Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Question 1 — Prioritization / Triage (Application)
A 54-year-old man arrives at triage after a one-vehicle rollover.
He is conscious but confused, RR 28, shallow respirations, O₂
saturation 86% on room air, large facial laceration actively
bleeding, probable neck pain. According to standard triage and
ABC principles, which action should the triage nurse perform
first?
A. Apply a cervical collar and immobilize the spine.
B. Open the airway with jaw-thrust and administer high-flow
oxygen via nonrebreather mask.
C. Control facial bleeding with direct pressure and dress the
wound.
D. Start two large-bore IVs and begin fluid resuscitation.
Answer: B
Rationale — correct (B):
, 1. Airway compromise is immediately life-threatening. The
patient has shallow respirations and hypoxemia (SpO₂
86%), so securing/assessing the airway and improving
oxygenation takes priority. A jaw-thrust is appropriate
when cervical spine injury is suspected. High-flow oxygen
via nonrebreather helps rapidly correct hypoxemia while
definitive airway planning occurs.
2. This follows ABCs (Airway first, then Breathing, then
Circulation).
Why the others are incorrect:
A: Cervical immobilization is important (and should be done
promptly) but only after basic airway maneuver and
oxygenation are addressed. Immobilization can be applied
concurrently if additional staff are present, but if only one
immediate action can correct hypoxemia, airway/oxygen take
precedence.
C: Controlling hemorrhage is vital for circulation (C) but comes
after establishing airway/oxygenation in immediate priority.
Severe airway compromise will cause death before uncontrolled
external bleeding in many cases.
D: IV access and fluids are essential for shock/trauma
management but are secondary to securing airway and
breathing.
Question 2 — Shock Recognition (Analysis)
,A patient in the ED has been hypotensive and tachycardic after
a penetrating abdominal injury. Vital signs: BP 82/48 mmHg, HR
128 bpm, RR 24, cool/clammy skin, decreased urine output.
Which type of shock is most likely, and what is the priority
nursing intervention?
A. Cardiogenic shock — administer inotropic support.
B. Hypovolemic shock — control hemorrhage and initiate rapid
volume resuscitation.
C. Distributive (septic) shock — start broad-spectrum
antibiotics.
D. Neurogenic shock — stabilize the spine and provide
vasopressors.
Answer: B
Rationale — correct (B):
1. Penetrating abdominal injury with hypotension,
tachycardia, cool/clammy skin, and oliguria strongly
suggests hypovolemic shock due to hemorrhage.
2. Priority is to control bleeding (surgical/interventional
control) and restore circulating volume rapidly (IV access,
large-bore IVs, blood products as indicated), which directly
addresses the cause.
Why the others are incorrect:
A: Cardiogenic shock usually follows myocardial pump failure
with signs like pulmonary edema; cool/clammy skin can occur,
but history of penetrating trauma makes hypovolemia more
, likely. Inotropes without volume replacement are not first-line
here.
C: Septic shock presents with warm, flushed skin early and
history of infection; antibiotics are critical but not the
immediate priority for hemorrhagic shock.
D: Neurogenic shock often features hypotension with
bradycardia and warm dry skin; this patient is tachycardic and
has trauma-to-bleeding context.
Question 3 — Burns (Application)
A 32-year-old firefighter with partial- and full-thickness burns to
his face, neck, and chest after a structure fire arrives alert but
hoarse and with singed nasal hairs. Which intervention should
the nurse prepare for immediately?
A. Initiate aggressive IV fluids per burn formula and monitor
urine output.
B. Provide humidified oxygen and prepare for early
endotracheal intubation.
C. Apply topical silver sulfadiazine to burn areas and cover with
sterile dressings.
D. Start prophylactic antibiotics to prevent wound infection.
Answer: B
Rationale — correct (B):
1. Inhalation injury is suspected (facial/neck burns,
hoarseness, singed nasal hairs). Airway edema can
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Question 1 — Prioritization / Triage (Application)
A 54-year-old man arrives at triage after a one-vehicle rollover.
He is conscious but confused, RR 28, shallow respirations, O₂
saturation 86% on room air, large facial laceration actively
bleeding, probable neck pain. According to standard triage and
ABC principles, which action should the triage nurse perform
first?
A. Apply a cervical collar and immobilize the spine.
B. Open the airway with jaw-thrust and administer high-flow
oxygen via nonrebreather mask.
C. Control facial bleeding with direct pressure and dress the
wound.
D. Start two large-bore IVs and begin fluid resuscitation.
Answer: B
Rationale — correct (B):
, 1. Airway compromise is immediately life-threatening. The
patient has shallow respirations and hypoxemia (SpO₂
86%), so securing/assessing the airway and improving
oxygenation takes priority. A jaw-thrust is appropriate
when cervical spine injury is suspected. High-flow oxygen
via nonrebreather helps rapidly correct hypoxemia while
definitive airway planning occurs.
2. This follows ABCs (Airway first, then Breathing, then
Circulation).
Why the others are incorrect:
A: Cervical immobilization is important (and should be done
promptly) but only after basic airway maneuver and
oxygenation are addressed. Immobilization can be applied
concurrently if additional staff are present, but if only one
immediate action can correct hypoxemia, airway/oxygen take
precedence.
C: Controlling hemorrhage is vital for circulation (C) but comes
after establishing airway/oxygenation in immediate priority.
Severe airway compromise will cause death before uncontrolled
external bleeding in many cases.
D: IV access and fluids are essential for shock/trauma
management but are secondary to securing airway and
breathing.
Question 2 — Shock Recognition (Analysis)
,A patient in the ED has been hypotensive and tachycardic after
a penetrating abdominal injury. Vital signs: BP 82/48 mmHg, HR
128 bpm, RR 24, cool/clammy skin, decreased urine output.
Which type of shock is most likely, and what is the priority
nursing intervention?
A. Cardiogenic shock — administer inotropic support.
B. Hypovolemic shock — control hemorrhage and initiate rapid
volume resuscitation.
C. Distributive (septic) shock — start broad-spectrum
antibiotics.
D. Neurogenic shock — stabilize the spine and provide
vasopressors.
Answer: B
Rationale — correct (B):
1. Penetrating abdominal injury with hypotension,
tachycardia, cool/clammy skin, and oliguria strongly
suggests hypovolemic shock due to hemorrhage.
2. Priority is to control bleeding (surgical/interventional
control) and restore circulating volume rapidly (IV access,
large-bore IVs, blood products as indicated), which directly
addresses the cause.
Why the others are incorrect:
A: Cardiogenic shock usually follows myocardial pump failure
with signs like pulmonary edema; cool/clammy skin can occur,
but history of penetrating trauma makes hypovolemia more
, likely. Inotropes without volume replacement are not first-line
here.
C: Septic shock presents with warm, flushed skin early and
history of infection; antibiotics are critical but not the
immediate priority for hemorrhagic shock.
D: Neurogenic shock often features hypotension with
bradycardia and warm dry skin; this patient is tachycardic and
has trauma-to-bleeding context.
Question 3 — Burns (Application)
A 32-year-old firefighter with partial- and full-thickness burns to
his face, neck, and chest after a structure fire arrives alert but
hoarse and with singed nasal hairs. Which intervention should
the nurse prepare for immediately?
A. Initiate aggressive IV fluids per burn formula and monitor
urine output.
B. Provide humidified oxygen and prepare for early
endotracheal intubation.
C. Apply topical silver sulfadiazine to burn areas and cover with
sterile dressings.
D. Start prophylactic antibiotics to prevent wound infection.
Answer: B
Rationale — correct (B):
1. Inhalation injury is suspected (facial/neck burns,
hoarseness, singed nasal hairs). Airway edema can
