Relias ED RN A Exam Complete Questions &
Answers Verified Actual Exam 2026/2027 – Complete
Exam-Style Q&As | 100% Certified Verified – Pass
Guaranteed – A+ Graded
Section 1: Triage & Initial Assessment
Q1: Which vital sign change is most concerning when triaging a 4-year-old who presents with fever and
lethargy?
A. Heart rate of 110 bpm
B. Respiratory rate of 28 breaths/min
C. Capillary refill time of 4 seconds
D. Temperature of 102.4°F (39.1°C)
C. Capillary refill time of 4 seconds [CORRECT]
D. Respiratory rate of 22 breaths/min
Correct Answer: C
Rationale: The best answer is C. A capillary refill time greater than 3 seconds signals poor perfusion and
possible septic shock, which takes priority over isolated fever or mild tachycardia in a pediatric patient.
This aligns with the principle that perfusion status drives triage acuity in febrile children.
Q2: A 62-year-old arrives by private vehicle with crushing chest pain radiating to the jaw, diaphoretic,
and pale. Using the Emergency Severity Index (ESI), what is the appropriate triage level?
A. ESI Level 3 – Multiple resources, stable vital signs
B. ESI Level 4 – One resource, stable patient
C. ESI Level 2 – High risk, requires immediate intervention
D. ESI Level 5 – No resources, can wait in lobby
C. ESI Level 2 – High risk, requires immediate intervention [CORRECT]
D. ESI Level 5 – No resources, can wait in lobby
,Correct Answer: C
Rationale: The best answer is C. Crushing chest pain with diaphoresis and pallor is a classic high-risk
presentation for acute coronary syndrome, mandating ESI Level 2 regardless of vital signs. This matches
the ESI triage rule that any patient with a high-risk chief complaint or presentation warrants immediate
bed placement and provider evaluation.
Q3: What is the primary purpose of the Emergency Severity Index (ESI) triage system?
A. To determine the exact medical diagnosis before the patient sees a provider
B. To prioritize patients based on acuity and predicted resource needs
C. To assign patients to specific treatment rooms based on insurance status
D. To predict hospital admission rates for emergency department census planning
B. To prioritize patients based on acuity and predicted resource needs [CORRECT]
D. To predict hospital admission rates for emergency department census planning
Correct Answer: B
Rationale: The best answer is B. ESI is designed to sort patients by how sick they are and how many
resources they will likely need, not to diagnose or manage bed assignments by payer. This aligns with
the fundamental purpose of all triage systems: getting the right patient to the right level of care at the
right time.
Q4: During the primary assessment of an unresponsive trauma patient, which finding requires the most
immediate intervention?
A. A 5-cm laceration on the forearm with controlled bleeding
B. Bilateral breath sounds present but diminished on the right
C. Open airway with snoring respirations and gurgling
D. Distal pulses palpable at the wrist bilaterally
C. Open airway with snoring respirations and gurgling [CORRECT]
D. Distal pulses palpable at the wrist bilaterally
Correct Answer: C
Rationale: The best answer is C. Snoring and gurgling indicate partial airway obstruction from the tongue
or secretions, which must be addressed before anything else in the ABC sequence. This matches the
,principle that airway always comes first in primary assessment, and an obstructed airway will kill a
patient faster than a compromised extremity.
Q5: Which patient would be classified as ESI Level 1?
A. A 30-year-old with a sprained ankle and no deformity
B. A 55-year-old with abdominal pain, stable vitals, and normal mentation
C. A 70-year-old in respiratory arrest requiring immediate intubation
D. A 25-year-old requesting a pregnancy test with no complaints
C. A 70-year-old in respiratory arrest requiring immediate intubation [CORRECT]
D. A 25-year-old requesting a pregnancy test with no complaints
Correct Answer: C
Rationale: The best answer is C. ESI Level 1 is reserved for patients who require immediate life-saving
intervention, such as respiratory arrest needing intubation. This aligns with the ESI algorithm where any
patient requiring immediate intervention to prevent death is automatically Level 1.
Q6: A patient presents with a headache, stiff neck, and photophobia. What is the priority triage
consideration?
A. Place the patient in a brightly lit area for better visualization
B. Consider meningitis and initiate droplet precautions immediately
C. Administer a narcotic analgesic for pain relief before provider evaluation
D. Obtain a CT scan of the head before any other intervention
B. Consider meningitis and initiate droplet precautions immediately [CORRECT]
D. Obtain a CT scan of the head before any other intervention
Correct Answer: B
Rationale: The best answer is B. The classic triad of headache, stiff neck, and photophobia raises strong
suspicion for meningitis, which requires immediate droplet precautions to protect staff and other
patients. This matches the principle that infection control measures take precedence over diagnostics or
comfort measures when a communicable disease is suspected.
Q7: In the START triage system used during mass casualty incidents, which category is assigned to a
patient who is breathing but has a respiratory rate greater than 30 breaths per minute?
A. Immediate (Red)
, B. Delayed (Yellow)
C. Minor (Green)
D. Expectant (Black)
A. Immediate (Red) [CORRECT]
D. Expectant (Black)
Correct Answer: A
Rationale: The best answer is A. In START triage, a respiratory rate over 30 after repositioning the airway
places the patient in the Immediate category due to respiratory compromise. This aligns with the START
algorithm where abnormal vital signs after basic interventions signal the need for rapid medical
attention.
Q8: What is the normal range for adult capillary refill time?
A. Less than 2 seconds
B. 2 to 4 seconds
C. 4 to 6 seconds
D. 6 to 8 seconds
A. Less than 2 seconds [CORRECT]
D. 6 to 8 seconds
Correct Answer: A
Rationale: The best answer is A. Normal capillary refill in adults is less than 2 seconds; anything beyond
that suggests delayed perfusion and warrants further assessment. This is a straightforward recall of a
standard vital sign parameter used in every initial patient assessment.
Q9: A 45-year-old male presents with sudden onset of severe back pain, tearing in quality, and a blood
pressure of 220/110 mmHg. He is diaphoretic and anxious. What is the triage nurse's priority action?
A. Place the patient in the waiting room and obtain a urine sample
B. Obtain a 12-lead ECG and cardiac enzymes immediately
C. Escort the patient immediately to a monitored bed and notify the provider
D. Administer ibuprofen 400 mg orally for pain control
C. Escort the patient immediately to a monitored bed and notify the provider [CORRECT]
Answers Verified Actual Exam 2026/2027 – Complete
Exam-Style Q&As | 100% Certified Verified – Pass
Guaranteed – A+ Graded
Section 1: Triage & Initial Assessment
Q1: Which vital sign change is most concerning when triaging a 4-year-old who presents with fever and
lethargy?
A. Heart rate of 110 bpm
B. Respiratory rate of 28 breaths/min
C. Capillary refill time of 4 seconds
D. Temperature of 102.4°F (39.1°C)
C. Capillary refill time of 4 seconds [CORRECT]
D. Respiratory rate of 22 breaths/min
Correct Answer: C
Rationale: The best answer is C. A capillary refill time greater than 3 seconds signals poor perfusion and
possible septic shock, which takes priority over isolated fever or mild tachycardia in a pediatric patient.
This aligns with the principle that perfusion status drives triage acuity in febrile children.
Q2: A 62-year-old arrives by private vehicle with crushing chest pain radiating to the jaw, diaphoretic,
and pale. Using the Emergency Severity Index (ESI), what is the appropriate triage level?
A. ESI Level 3 – Multiple resources, stable vital signs
B. ESI Level 4 – One resource, stable patient
C. ESI Level 2 – High risk, requires immediate intervention
D. ESI Level 5 – No resources, can wait in lobby
C. ESI Level 2 – High risk, requires immediate intervention [CORRECT]
D. ESI Level 5 – No resources, can wait in lobby
,Correct Answer: C
Rationale: The best answer is C. Crushing chest pain with diaphoresis and pallor is a classic high-risk
presentation for acute coronary syndrome, mandating ESI Level 2 regardless of vital signs. This matches
the ESI triage rule that any patient with a high-risk chief complaint or presentation warrants immediate
bed placement and provider evaluation.
Q3: What is the primary purpose of the Emergency Severity Index (ESI) triage system?
A. To determine the exact medical diagnosis before the patient sees a provider
B. To prioritize patients based on acuity and predicted resource needs
C. To assign patients to specific treatment rooms based on insurance status
D. To predict hospital admission rates for emergency department census planning
B. To prioritize patients based on acuity and predicted resource needs [CORRECT]
D. To predict hospital admission rates for emergency department census planning
Correct Answer: B
Rationale: The best answer is B. ESI is designed to sort patients by how sick they are and how many
resources they will likely need, not to diagnose or manage bed assignments by payer. This aligns with
the fundamental purpose of all triage systems: getting the right patient to the right level of care at the
right time.
Q4: During the primary assessment of an unresponsive trauma patient, which finding requires the most
immediate intervention?
A. A 5-cm laceration on the forearm with controlled bleeding
B. Bilateral breath sounds present but diminished on the right
C. Open airway with snoring respirations and gurgling
D. Distal pulses palpable at the wrist bilaterally
C. Open airway with snoring respirations and gurgling [CORRECT]
D. Distal pulses palpable at the wrist bilaterally
Correct Answer: C
Rationale: The best answer is C. Snoring and gurgling indicate partial airway obstruction from the tongue
or secretions, which must be addressed before anything else in the ABC sequence. This matches the
,principle that airway always comes first in primary assessment, and an obstructed airway will kill a
patient faster than a compromised extremity.
Q5: Which patient would be classified as ESI Level 1?
A. A 30-year-old with a sprained ankle and no deformity
B. A 55-year-old with abdominal pain, stable vitals, and normal mentation
C. A 70-year-old in respiratory arrest requiring immediate intubation
D. A 25-year-old requesting a pregnancy test with no complaints
C. A 70-year-old in respiratory arrest requiring immediate intubation [CORRECT]
D. A 25-year-old requesting a pregnancy test with no complaints
Correct Answer: C
Rationale: The best answer is C. ESI Level 1 is reserved for patients who require immediate life-saving
intervention, such as respiratory arrest needing intubation. This aligns with the ESI algorithm where any
patient requiring immediate intervention to prevent death is automatically Level 1.
Q6: A patient presents with a headache, stiff neck, and photophobia. What is the priority triage
consideration?
A. Place the patient in a brightly lit area for better visualization
B. Consider meningitis and initiate droplet precautions immediately
C. Administer a narcotic analgesic for pain relief before provider evaluation
D. Obtain a CT scan of the head before any other intervention
B. Consider meningitis and initiate droplet precautions immediately [CORRECT]
D. Obtain a CT scan of the head before any other intervention
Correct Answer: B
Rationale: The best answer is B. The classic triad of headache, stiff neck, and photophobia raises strong
suspicion for meningitis, which requires immediate droplet precautions to protect staff and other
patients. This matches the principle that infection control measures take precedence over diagnostics or
comfort measures when a communicable disease is suspected.
Q7: In the START triage system used during mass casualty incidents, which category is assigned to a
patient who is breathing but has a respiratory rate greater than 30 breaths per minute?
A. Immediate (Red)
, B. Delayed (Yellow)
C. Minor (Green)
D. Expectant (Black)
A. Immediate (Red) [CORRECT]
D. Expectant (Black)
Correct Answer: A
Rationale: The best answer is A. In START triage, a respiratory rate over 30 after repositioning the airway
places the patient in the Immediate category due to respiratory compromise. This aligns with the START
algorithm where abnormal vital signs after basic interventions signal the need for rapid medical
attention.
Q8: What is the normal range for adult capillary refill time?
A. Less than 2 seconds
B. 2 to 4 seconds
C. 4 to 6 seconds
D. 6 to 8 seconds
A. Less than 2 seconds [CORRECT]
D. 6 to 8 seconds
Correct Answer: A
Rationale: The best answer is A. Normal capillary refill in adults is less than 2 seconds; anything beyond
that suggests delayed perfusion and warrants further assessment. This is a straightforward recall of a
standard vital sign parameter used in every initial patient assessment.
Q9: A 45-year-old male presents with sudden onset of severe back pain, tearing in quality, and a blood
pressure of 220/110 mmHg. He is diaphoretic and anxious. What is the triage nurse's priority action?
A. Place the patient in the waiting room and obtain a urine sample
B. Obtain a 12-lead ECG and cardiac enzymes immediately
C. Escort the patient immediately to a monitored bed and notify the provider
D. Administer ibuprofen 400 mg orally for pain control
C. Escort the patient immediately to a monitored bed and notify the provider [CORRECT]
