Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
Questions
1. (Prioritization — Triage / Multiple-Choice)
A 32-year-old man arrives at a mass-casualty field
triage after a bus crash. He is not breathing. After
repositioning his airway he still does not breathe,
and he has no palpable radial pulse. According to
START triage, what tag/priority should the triage
nurse assign?
,A. Minor (Green)
B. Delayed (Yellow)
C. Immediate (Red)
D. Expectant (Black)
Correct answer: C — Immediate (Red)
Rationale (stepwise):
1. START triage focuses on breathing, perfusion
(radial pulse/capillary refill), and mental status;
lack of spontaneous breathing after airway
repositioning suggests a patient who may be
salvageable with immediate intervention. START
classifies patients requiring intervention within
minutes as Immediate (Red). REMM+1
2. Expectant (Black) is for patients unlikely to
survive given available resources (e.g., absent
breathing even after repositioning and signs of
non-survivable injuries); because this patient
lacks a pulse but might respond to immediate
resuscitation, Red is appropriate.
Why the other answers are incorrect:
A. Minor (Green) = walking wounded or nonurgent
,injuries — not applicable.
B. Delayed (Yellow) = serious but can wait hours —
not appropriate for absent breathing/pulse.
D. Expectant (Black) = used when survival is unlikely
even with intervention (e.g., catastrophic injuries,
prolonged arrest with signs of nonviability); here
immediate resuscitation is indicated, making Red
the correct tag.
2. (Prioritization — ABCs / Case-based)
A 46-year-old man is brought to the ED after a stab
wound to the chest. He is conscious but pale,
tachycardic, RR 28, BP 86/50 mm Hg, O₂ sat 92% on
room air. Which action should the ED nurse perform
first?
A. Obtain a 12-lead ECG.
B. Establish two large-bore IVs and begin isotonic
crystalloid.
C. Administer broad-spectrum antibiotics.
D. Prepare for emergent bedside chest x-ray.
, Correct answer: B — Establish two large-bore IVs
and begin isotonic crystalloid.
Rationale (stepwise):
1. In trauma with hypotension and tachycardia,
circulation (control of hemorrhage and vascular
access for resuscitation) is immediately
lifesaving; ATLS emphasizes rapid vascular
access and hemorrhage control during the
primary survey. NCBI+1
2. Two large-bore IVs allow rapid fluid and blood
product administration while definitive control
(surgery) is arranged.
Why the other answers are incorrect:
A. 12-lead ECG is important for cardiac complaints
but is not the priority when the patient is
hypotensive from possible hemorrhage.
C. Antibiotics are not priority in immediate
hemorrhagic shock.
D. Chest x-ray may be useful but should not delay
immediate circulatory resuscitation and vascular
access.
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
Questions
1. (Prioritization — Triage / Multiple-Choice)
A 32-year-old man arrives at a mass-casualty field
triage after a bus crash. He is not breathing. After
repositioning his airway he still does not breathe,
and he has no palpable radial pulse. According to
START triage, what tag/priority should the triage
nurse assign?
,A. Minor (Green)
B. Delayed (Yellow)
C. Immediate (Red)
D. Expectant (Black)
Correct answer: C — Immediate (Red)
Rationale (stepwise):
1. START triage focuses on breathing, perfusion
(radial pulse/capillary refill), and mental status;
lack of spontaneous breathing after airway
repositioning suggests a patient who may be
salvageable with immediate intervention. START
classifies patients requiring intervention within
minutes as Immediate (Red). REMM+1
2. Expectant (Black) is for patients unlikely to
survive given available resources (e.g., absent
breathing even after repositioning and signs of
non-survivable injuries); because this patient
lacks a pulse but might respond to immediate
resuscitation, Red is appropriate.
Why the other answers are incorrect:
A. Minor (Green) = walking wounded or nonurgent
,injuries — not applicable.
B. Delayed (Yellow) = serious but can wait hours —
not appropriate for absent breathing/pulse.
D. Expectant (Black) = used when survival is unlikely
even with intervention (e.g., catastrophic injuries,
prolonged arrest with signs of nonviability); here
immediate resuscitation is indicated, making Red
the correct tag.
2. (Prioritization — ABCs / Case-based)
A 46-year-old man is brought to the ED after a stab
wound to the chest. He is conscious but pale,
tachycardic, RR 28, BP 86/50 mm Hg, O₂ sat 92% on
room air. Which action should the ED nurse perform
first?
A. Obtain a 12-lead ECG.
B. Establish two large-bore IVs and begin isotonic
crystalloid.
C. Administer broad-spectrum antibiotics.
D. Prepare for emergent bedside chest x-ray.
, Correct answer: B — Establish two large-bore IVs
and begin isotonic crystalloid.
Rationale (stepwise):
1. In trauma with hypotension and tachycardia,
circulation (control of hemorrhage and vascular
access for resuscitation) is immediately
lifesaving; ATLS emphasizes rapid vascular
access and hemorrhage control during the
primary survey. NCBI+1
2. Two large-bore IVs allow rapid fluid and blood
product administration while definitive control
(surgery) is arranged.
Why the other answers are incorrect:
A. 12-lead ECG is important for cardiac complaints
but is not the priority when the patient is
hypotensive from possible hemorrhage.
C. Antibiotics are not priority in immediate
hemorrhagic shock.
D. Chest x-ray may be useful but should not delay
immediate circulatory resuscitation and vascular
access.
