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 — ESI level assignment (adult)
A 62-year-old male arrives to triage with sudden onset chest
pressure, diaphoresis, and nausea for 30 minutes. He is pale
and anxious. Vital signs: HR 110, BP 90/58, RR 22, SpO₂ 94% on
room air. The triage nurse must assign an ESI level. Which ESI
level is most appropriate?
A. ESI Level 1
B. ESI Level 2
C. ESI Level 3
D. ESI Level 4
E. ESI Level 5
Answer: B — ESI Level 2.
,Rationale (correct): The patient is unstable (hypotensive, chest
pressure, diaphoresis) with potential life-threatening condition
(acute coronary syndrome) that requires rapid evaluation and
treatment but not immediate lifesaving interventions in triage
(ESI 1 is for immediate life-saving intervention such as cardiac
arrest). ESI Level 2 is for high-risk situations or those with
severe pain/distress who should be seen quickly. This
assignment aligns with ESI guidance that flags acute coronary
symptoms and hemodynamic compromise as high priority. NCBI
Rationale (incorrect answers):
• A (ESI 1): Reserved when an immediate life-saving
intervention is required (e.g., apnea, CPR, active
hemorrhage requiring immediate control). Patient is
unstable but not in cardiac arrest.
• C (ESI 3): For stable patients who will likely need multiple
resources; this patient needs immediate rapid evaluation.
• D/E (ESI 4/5): For nonurgent/minor complaints—clearly
inappropriate given hypotension and chest pain.
Question 2 — Mass casualty triage (START)
During a mass-casualty incident, a rescuer performing the
walking wounded command finds a man who is not walking, is
breathing at 30 breaths/min, has a palpable radial pulse, and
does not follow commands. Under START triage (adult), what
color tag should be applied?
,A. Black (expectant)
B. Red (immediate)
C. Yellow (delayed)
D. Green (minor)
E. White (refused care)
Answer: B — Red (immediate).
Rationale (correct): START uses quick criteria: if not walking,
assess breathing rate, perfusion, and mental status. Respiratory
rate > 30 indicates respiratory compromise and qualifies for
immediate (red) triage; inability to follow commands (altered
mental status) and tachypnea are markers of high acuity. START
prioritizes rapid interventions for those who can be saved with
immediate resources. NCBI+1
Rationale (incorrect answers):
• A (Black): For deceased/unsalvageable (no breathing after
airway repositioning) — not the case; patient breathes and
has pulse.
• C (Yellow): For delayed injuries; patient shows high
respiratory rate and altered mental status—immediate.
• D/E (Green/White): Not appropriate; patient is not
ambulatory and is high acuity.
Question 3 — Chemical exposure initial nursing action
, A patient is brought to the ED after an industrial chemical
exposure. They are conscious but complaining of burning eyes
and skin redness. The nearest entrance is contaminated by a
plume. What is the nurse’s first action?
A. Bring the patient directly into the ED for rapid
decontamination and treatment.
B. Begin cardiopulmonary monitoring and obtain IV access
immediately inside ED entrance.
C. Direct patient to move upwind/uphill to a safe area and
remove contaminated clothing; perform gross decontamination
outside or at designated decon area.
D. Administer IV fluids and analgesics before decontamination
to stabilize.
E. Place a surgical mask on the patient and transport inside.
Answer: C — Move patient upwind/uphill and remove
clothing; perform gross decontamination.
Rationale (correct): Evidence-based chemical exposure
guidance emphasizes “get away, get clean, get help.” The first
priority is removing the patient from contamination source
(upwind/uphill), removing clothing, and gross decontamination
(flushing with water, avoid spreading contamination) before
entering the ED to protect staff and other patients. Immediate
life-saving interventions that cannot wait are performed, but
routine interventions should be deferred until decon. CDC+1
Rationale (incorrect):
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
Question 1 — ESI level assignment (adult)
A 62-year-old male arrives to triage with sudden onset chest
pressure, diaphoresis, and nausea for 30 minutes. He is pale
and anxious. Vital signs: HR 110, BP 90/58, RR 22, SpO₂ 94% on
room air. The triage nurse must assign an ESI level. Which ESI
level is most appropriate?
A. ESI Level 1
B. ESI Level 2
C. ESI Level 3
D. ESI Level 4
E. ESI Level 5
Answer: B — ESI Level 2.
,Rationale (correct): The patient is unstable (hypotensive, chest
pressure, diaphoresis) with potential life-threatening condition
(acute coronary syndrome) that requires rapid evaluation and
treatment but not immediate lifesaving interventions in triage
(ESI 1 is for immediate life-saving intervention such as cardiac
arrest). ESI Level 2 is for high-risk situations or those with
severe pain/distress who should be seen quickly. This
assignment aligns with ESI guidance that flags acute coronary
symptoms and hemodynamic compromise as high priority. NCBI
Rationale (incorrect answers):
• A (ESI 1): Reserved when an immediate life-saving
intervention is required (e.g., apnea, CPR, active
hemorrhage requiring immediate control). Patient is
unstable but not in cardiac arrest.
• C (ESI 3): For stable patients who will likely need multiple
resources; this patient needs immediate rapid evaluation.
• D/E (ESI 4/5): For nonurgent/minor complaints—clearly
inappropriate given hypotension and chest pain.
Question 2 — Mass casualty triage (START)
During a mass-casualty incident, a rescuer performing the
walking wounded command finds a man who is not walking, is
breathing at 30 breaths/min, has a palpable radial pulse, and
does not follow commands. Under START triage (adult), what
color tag should be applied?
,A. Black (expectant)
B. Red (immediate)
C. Yellow (delayed)
D. Green (minor)
E. White (refused care)
Answer: B — Red (immediate).
Rationale (correct): START uses quick criteria: if not walking,
assess breathing rate, perfusion, and mental status. Respiratory
rate > 30 indicates respiratory compromise and qualifies for
immediate (red) triage; inability to follow commands (altered
mental status) and tachypnea are markers of high acuity. START
prioritizes rapid interventions for those who can be saved with
immediate resources. NCBI+1
Rationale (incorrect answers):
• A (Black): For deceased/unsalvageable (no breathing after
airway repositioning) — not the case; patient breathes and
has pulse.
• C (Yellow): For delayed injuries; patient shows high
respiratory rate and altered mental status—immediate.
• D/E (Green/White): Not appropriate; patient is not
ambulatory and is high acuity.
Question 3 — Chemical exposure initial nursing action
, A patient is brought to the ED after an industrial chemical
exposure. They are conscious but complaining of burning eyes
and skin redness. The nearest entrance is contaminated by a
plume. What is the nurse’s first action?
A. Bring the patient directly into the ED for rapid
decontamination and treatment.
B. Begin cardiopulmonary monitoring and obtain IV access
immediately inside ED entrance.
C. Direct patient to move upwind/uphill to a safe area and
remove contaminated clothing; perform gross decontamination
outside or at designated decon area.
D. Administer IV fluids and analgesics before decontamination
to stabilize.
E. Place a surgical mask on the patient and transport inside.
Answer: C — Move patient upwind/uphill and remove
clothing; perform gross decontamination.
Rationale (correct): Evidence-based chemical exposure
guidance emphasizes “get away, get clean, get help.” The first
priority is removing the patient from contamination source
(upwind/uphill), removing clothing, and gross decontamination
(flushing with water, avoid spreading contamination) before
entering the ED to protect staff and other patients. Immediate
life-saving interventions that cannot wait are performed, but
routine interventions should be deferred until decon. CDC+1
Rationale (incorrect):
