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 (START)
A mass-casualty incident: four victims arrive. Which patient
should be triaged IMMEDIATE (red) first using START principles?
A. Conscious adult walking and complaining of leg pain.
B. Unresponsive adult not breathing; airway opens with jaw
thrust and respirations return.
C. Adult with respiratory rate 10, radial pulse present, follows
commands.
D. Adult who is breathing >30/min, has radial pulse absent, and
cannot follow commands.
Answer: D
Rationale (stepwise):
1. START triage uses: (A) respirations, (B) perfusion (radial
pulse/capillary refill), (C) mental status. Patients with RR
>30, absent radial pulse, or unable to follow commands
, are immediate (red) if salvageable. Option D meets two
immediate criteria (RR >30 and altered mental
status/perfusion) and is prioritized. REMM+1
2. A (walking wounded) → minor/green.
3. B (initially apneic but begins breathing with airway
maneuver) → if respirations present and perfusion/ability
to follow commands acceptable, could be immediate or
delayed depending on perfusion/mental status; but D is
clearly higher acuity.
4. C has normal RR, pulse, and mental status → delayed or
minor.
Why other options wrong: they do not meet the
immediate START physiologic thresholds. REMM
2 — ABC priority in trauma
A motor-vehicle crash patient has decreased level of
consciousness, suspected C-spine injury, gurgling respirations,
and a palpable femoral pulse. Which action is highest priority?
A. Immobilize C-spine with collar and backboard, then assess
airway.
B. Open airway (jaw thrust) while maintaining in-line
stabilization.
C. Rapid IV access and large-volume crystalloid bolus.
D. Apply cervical collar after securing two peripheral IVs.
,Answer: B
Rationale (stepwise):
1. ABCs: Airway with cervical spine protection is top priority.
For suspected C-spine injury, use jaw-thrust (not head tilt–
chin lift) to open airway while maintaining in-line
stabilization. This directly addresses the gurgling
respirations and risk of hypoxia. cpr.heart.org
2. A delays immediate airway opening; immobilization is
important but airway must be established concurrently.
3. C (IV fluids) is secondary — circulation interventions follow
airway and breathing in trauma unless patient is in
extremis from hemorrhage.
4. D places IVs before airway — incorrect priority.
Why other options wrong: They either delay airway or
prioritize less immediate needs. cpr.heart.org
3 — Maslow applied to triage decisions
Which need (Maslow) is most relevant when deciding which
patient receives immediate lifesaving interventions in the ED?
A. Self-actualization needs.
B. Safety and physiological needs.
C. Love and belonging needs.
D. Esteem needs.
Answer: B
, Rationale (stepwise):
1. Maslow’s hierarchy places physiological (airway, breathing,
circulation) and safety needs at the base and highest
priority in acute care decisions. Triage/priority decisions
focus on life-preserving physiologic and safety needs first.
2. A, C, D are higher-order (psychosocial) needs which are
addressed after immediate physiological stabilization.
Why other options wrong: They are not time-critical in
emergency/triage settings when physiologic threats exist.
NCSBN
4 — Shock recognition (early hypovolemic)
A postoperative patient has HR 128, BP 92/56, cool clammy
skin, urine output 15 mL/hr, and restless behavior. Which is the
best immediate nursing action?
A. Raise the head of the bed to 45° and encourage deep
breaths.
B. Begin rapid IV crystalloid bolus and notify provider.
C. Administer lorazepam for anxiety and reassess.
D. Obtain a 12-lead ECG and prepare for cardioversion.
Answer: B
Rationale (stepwise):
1. The patient’s tachycardia, hypotension, oliguria, cool skin,
and restlessness are classic for early hypovolemic shock
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1 — Triage priority (START)
A mass-casualty incident: four victims arrive. Which patient
should be triaged IMMEDIATE (red) first using START principles?
A. Conscious adult walking and complaining of leg pain.
B. Unresponsive adult not breathing; airway opens with jaw
thrust and respirations return.
C. Adult with respiratory rate 10, radial pulse present, follows
commands.
D. Adult who is breathing >30/min, has radial pulse absent, and
cannot follow commands.
Answer: D
Rationale (stepwise):
1. START triage uses: (A) respirations, (B) perfusion (radial
pulse/capillary refill), (C) mental status. Patients with RR
>30, absent radial pulse, or unable to follow commands
, are immediate (red) if salvageable. Option D meets two
immediate criteria (RR >30 and altered mental
status/perfusion) and is prioritized. REMM+1
2. A (walking wounded) → minor/green.
3. B (initially apneic but begins breathing with airway
maneuver) → if respirations present and perfusion/ability
to follow commands acceptable, could be immediate or
delayed depending on perfusion/mental status; but D is
clearly higher acuity.
4. C has normal RR, pulse, and mental status → delayed or
minor.
Why other options wrong: they do not meet the
immediate START physiologic thresholds. REMM
2 — ABC priority in trauma
A motor-vehicle crash patient has decreased level of
consciousness, suspected C-spine injury, gurgling respirations,
and a palpable femoral pulse. Which action is highest priority?
A. Immobilize C-spine with collar and backboard, then assess
airway.
B. Open airway (jaw thrust) while maintaining in-line
stabilization.
C. Rapid IV access and large-volume crystalloid bolus.
D. Apply cervical collar after securing two peripheral IVs.
,Answer: B
Rationale (stepwise):
1. ABCs: Airway with cervical spine protection is top priority.
For suspected C-spine injury, use jaw-thrust (not head tilt–
chin lift) to open airway while maintaining in-line
stabilization. This directly addresses the gurgling
respirations and risk of hypoxia. cpr.heart.org
2. A delays immediate airway opening; immobilization is
important but airway must be established concurrently.
3. C (IV fluids) is secondary — circulation interventions follow
airway and breathing in trauma unless patient is in
extremis from hemorrhage.
4. D places IVs before airway — incorrect priority.
Why other options wrong: They either delay airway or
prioritize less immediate needs. cpr.heart.org
3 — Maslow applied to triage decisions
Which need (Maslow) is most relevant when deciding which
patient receives immediate lifesaving interventions in the ED?
A. Self-actualization needs.
B. Safety and physiological needs.
C. Love and belonging needs.
D. Esteem needs.
Answer: B
, Rationale (stepwise):
1. Maslow’s hierarchy places physiological (airway, breathing,
circulation) and safety needs at the base and highest
priority in acute care decisions. Triage/priority decisions
focus on life-preserving physiologic and safety needs first.
2. A, C, D are higher-order (psychosocial) needs which are
addressed after immediate physiological stabilization.
Why other options wrong: They are not time-critical in
emergency/triage settings when physiologic threats exist.
NCSBN
4 — Shock recognition (early hypovolemic)
A postoperative patient has HR 128, BP 92/56, cool clammy
skin, urine output 15 mL/hr, and restless behavior. Which is the
best immediate nursing action?
A. Raise the head of the bed to 45° and encourage deep
breaths.
B. Begin rapid IV crystalloid bolus and notify provider.
C. Administer lorazepam for anxiety and reassess.
D. Obtain a 12-lead ECG and prepare for cardioversion.
Answer: B
Rationale (stepwise):
1. The patient’s tachycardia, hypotension, oliguria, cool skin,
and restlessness are classic for early hypovolemic shock
