Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
Question 1 — Triage priority (ESI/ABCs)
A 62-year-old man arrives at the ED after sudden
onset of chest pain. He is diaphoretic, complaining
of severe substernal pressure, and is pale.
Respirations 20/min, SpO₂ 93% on room air, radial
pulse 110 and weak, blood pressure 86/52 mm Hg.
Which triage category is most appropriate?
A. ESI level 1 — Immediate (requires lifesaving
intervention)
B. ESI level 2 — Emergent (high risk or
confused/lethargic)
C. ESI level 3 — Urgent (multiple resources
expected)
D. ESI level 4 — Nonurgent (one resource expected)
Correct answer: A
,Rationale (stepwise):
1. Primary assessment: hemodynamic instability
(BP 86/52, weak pulse) and signs of shock —
immediate threat to life (ABCs: circulation
compromised).
2. ESI level 1 is for patients who require immediate
lifesaving interventions (e.g., immediate
resuscitation, vasopressors, airway support).
This patient likely needs immediate
interventions (cardiac monitor, IV access,
fluids/pressors, ECG, CXR, emergent physician
evaluation). EMSC Improvement
3. Option B (ESI 2) is for high-risk patients who are
not immediately requiring lifesaving
interventions but may deteriorate; here the
patient is hypotensive and likely needs lifesaving
measures — so ESI 1 is correct.
4. Options C and D are lower acuity and
inappropriate given unstable vitals.
,Question 2 — ABC prioritization (NGN-style)
A triage nurse evaluates four patients arriving
simultaneously. Which patient should be seen first?
1. A 30-year-old with a 1-inch laceration to the
forearm, active bleeding controlled with
pressure, normal vitals.
2. A 78-year-old with shortness of breath, RR 30,
SpO₂ 86% on room air, speaking in short
phrases.
3. A 45-year-old with abdominal pain rated 6/10,
afebrile, vitals stable.
4. A 22-year-old with ankle pain after twisting,
able to bear weight.
A. Patient 1
B. Patient 2
C. Patient 3
D. Patient 4
Correct answer: B
Rationale:
, 1. Use ABCs (airway/breathing first). Patient 2 has
respiratory compromise (RR 30, SpO₂ 86%,
speaking in short phrases) — immediate
airway/oxygenation intervention needed.
cpr.heart.org
2. Patient 1: bleeding controlled and stable vitals -
> lower immediate priority.
3. Patients 3 and 4: stable vitals and non-life-
threatening problems.
4. Therefore Patient 2 is highest priority.
Question 3 — Mass casualty triage (START)
During a mass-casualty incident, you encounter an
adult who is not breathing after you open the
airway and reposition the head; they are apneic and
have no pulse. According to START triage, what
tag/category should you assign?
A. Immediate (Red)
B. Delayed (Yellow)
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
Question 1 — Triage priority (ESI/ABCs)
A 62-year-old man arrives at the ED after sudden
onset of chest pain. He is diaphoretic, complaining
of severe substernal pressure, and is pale.
Respirations 20/min, SpO₂ 93% on room air, radial
pulse 110 and weak, blood pressure 86/52 mm Hg.
Which triage category is most appropriate?
A. ESI level 1 — Immediate (requires lifesaving
intervention)
B. ESI level 2 — Emergent (high risk or
confused/lethargic)
C. ESI level 3 — Urgent (multiple resources
expected)
D. ESI level 4 — Nonurgent (one resource expected)
Correct answer: A
,Rationale (stepwise):
1. Primary assessment: hemodynamic instability
(BP 86/52, weak pulse) and signs of shock —
immediate threat to life (ABCs: circulation
compromised).
2. ESI level 1 is for patients who require immediate
lifesaving interventions (e.g., immediate
resuscitation, vasopressors, airway support).
This patient likely needs immediate
interventions (cardiac monitor, IV access,
fluids/pressors, ECG, CXR, emergent physician
evaluation). EMSC Improvement
3. Option B (ESI 2) is for high-risk patients who are
not immediately requiring lifesaving
interventions but may deteriorate; here the
patient is hypotensive and likely needs lifesaving
measures — so ESI 1 is correct.
4. Options C and D are lower acuity and
inappropriate given unstable vitals.
,Question 2 — ABC prioritization (NGN-style)
A triage nurse evaluates four patients arriving
simultaneously. Which patient should be seen first?
1. A 30-year-old with a 1-inch laceration to the
forearm, active bleeding controlled with
pressure, normal vitals.
2. A 78-year-old with shortness of breath, RR 30,
SpO₂ 86% on room air, speaking in short
phrases.
3. A 45-year-old with abdominal pain rated 6/10,
afebrile, vitals stable.
4. A 22-year-old with ankle pain after twisting,
able to bear weight.
A. Patient 1
B. Patient 2
C. Patient 3
D. Patient 4
Correct answer: B
Rationale:
, 1. Use ABCs (airway/breathing first). Patient 2 has
respiratory compromise (RR 30, SpO₂ 86%,
speaking in short phrases) — immediate
airway/oxygenation intervention needed.
cpr.heart.org
2. Patient 1: bleeding controlled and stable vitals -
> lower immediate priority.
3. Patients 3 and 4: stable vitals and non-life-
threatening problems.
4. Therefore Patient 2 is highest priority.
Question 3 — Mass casualty triage (START)
During a mass-casualty incident, you encounter an
adult who is not breathing after you open the
airway and reposition the head; they are apneic and
have no pulse. According to START triage, what
tag/category should you assign?
A. Immediate (Red)
B. Delayed (Yellow)
