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 priority (mass-casualty)
A rescue team arrives at a multi-vehicle crash with many
injured. You are performing START triage. Which patient should
be tagged Immediate (red) and transported first?
A. A conscious adult breathing 34/min, radial pulse present,
follows simple commands.
B. An adult who is unresponsive, has agonal respirations after
airway repositioning, and no palpable pulse.
C. An adult breathing 10/min, radial pulse present, can follow
commands but has an open femur fracture.
D. An adult who is walking and complaining of minor arm pain
only.
Answer: A
Rationale (stepwise):
, 1. START triage uses RPM (Respiration → Perfusion → Mental
status). A breathing rate >30/min is one criterion for
Immediate (red). Option A meets RR >30 and can still
follow commands — immediate transport required. cert-
la.com
2. Option B: agonal respirations and no pulse after
repositioning indicate likely deceased/expectant (black) on
initial START; not immediate transport.
3. Option C: breathing 10/min and able to follow commands
suggests Delayed (yellow) despite serious extremity injury.
4. Option D: walking wounded = Minor (green).
Why others are wrong: B is expectant/deceased; C and D
are lower priority than A. (START triage prioritizes life-
threatening physiologic derangements first.) cert-la.com
2 — ABCs and airway management
A 56-year-old man arrives by ambulance after being found
unconscious at home. He is snoring and has partial obstruction
of the airway. He is breathing spontaneously with SpO₂ 88% on
room air. What is the nurse’s immediate priority action?
A. Perform jaw-thrust and supplemental oxygen via
nonrebreather mask at 15 L/min.
B. Obtain a chest x-ray before instituting oxygen therapy.
C. Place an oropharyngeal airway and begin bag-valve-mask
,ventilation with 100% O₂.
D. Insert an IV line and administer naloxone empirically.
Answer: A
Rationale (stepwise):
1. Airway first (A in ABCs). Snoring indicates partial airway
obstruction; immediate airway opening maneuver is
needed. A jaw-thrust (or chin-lift if no c-spine concern) is
appropriate and can be done immediately while starting
high-flow oxygen via nonrebreather to improve SpO₂.
2. Option C (oropharyngeal airway + BVM) is appropriate if
the patient cannot protect airway or ventilation is
inadequate; because the patient is breathing
spontaneously, starting with repositioning and high-flow
O₂ is less invasive and immediate.
3. Option D (IV + naloxone) may be indicated if opioid
overdose suspected, but airway patency and oxygenation
are higher immediate priorities.
4. Option B delays life-saving actions; imaging is not first.
Why others are wrong: Imaging (B) is not emergent before
airway/oxygen. BVM (C) is reasonable if airway maneuvers
fail; naloxone (D) is situational and secondary to securing
airway/oxygenation.
3 — Maslow and prioritization (non-acute)
, Which nursing problem best demonstrates application of
Maslow’s hierarchy when prioritizing care for a group of ED
patients?
A. Treat pain after ensuring airway and hemodynamic stability.
B. Provide spiritual care before assessing vitals.
C. Reassure a patient emotionally disturbed before treating
hemorrhage.
D. Offer patient education about discharge instructions before
addressing breathing difficulty.
Answer: A
Rationale (stepwise):
1. Maslow’s hierarchy places physiologic needs (airway,
breathing, circulation, pain control) at the base; safety and
security follow. Thus, treating pain after ensuring
airway/hemodynamic stability respects physiologic
priority.
2. Options B–D prioritize secondary needs (spiritual,
emotional, education) ahead of life-threatening physiologic
problems — incorrect for triage/acute care.
Why others are wrong: Emotional and educational needs
are important but come after immediate physiologic
stabilization.
4 — Anaphylaxis immediate treatment
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1 — Triage priority (mass-casualty)
A rescue team arrives at a multi-vehicle crash with many
injured. You are performing START triage. Which patient should
be tagged Immediate (red) and transported first?
A. A conscious adult breathing 34/min, radial pulse present,
follows simple commands.
B. An adult who is unresponsive, has agonal respirations after
airway repositioning, and no palpable pulse.
C. An adult breathing 10/min, radial pulse present, can follow
commands but has an open femur fracture.
D. An adult who is walking and complaining of minor arm pain
only.
Answer: A
Rationale (stepwise):
, 1. START triage uses RPM (Respiration → Perfusion → Mental
status). A breathing rate >30/min is one criterion for
Immediate (red). Option A meets RR >30 and can still
follow commands — immediate transport required. cert-
la.com
2. Option B: agonal respirations and no pulse after
repositioning indicate likely deceased/expectant (black) on
initial START; not immediate transport.
3. Option C: breathing 10/min and able to follow commands
suggests Delayed (yellow) despite serious extremity injury.
4. Option D: walking wounded = Minor (green).
Why others are wrong: B is expectant/deceased; C and D
are lower priority than A. (START triage prioritizes life-
threatening physiologic derangements first.) cert-la.com
2 — ABCs and airway management
A 56-year-old man arrives by ambulance after being found
unconscious at home. He is snoring and has partial obstruction
of the airway. He is breathing spontaneously with SpO₂ 88% on
room air. What is the nurse’s immediate priority action?
A. Perform jaw-thrust and supplemental oxygen via
nonrebreather mask at 15 L/min.
B. Obtain a chest x-ray before instituting oxygen therapy.
C. Place an oropharyngeal airway and begin bag-valve-mask
,ventilation with 100% O₂.
D. Insert an IV line and administer naloxone empirically.
Answer: A
Rationale (stepwise):
1. Airway first (A in ABCs). Snoring indicates partial airway
obstruction; immediate airway opening maneuver is
needed. A jaw-thrust (or chin-lift if no c-spine concern) is
appropriate and can be done immediately while starting
high-flow oxygen via nonrebreather to improve SpO₂.
2. Option C (oropharyngeal airway + BVM) is appropriate if
the patient cannot protect airway or ventilation is
inadequate; because the patient is breathing
spontaneously, starting with repositioning and high-flow
O₂ is less invasive and immediate.
3. Option D (IV + naloxone) may be indicated if opioid
overdose suspected, but airway patency and oxygenation
are higher immediate priorities.
4. Option B delays life-saving actions; imaging is not first.
Why others are wrong: Imaging (B) is not emergent before
airway/oxygen. BVM (C) is reasonable if airway maneuvers
fail; naloxone (D) is situational and secondary to securing
airway/oxygenation.
3 — Maslow and prioritization (non-acute)
, Which nursing problem best demonstrates application of
Maslow’s hierarchy when prioritizing care for a group of ED
patients?
A. Treat pain after ensuring airway and hemodynamic stability.
B. Provide spiritual care before assessing vitals.
C. Reassure a patient emotionally disturbed before treating
hemorrhage.
D. Offer patient education about discharge instructions before
addressing breathing difficulty.
Answer: A
Rationale (stepwise):
1. Maslow’s hierarchy places physiologic needs (airway,
breathing, circulation, pain control) at the base; safety and
security follow. Thus, treating pain after ensuring
airway/hemodynamic stability respects physiologic
priority.
2. Options B–D prioritize secondary needs (spiritual,
emotional, education) ahead of life-threatening physiologic
problems — incorrect for triage/acute care.
Why others are wrong: Emotional and educational needs
are important but come after immediate physiologic
stabilization.
4 — Anaphylaxis immediate treatment
