Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 (Application — Prioritization / ABCs)
A 48-year-old man arrives by ambulance after a
motor vehicle crash. He is conscious but confused,
breathing 10/min with shallow respirations, has
audible stridor, and a large mid-sternal bruise. Heart
rate 120, BP 90/60, SpO₂ 88% on room air. Which
action should the nurse perform first?
A. Obtain IV access and begin a fluid bolus.
B. Prepare for immediate endotracheal intubation
with rapid-sequence induction.
C. Apply a cervical collar and spinal immobilization.
D. Administer high-flow oxygen by non-rebreather
mask.
Answer: B. Prepare for immediate endotracheal
intubation with rapid-sequence induction.
,Rationale — correct (B): Stridor, shallow
respirations, hypoxia, and mid-sternal trauma
indicate potential airway compromise (threat to A in
ABCs). Securing the airway is the immediate
priority; intubation with rapid-sequence induction
(RSI) is indicated when airway compromise is
imminent.
Rationale — A (incorrect): IV access and fluids are
important (C for circulation) but come after securing
the airway when airway is threatened. Starting
fluids before the airway could delay life-saving
intubation.
Rationale — C (incorrect): Cervical immobilization is
important in trauma and should be done promptly,
but it does not supersede immediate steps to
secure an airway when airway compromise is
present. Immobilization can be done concurrently if
staffing allows.
Rationale — D (incorrect): High-flow O₂ is
appropriate initial support, but with audible stridor
,and progressive hypoxia, it may be insufficient —
definitive airway control (intubation) is required.
2 (Application — Triage / Mass casualty)
At a mass casualty incident using START triage,
which description fits a patient tagged Red
(Immediate)?
A. Walking wounded with minor lacerations, stable
vitals.
B. Respirations >30/min, unable to follow
commands, palpable radial pulse present.
C. Not breathing, remains apneic after repositioning
airway.
D. Breathing 20/min, has deformity but can follow
commands.
Answer: B. Respirations >30/min, unable to follow
commands, palpable radial pulse present.
Rationale — correct (B): START red/immediate
category includes patients with compromised
airway/respiratory >30, poor perfusion, or altered
mental status who need immediate interventions.
, Respiratory rate >30 and inability to follow
commands indicate high priority.
Rationale — A (incorrect): Walking wounded are
tagged Green (minor).
Rationale — C (incorrect): In START, apneic after
repositioning is typically tagged Black
(expectant/deceased) in mass-casualty triage when
resources are limited.
Rationale — D (incorrect): This patient is more
consistent with Yellow (delayed) if stable but
injured; not immediate.
3 (Analysis — ESI triage / resource prediction)
A 65-year-old woman presents to the ED with chest
pain and diaphoresis. She is alert, pain 8/10, BP
140/88, HR 92, SpO₂ 97% on room air. Which
Emergency Severity Index (ESI) level is most
appropriate?
A. ESI level 1 — immediate life-saving intervention
required.
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 (Application — Prioritization / ABCs)
A 48-year-old man arrives by ambulance after a
motor vehicle crash. He is conscious but confused,
breathing 10/min with shallow respirations, has
audible stridor, and a large mid-sternal bruise. Heart
rate 120, BP 90/60, SpO₂ 88% on room air. Which
action should the nurse perform first?
A. Obtain IV access and begin a fluid bolus.
B. Prepare for immediate endotracheal intubation
with rapid-sequence induction.
C. Apply a cervical collar and spinal immobilization.
D. Administer high-flow oxygen by non-rebreather
mask.
Answer: B. Prepare for immediate endotracheal
intubation with rapid-sequence induction.
,Rationale — correct (B): Stridor, shallow
respirations, hypoxia, and mid-sternal trauma
indicate potential airway compromise (threat to A in
ABCs). Securing the airway is the immediate
priority; intubation with rapid-sequence induction
(RSI) is indicated when airway compromise is
imminent.
Rationale — A (incorrect): IV access and fluids are
important (C for circulation) but come after securing
the airway when airway is threatened. Starting
fluids before the airway could delay life-saving
intubation.
Rationale — C (incorrect): Cervical immobilization is
important in trauma and should be done promptly,
but it does not supersede immediate steps to
secure an airway when airway compromise is
present. Immobilization can be done concurrently if
staffing allows.
Rationale — D (incorrect): High-flow O₂ is
appropriate initial support, but with audible stridor
,and progressive hypoxia, it may be insufficient —
definitive airway control (intubation) is required.
2 (Application — Triage / Mass casualty)
At a mass casualty incident using START triage,
which description fits a patient tagged Red
(Immediate)?
A. Walking wounded with minor lacerations, stable
vitals.
B. Respirations >30/min, unable to follow
commands, palpable radial pulse present.
C. Not breathing, remains apneic after repositioning
airway.
D. Breathing 20/min, has deformity but can follow
commands.
Answer: B. Respirations >30/min, unable to follow
commands, palpable radial pulse present.
Rationale — correct (B): START red/immediate
category includes patients with compromised
airway/respiratory >30, poor perfusion, or altered
mental status who need immediate interventions.
, Respiratory rate >30 and inability to follow
commands indicate high priority.
Rationale — A (incorrect): Walking wounded are
tagged Green (minor).
Rationale — C (incorrect): In START, apneic after
repositioning is typically tagged Black
(expectant/deceased) in mass-casualty triage when
resources are limited.
Rationale — D (incorrect): This patient is more
consistent with Yellow (delayed) if stable but
injured; not immediate.
3 (Analysis — ESI triage / resource prediction)
A 65-year-old woman presents to the ED with chest
pain and diaphoresis. She is alert, pain 8/10, BP
140/88, HR 92, SpO₂ 97% on room air. Which
Emergency Severity Index (ESI) level is most
appropriate?
A. ESI level 1 — immediate life-saving intervention
required.
