /
decontamination)
A patient exposed to a chlorine gas leak presents with coughing,
eye irritation, and mild dyspnea. Which of the following is the
nurse’s highest priority immediate action in the ED?
A. Administer nebulized albuterol immediately.
B. Remove the patient’s clothing and irrigate exposed skin/eyes
with water.
C. Start intravenous corticosteroids.
D. Obtain an arterial blood gas (ABG).
, Correct answer: B. Remove the patient’s clothing and irrigate
exposed skin/eyes with water.
Rationale (correct): For chemical exposures, immediate
decontamination (remove contaminated clothing, irrigate
skin/eyes with copious water) reduces ongoing absorption and
further injury; protect staff with appropriate PPE. This is the
first, time-sensitive step before many treatments. CDC/CHEMM
guidance emphasizes decontamination and PPE for responders.
CDC+1
Rationale (incorrect options):
A (nebulized albuterol) may be indicated after assessment, but
decontamination comes first to prevent continued exposure.
C (IV corticosteroids) are not first-line immediate measures for
acute inhalation irritant exposure.
D (ABG) may be useful for severity assessment but is secondary
to stopping further exposure.
Question 4 — Single best answer (CPR — AHA 2025 adult BLS)
An adult collapses and is unresponsive. A bystander calls 911
and notes the patient is not breathing normally. What is the
nurse’s immediate action according to current AHA adult BLS
guidance?
A. Open the airway, check pulse for up to 10 seconds, if no
pulse start CPR.
B. Deliver 2 rescue breaths, then check for a pulse.
