Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Triage category (mass-casualty)
A 32-year-old construction worker arrives at a mass-
casualty triage site with a partial-thickness burn to
25% of his anterior chest and upper abdomen,
severe respiratory distress (stridor, hoarseness), and
singed facial hairs. Which triage category should the
triage nurse assign?
A. Green — Delayed
B. Yellow — Urgent
C. Red — Immediate
D. Black — Expectant
Answer: C. Red — Immediate
,Rationale (correct): Airway compromise signs
(stridor, hoarseness) and inhalation injury are life-
threatening and require immediate
assessment/intervention (secure airway, oxygen,
possible intubation). In mass-casualty triage,
patients with compromised airway/respiration
receive “Immediate/Red” priority.
Rationale (incorrect):
A — Green is for minor injuries; this patient is
unstable.
B — Yellow is for serious but not immediately life-
threatening; respiratory compromise makes this
immediate.
D — Black is for expected to die/unsalvageable; this
patient has survivable injuries with immediate care.
2 — ABC prioritization in trauma
During initial assessment of a trauma patient, the
nurse notes massive external bleeding from the
right femoral artery, an open airway with intact gag,
,and strong radial pulses but pale skin. Which action
has highest priority?
A. Apply direct pressure and a pressure dressing to
the femoral wound.
B. Start two large-bore IVs and hang normal saline.
C. Palpate all peripheral pulses and document
findings.
D. Administer oxygen by nonrebreather at 15 L/min.
Answer: A. Apply direct pressure and a pressure
dressing to the femoral wound.
Rationale (correct): Massive hemorrhage can
rapidly cause death; controlling life-threatening
external bleeding is the immediate priority (before
IVs or oxygen) per ABCs/hemorrhage control
principle.
Rationale (incorrect):
B — IV access is important but comes after
immediate hemorrhage control.
C — Documentation is lower priority when life-
threatening bleeding exists.
, D — Oxygen supports respiration but will not stop
exsanguination; bleeding must be controlled first.
3 — Shock recognition (early hypovolemic)
A 70-year-old patient with gastrointestinal bleeding
presents with cool, clammy skin, tachycardia 120
bpm, blood pressure 90/56 mm Hg, and a
respiratory rate of 26. The nurse suspects
hypovolemic shock. Which lab/result supports this
diagnosis most directly?
A. Elevated serum potassium
B. Decreased hemoglobin/hematocrit
C. Elevated BUN and creatinine ratio
D. Increased white blood cell count
Answer: B. Decreased hemoglobin/hematocrit
Rationale (correct): Hypovolemic shock due to
acute blood loss will lower H/H. Decreased
hemoglobin/hematocrit directly reflects blood loss
and supports the diagnosis.
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Triage category (mass-casualty)
A 32-year-old construction worker arrives at a mass-
casualty triage site with a partial-thickness burn to
25% of his anterior chest and upper abdomen,
severe respiratory distress (stridor, hoarseness), and
singed facial hairs. Which triage category should the
triage nurse assign?
A. Green — Delayed
B. Yellow — Urgent
C. Red — Immediate
D. Black — Expectant
Answer: C. Red — Immediate
,Rationale (correct): Airway compromise signs
(stridor, hoarseness) and inhalation injury are life-
threatening and require immediate
assessment/intervention (secure airway, oxygen,
possible intubation). In mass-casualty triage,
patients with compromised airway/respiration
receive “Immediate/Red” priority.
Rationale (incorrect):
A — Green is for minor injuries; this patient is
unstable.
B — Yellow is for serious but not immediately life-
threatening; respiratory compromise makes this
immediate.
D — Black is for expected to die/unsalvageable; this
patient has survivable injuries with immediate care.
2 — ABC prioritization in trauma
During initial assessment of a trauma patient, the
nurse notes massive external bleeding from the
right femoral artery, an open airway with intact gag,
,and strong radial pulses but pale skin. Which action
has highest priority?
A. Apply direct pressure and a pressure dressing to
the femoral wound.
B. Start two large-bore IVs and hang normal saline.
C. Palpate all peripheral pulses and document
findings.
D. Administer oxygen by nonrebreather at 15 L/min.
Answer: A. Apply direct pressure and a pressure
dressing to the femoral wound.
Rationale (correct): Massive hemorrhage can
rapidly cause death; controlling life-threatening
external bleeding is the immediate priority (before
IVs or oxygen) per ABCs/hemorrhage control
principle.
Rationale (incorrect):
B — IV access is important but comes after
immediate hemorrhage control.
C — Documentation is lower priority when life-
threatening bleeding exists.
, D — Oxygen supports respiration but will not stop
exsanguination; bleeding must be controlled first.
3 — Shock recognition (early hypovolemic)
A 70-year-old patient with gastrointestinal bleeding
presents with cool, clammy skin, tachycardia 120
bpm, blood pressure 90/56 mm Hg, and a
respiratory rate of 26. The nurse suspects
hypovolemic shock. Which lab/result supports this
diagnosis most directly?
A. Elevated serum potassium
B. Decreased hemoglobin/hematocrit
C. Elevated BUN and creatinine ratio
D. Increased white blood cell count
Answer: B. Decreased hemoglobin/hematocrit
Rationale (correct): Hypovolemic shock due to
acute blood loss will lower H/H. Decreased
hemoglobin/hematocrit directly reflects blood loss
and supports the diagnosis.
