Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Triage Priority (START principle)
A 42-year-old male arrives to the ED after a motor
vehicle crash. He is breathing 28 breaths/min with
labored respirations, responds only to voice, has a
palpable radial pulse, and is bleeding from a
laceration to the thigh. According to standard mass-
casualty triage categories (START/SALT principles),
which triage category should the nurse assign first?
A. Red (Immediate)
B. Yellow (Delayed)
C. Green (Minimal/walking wounded)
D. Black (Expectant/deceased)
Correct answer: A — Red (Immediate).
,Rationale (stepwise):
1. Triage framework: START/SALT prioritize
immediate (red) for patients with compromised
airway, breathing, or circulation but who have a
good chance of survival with rapid intervention.
NCBI
2. Assessment: This patient has labored
respirations (breathing problem) and altered
responsiveness (responds only to voice). He also
has an active hemorrhage — all suggest life-
threatening issues that are potentially
reversible.
3. Why A is correct: Red/immediate is for those
requiring rapid interventions (airway
management, control hemorrhage, emergent
breathing support).
4. Why B is incorrect: Yellow/delayed are serious
injuries without immediate threat to life — this
patient has respiratory compromise.
5. Why C is incorrect: Green is minor injuries —
not applicable.
, 6. Why D is incorrect: Black/expectant is for
unsalvageable or deceased where resources are
extremely scarce; this patient is salvageable.
2 — Prioritization: ABCs and Cervical Spine
A 28-year-old male with blunt head trauma arrives
unconscious after a fall. On initial assessment he has
snoring respirations, oxygen saturation 88% on
room air, and a possible cervical spine injury
mechanism. Which is the nurse’s immediate action?
A. Place a hard cervical collar and administer high-
flow oxygen via nonrebreather mask.
B. Insert an oropharyngeal airway without c-spine
stabilization.
C. Begin chest compressions and call a code.
D. Rapidly log-roll the patient to inspect the back for
bleeding.
Correct answer: A. Place a hard cervical collar and
administer high-flow oxygen via nonrebreather
mask.
, Rationale (stepwise):
1. Airway first (A of ABCs): Snoring respirations
indicate potential airway obstruction — opening
airway and ensuring oxygenation is highest
priority. Maintain c-spine.
2. Why A is correct: Simultaneously protecting the
cervical spine (hard collar) and improving
oxygenation (NRB) addresses both
airway/oxygenation while preventing further
spinal injury.
3. Why B is incorrect: An oropharyngeal airway
might be indicated for airway obstruction but
should not be inserted without c-spine
stabilization in trauma.
4. Why C is incorrect: Chest compressions are for
cardiac arrest; patient has respirations (albeit
compromised) and SpO2 88% — not
immediately a code.
5. Why D is incorrect: Log-rolling and full
inspection are secondary once
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Triage Priority (START principle)
A 42-year-old male arrives to the ED after a motor
vehicle crash. He is breathing 28 breaths/min with
labored respirations, responds only to voice, has a
palpable radial pulse, and is bleeding from a
laceration to the thigh. According to standard mass-
casualty triage categories (START/SALT principles),
which triage category should the nurse assign first?
A. Red (Immediate)
B. Yellow (Delayed)
C. Green (Minimal/walking wounded)
D. Black (Expectant/deceased)
Correct answer: A — Red (Immediate).
,Rationale (stepwise):
1. Triage framework: START/SALT prioritize
immediate (red) for patients with compromised
airway, breathing, or circulation but who have a
good chance of survival with rapid intervention.
NCBI
2. Assessment: This patient has labored
respirations (breathing problem) and altered
responsiveness (responds only to voice). He also
has an active hemorrhage — all suggest life-
threatening issues that are potentially
reversible.
3. Why A is correct: Red/immediate is for those
requiring rapid interventions (airway
management, control hemorrhage, emergent
breathing support).
4. Why B is incorrect: Yellow/delayed are serious
injuries without immediate threat to life — this
patient has respiratory compromise.
5. Why C is incorrect: Green is minor injuries —
not applicable.
, 6. Why D is incorrect: Black/expectant is for
unsalvageable or deceased where resources are
extremely scarce; this patient is salvageable.
2 — Prioritization: ABCs and Cervical Spine
A 28-year-old male with blunt head trauma arrives
unconscious after a fall. On initial assessment he has
snoring respirations, oxygen saturation 88% on
room air, and a possible cervical spine injury
mechanism. Which is the nurse’s immediate action?
A. Place a hard cervical collar and administer high-
flow oxygen via nonrebreather mask.
B. Insert an oropharyngeal airway without c-spine
stabilization.
C. Begin chest compressions and call a code.
D. Rapidly log-roll the patient to inspect the back for
bleeding.
Correct answer: A. Place a hard cervical collar and
administer high-flow oxygen via nonrebreather
mask.
, Rationale (stepwise):
1. Airway first (A of ABCs): Snoring respirations
indicate potential airway obstruction — opening
airway and ensuring oxygenation is highest
priority. Maintain c-spine.
2. Why A is correct: Simultaneously protecting the
cervical spine (hard collar) and improving
oxygenation (NRB) addresses both
airway/oxygenation while preventing further
spinal injury.
3. Why B is incorrect: An oropharyngeal airway
might be indicated for airway obstruction but
should not be inserted without c-spine
stabilization in trauma.
4. Why C is incorrect: Chest compressions are for
cardiac arrest; patient has respirations (albeit
compromised) and SpO2 88% — not
immediately a code.
5. Why D is incorrect: Log-rolling and full
inspection are secondary once
