Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1) (Prioritization / ABCs — case)
A 58-year-old woman arrives by ambulance after a
syncopal episode at home. On arrival she is
unconscious, snoring respirations, pulse 48/min,
blood pressure 86/48 mm Hg. Which action should
the ED nurse perform first?
A. Place two large-bore IVs and begin rapid infusion
of normal saline.
B. Open the airway with head-tilt–chin-lift and
insert an oral airway if needed.
C. Attach the cardiac monitor and prepare atropine.
D. Give 0.4 mg sublingual nitroglycerin for chest
pain.
,Correct answer: B
Rationale (stepwise):
• Why B is correct: Airway is the first priority
(ABCs). Snoring indicates partial airway
obstruction — immediate airway opening
maneuvers and adjuncts (oral airway) restore
patency before circulation interventions. This
follows basic life support priorities. NCBI+1
• Why A is incorrect: While IV access and fluid
resuscitation are essential for hypotension, they
come after securing airway in an unconscious
patient. Starting fluids before airway risks
hypoxia.
• Why C is incorrect: Cardiac monitoring and
medication (atropine) for bradycardia are
important, but addressing airway and
ventilation first is higher priority. After airway
secured, simultaneous monitor/medications
may be initiated.
• Why D is incorrect: Nitroglycerin may lower
blood pressure further and is contraindicated in
, hypotension (BP 86/48) and in an unconscious
patient—it is not a priority.
2) (Triage — mass-casualty / START)
During a mass-casualty incident using START triage,
a walking, alert adult arrives to the triage area.
Which triage color/category should this patient
receive?
A. Red (Immediate)
B. Yellow (Delayed)
C. Green (Minor/walking wounded)
D. Black (Expectant/deceased)
Correct answer: C
Rationale (stepwise):
• Why C is correct: START sorts “walking
wounded” as green (minimal) — patients who
can ambulate and have minor injuries are
lowest transport/treatment priority in MCI.
NCBI+1
, • Why A is incorrect: Red/immediate is for
patients with life-threatening but salvageable
conditions (e.g., compromised airway, major
hemorrhage) — not walking, alert patients.
• Why B is incorrect: Yellow/delayed is for serious
injuries needing care within hours but who are
not immediately life-threatened; walking
wounded generally are green.
• Why D is incorrect: Black denotes deceased or
non-survivable injuries — not applicable to an
ambulatory, alert person.
3) (Maslow/priority decision — case)
Four patients are waiting for triage in the ED. Which
patient should the triage nurse see first?
A. A 25-year-old with panic attack, hyperventilating
but alert.
B. A 67-year-old with sudden right-sided weakness
and slurred speech (last known well 30 minutes).
C. A 40-year-old with ankle fracture, deformity,
stable vitals.
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1) (Prioritization / ABCs — case)
A 58-year-old woman arrives by ambulance after a
syncopal episode at home. On arrival she is
unconscious, snoring respirations, pulse 48/min,
blood pressure 86/48 mm Hg. Which action should
the ED nurse perform first?
A. Place two large-bore IVs and begin rapid infusion
of normal saline.
B. Open the airway with head-tilt–chin-lift and
insert an oral airway if needed.
C. Attach the cardiac monitor and prepare atropine.
D. Give 0.4 mg sublingual nitroglycerin for chest
pain.
,Correct answer: B
Rationale (stepwise):
• Why B is correct: Airway is the first priority
(ABCs). Snoring indicates partial airway
obstruction — immediate airway opening
maneuvers and adjuncts (oral airway) restore
patency before circulation interventions. This
follows basic life support priorities. NCBI+1
• Why A is incorrect: While IV access and fluid
resuscitation are essential for hypotension, they
come after securing airway in an unconscious
patient. Starting fluids before airway risks
hypoxia.
• Why C is incorrect: Cardiac monitoring and
medication (atropine) for bradycardia are
important, but addressing airway and
ventilation first is higher priority. After airway
secured, simultaneous monitor/medications
may be initiated.
• Why D is incorrect: Nitroglycerin may lower
blood pressure further and is contraindicated in
, hypotension (BP 86/48) and in an unconscious
patient—it is not a priority.
2) (Triage — mass-casualty / START)
During a mass-casualty incident using START triage,
a walking, alert adult arrives to the triage area.
Which triage color/category should this patient
receive?
A. Red (Immediate)
B. Yellow (Delayed)
C. Green (Minor/walking wounded)
D. Black (Expectant/deceased)
Correct answer: C
Rationale (stepwise):
• Why C is correct: START sorts “walking
wounded” as green (minimal) — patients who
can ambulate and have minor injuries are
lowest transport/treatment priority in MCI.
NCBI+1
, • Why A is incorrect: Red/immediate is for
patients with life-threatening but salvageable
conditions (e.g., compromised airway, major
hemorrhage) — not walking, alert patients.
• Why B is incorrect: Yellow/delayed is for serious
injuries needing care within hours but who are
not immediately life-threatened; walking
wounded generally are green.
• Why D is incorrect: Black denotes deceased or
non-survivable injuries — not applicable to an
ambulatory, alert person.
3) (Maslow/priority decision — case)
Four patients are waiting for triage in the ED. Which
patient should the triage nurse see first?
A. A 25-year-old with panic attack, hyperventilating
but alert.
B. A 67-year-old with sudden right-sided weakness
and slurred speech (last known well 30 minutes).
C. A 40-year-old with ankle fracture, deformity,
stable vitals.
