Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1 — Triage acuity (ESI)
A 68-year-old man arrives to triage with sudden collapse at
home, unresponsive, apneic, and pulseless. According to a 5-
level triage tool (ESI), which triage level is appropriate and why?
A. ESI level 1 — immediate, life-saving intervention required
B. ESI level 2 — high risk of deterioration
C. ESI level 3 — stable but needs multiple resources
D. ESI level 4 — stable, one resource anticipated
Correct answer: A
Rationale (stepwise):
1. ESI Level 1 is for patients who require immediate life-
saving interventions (e.g., cardiac arrest, unresponsive and
apneic). This patient is pulseless and apneic — immediate
resuscitation is required. EMSC Improvement Center
, 2. Option B (Level 2) is for high-risk but not actively requiring
immediate life-saving measures. Option C and D reflect
progressively lower acuity and are inappropriate given
active cardiac arrest.
3. Prioritization principle: immediate
airway/breathing/circulation (ABCs) and activation of the
resuscitation team take precedence.
2 — Initial action for suspected tension pneumothorax in
trauma
During the primary survey of a trauma patient, the nurse notes
respiratory distress, tracheal deviation away from the injured
side, absent breath sounds on the left, and hypotension. The
most immediate nursing action is:
A. Apply high-flow oxygen and arrange chest x-ray.
B. Prepare for immediate needle decompression
(thoracostomy) of the left chest.
C. Start IV fluids and wait for surgeon arrival.
D. Insert an orogastric tube to decompress the stomach.
Correct answer: B
Rationale (stepwise):
1. Findings (distended neck veins, tracheal deviation, absent
breath sounds, hypotension) are classic for tension
pneumothorax — a life-threatening obstructive shock
requiring immediate decompression. Immediate needle
, decompression followed by chest tube placement is
indicated.
2. Option A (CXR) would delay life-saving intervention. Option
C (IV fluids) may be needed but will not relieve the
mechanical compression of the mediastinum. Option D
(orogastric tube) is irrelevant to relief of tension
physiology.
3. This follows ATLS/trauma primary survey priorities: airway,
breathing (treat life-threatening thoracic causes), then
circulation. Medscape
3 — Maslow and prioritization
Which of the following nursing actions best reflects application
of Maslow’s hierarchy when triaging multiple ED patients?
A. First see the patient requesting social work for housing.
B. First assess the patient with active hemorrhage and
hypotension.
C. First see the patient requesting pain medication for chronic
back pain.
D. First see the patient needing prescription refill.
Correct answer: B
Rationale (stepwise):
1. Maslow and clinical prioritization place physiological needs
(airway, breathing, circulation) at highest priority; active
, hemorrhage/hypotension is an immediate life/physiologic
threat.
2. Options A, C, and D address higher-level needs (safety,
comfort, psychosocial) that are lower priority when
physiologic stability is compromised.
4 — Cardiac arrest — immediate nurse action
A 55-year-old man in the ED becomes unresponsive and
pulseless. The nurse identifies ventricular fibrillation on the
monitor. According to current AHA guidelines, the nurse should
first:
A. Deliver immediate defibrillation (unsynchronized shock) and
begin CPR.
B. Give IV epinephrine before chest compressions.
C. Intubate the patient immediately before compressions.
D. Administer amiodarone as first drug.
Correct answer: A
Rationale (stepwise):
1. For shockable rhythms (VF/pulseless VT), early
defibrillation and high-quality CPR are paramount. AHA
recommends immediate shock and continuous chest
compressions with minimal interruptions. cpr.heart.org
2. Option B is incorrect: epinephrine is given after initial
defibrillation attempts per algorithm timing, not before
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1 — Triage acuity (ESI)
A 68-year-old man arrives to triage with sudden collapse at
home, unresponsive, apneic, and pulseless. According to a 5-
level triage tool (ESI), which triage level is appropriate and why?
A. ESI level 1 — immediate, life-saving intervention required
B. ESI level 2 — high risk of deterioration
C. ESI level 3 — stable but needs multiple resources
D. ESI level 4 — stable, one resource anticipated
Correct answer: A
Rationale (stepwise):
1. ESI Level 1 is for patients who require immediate life-
saving interventions (e.g., cardiac arrest, unresponsive and
apneic). This patient is pulseless and apneic — immediate
resuscitation is required. EMSC Improvement Center
, 2. Option B (Level 2) is for high-risk but not actively requiring
immediate life-saving measures. Option C and D reflect
progressively lower acuity and are inappropriate given
active cardiac arrest.
3. Prioritization principle: immediate
airway/breathing/circulation (ABCs) and activation of the
resuscitation team take precedence.
2 — Initial action for suspected tension pneumothorax in
trauma
During the primary survey of a trauma patient, the nurse notes
respiratory distress, tracheal deviation away from the injured
side, absent breath sounds on the left, and hypotension. The
most immediate nursing action is:
A. Apply high-flow oxygen and arrange chest x-ray.
B. Prepare for immediate needle decompression
(thoracostomy) of the left chest.
C. Start IV fluids and wait for surgeon arrival.
D. Insert an orogastric tube to decompress the stomach.
Correct answer: B
Rationale (stepwise):
1. Findings (distended neck veins, tracheal deviation, absent
breath sounds, hypotension) are classic for tension
pneumothorax — a life-threatening obstructive shock
requiring immediate decompression. Immediate needle
, decompression followed by chest tube placement is
indicated.
2. Option A (CXR) would delay life-saving intervention. Option
C (IV fluids) may be needed but will not relieve the
mechanical compression of the mediastinum. Option D
(orogastric tube) is irrelevant to relief of tension
physiology.
3. This follows ATLS/trauma primary survey priorities: airway,
breathing (treat life-threatening thoracic causes), then
circulation. Medscape
3 — Maslow and prioritization
Which of the following nursing actions best reflects application
of Maslow’s hierarchy when triaging multiple ED patients?
A. First see the patient requesting social work for housing.
B. First assess the patient with active hemorrhage and
hypotension.
C. First see the patient requesting pain medication for chronic
back pain.
D. First see the patient needing prescription refill.
Correct answer: B
Rationale (stepwise):
1. Maslow and clinical prioritization place physiological needs
(airway, breathing, circulation) at highest priority; active
, hemorrhage/hypotension is an immediate life/physiologic
threat.
2. Options A, C, and D address higher-level needs (safety,
comfort, psychosocial) that are lower priority when
physiologic stability is compromised.
4 — Cardiac arrest — immediate nurse action
A 55-year-old man in the ED becomes unresponsive and
pulseless. The nurse identifies ventricular fibrillation on the
monitor. According to current AHA guidelines, the nurse should
first:
A. Deliver immediate defibrillation (unsynchronized shock) and
begin CPR.
B. Give IV epinephrine before chest compressions.
C. Intubate the patient immediately before compressions.
D. Administer amiodarone as first drug.
Correct answer: A
Rationale (stepwise):
1. For shockable rhythms (VF/pulseless VT), early
defibrillation and high-quality CPR are paramount. AHA
recommends immediate shock and continuous chest
compressions with minimal interruptions. cpr.heart.org
2. Option B is incorrect: epinephrine is given after initial
defibrillation attempts per algorithm timing, not before
