Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
Item 1 — Triage / START prioritization (single best
answer)
A 28-year-old male is brought to a mass-casualty
triage area after a multi-vehicle crash. He is
breathing at 10 breaths/min, has a palpable radial
pulse, and follows commands. Using START triage
principles, which category/tag should the triage
nurse assign?
A. Immediate (Red)
B. Delayed (Yellow)
C. Minor/Walking wounded (Green)
D. Deceased/Expectant (Black)
,Correct answer: B. Delayed (Yellow)
Rationale — correct (stepwise):
1. START uses (in order) ability to walk,
respirations, perfusion (radial pulse), and
mental status.
2. Respiratory rate < 30, radial pulse present, and
he follows commands → patient does not meet
Immediate criteria.
3. He is not ambulatory-walking wounded, so not
Green; not apneic and not expectant. Therefore
Delayed (Yellow) is appropriate for serious but
not immediately life-threatening injuries.
(START/SALT triage principles). REMM+1
Why other options are incorrect:
A. Immediate (Red) would apply if respiratory rate
>30, absent radial pulse, or altered mental status
requiring immediate intervention.
C. Minor (Green) requires minimal injuries and often
ambulatory; he is non-ambulatory.
D. Expectant (Black) reserved for unsurvivable
,injuries or apneic after attempts at basic
interventions.
Item 2 — Prioritization: ABCs vs. Maslow (single
best answer)
An emergency nurse receives four newly admitted
patients. Which patient should the nurse assess
first?
1. Client A: 62-year-old with chest pain, anxious,
SpO₂ 92% on room air.
2. Client B: 45-year-old with a laceration to the
forearm, steady bleeding controlled with
pressure.
3. Client C: 30-year-old scheduled for discharge
after suturing for an ankle sprain.
4. Client D: 78-year-old with urinary incontinence
requesting bedpan.
A. Client A
B. Client B
, C. Client C
D. Client D
Correct answer: A. Client A
Rationale — correct (stepwise):
1. Use ABCs (Airway, Breathing, Circulation) and
Maslow’s physiologic priority: chest pain with
borderline oxygenation (SpO₂ 92%) indicates
potential cardiopulmonary compromise →
highest immediate risk.
2. Next would be active bleeding if uncontrolled,
then discharge/post-op concerns, then
comfort/continence issues. Prioritization for
life/threatening problems takes precedence.
Why other options are incorrect:
B. Controlled bleeding is important but less
immediate than potential ischemia/hypoxia.
C. Discharge patient is stable and lower priority.
D. Incontinence is a safety/comfort need, not life-
threatening.
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
Item 1 — Triage / START prioritization (single best
answer)
A 28-year-old male is brought to a mass-casualty
triage area after a multi-vehicle crash. He is
breathing at 10 breaths/min, has a palpable radial
pulse, and follows commands. Using START triage
principles, which category/tag should the triage
nurse assign?
A. Immediate (Red)
B. Delayed (Yellow)
C. Minor/Walking wounded (Green)
D. Deceased/Expectant (Black)
,Correct answer: B. Delayed (Yellow)
Rationale — correct (stepwise):
1. START uses (in order) ability to walk,
respirations, perfusion (radial pulse), and
mental status.
2. Respiratory rate < 30, radial pulse present, and
he follows commands → patient does not meet
Immediate criteria.
3. He is not ambulatory-walking wounded, so not
Green; not apneic and not expectant. Therefore
Delayed (Yellow) is appropriate for serious but
not immediately life-threatening injuries.
(START/SALT triage principles). REMM+1
Why other options are incorrect:
A. Immediate (Red) would apply if respiratory rate
>30, absent radial pulse, or altered mental status
requiring immediate intervention.
C. Minor (Green) requires minimal injuries and often
ambulatory; he is non-ambulatory.
D. Expectant (Black) reserved for unsurvivable
,injuries or apneic after attempts at basic
interventions.
Item 2 — Prioritization: ABCs vs. Maslow (single
best answer)
An emergency nurse receives four newly admitted
patients. Which patient should the nurse assess
first?
1. Client A: 62-year-old with chest pain, anxious,
SpO₂ 92% on room air.
2. Client B: 45-year-old with a laceration to the
forearm, steady bleeding controlled with
pressure.
3. Client C: 30-year-old scheduled for discharge
after suturing for an ankle sprain.
4. Client D: 78-year-old with urinary incontinence
requesting bedpan.
A. Client A
B. Client B
, C. Client C
D. Client D
Correct answer: A. Client A
Rationale — correct (stepwise):
1. Use ABCs (Airway, Breathing, Circulation) and
Maslow’s physiologic priority: chest pain with
borderline oxygenation (SpO₂ 92%) indicates
potential cardiopulmonary compromise →
highest immediate risk.
2. Next would be active bleeding if uncontrolled,
then discharge/post-op concerns, then
comfort/continence issues. Prioritization for
life/threatening problems takes precedence.
Why other options are incorrect:
B. Controlled bleeding is important but less
immediate than potential ischemia/hypoxia.
C. Discharge patient is stable and lower priority.
D. Incontinence is a safety/comfort need, not life-
threatening.
