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 categorization (ESI-style)
A 58-year-old man arrives to the ED with sudden, severe
shortness of breath. He is sitting upright, using accessory
muscles, pulse 120, SpO₂ 84% on room air. He is diaphoretic and
reports chest tightness. According to standard ED triage
categories (ESI/typical triage logic), which triage level is most
appropriate?
A. ESI level 1 — immediate life-saving intervention required
B. ESI level 2 — high risk or confused/lethargic/disoriented or
severe pain/distress
C. ESI level 3 — urgent; multiple resources expected
D. ESI level 4 — less urgent; 1 resource needed
Correct: A
Rationale (correct):
, 1. The patient is in respiratory distress with hypoxia (SpO₂
84%), tachycardia, and severe work of breathing — this
suggests imminent threat to life and requires immediate
life-saving interventions (oxygen, airway support, possible
intubation). Under ESI, patients who need immediate life-
saving interventions are ESI level 1.
media.emscimprovement.center
Why other options are wrong:
• B (ESI 2): Appropriate for high-risk patients who are not yet
requiring immediate life-saving intervention; this patient
already meets criteria for immediate intervention.
• C/D: Underestimate acuity — not acceptable given hypoxia
and respiratory distress.
2 — ABC prioritization in polytrauma
A motor vehicle crash victim arrives alert but pale. Primary
survey: airway patent, RR 28, breath sounds diminished on the
left, BP 86/48, HR 134, GCS 14. Which action should the nurse
perform first?
A. Secure two large-bore IVs and begin fluid resuscitation.
B. Prep for emergent chest tube insertion on the left.
C. Administer high-flow oxygen via non-rebreather mask.
D. Obtain portable chest x-ray.
Correct: C
,Rationale (correct):
1. ABC priority: Airway → Breathing → Circulation. The
airway is patent but breathing is compromised (tachypnea,
diminished left breath sounds, hypotension — possible
tension/large hemothorax). Immediate oxygen supports
oxygenation while preparing definitive interventions. High-
flow oxygen is rapid and lifesaving and can be started
immediately.
2. After oxygen, simultaneous actions include rapid IV access
and preparing chest tube/emergent decompression
depending on assessment. ATLS emphasizes rapid
stabilization and simultaneous life-saving interventions.
store.facs.org
Why other options are wrong:
• A: Important and should be started quickly, but
oxygenation must be ensured first; IV access can be
established concurrently after oxygen is applied.
• B: If tension pneumothorax suspected with hemodynamic
compromise, immediate decompression (needle
decompression) could be needed; however, initial step by
the nurse is to apply oxygen while mobilizing the team and
chest decompression equipment. If the scenario indicated
absent breath sounds and severe distention with tracheal
deviation, chest decompression would be first.
, • D: Imaging should not precede immediate stabilization in
the hypotensive, unstable trauma patient.
3 — Maslow & prioritization (psychosocial element)
A 32-year-old woman with multiple lacerations is crying and
requests that her mother be allowed into the treatment area
immediately. She is hemodynamically stable, GCS 15, no airway
compromise. Using Maslow’s hierarchy in prioritization of
needs, the nurse should:
A. Deny the request — family are not allowed until treatment
complete.
B. Allow mother to accompany patient to reduce anxiety
(safety/belonging needs).
C. Defer to provider decision; do nothing until physician asks.
D. Explain that family may join later after discharge planning
(esteem needs).
Correct: B
Rationale (correct):
1. Maslow’s hierarchy places physiologic and safety needs
first. This patient’s physiologic needs are currently met and
she is stable; next level includes belonging and emotional
support. Allowing the mother provides emotional support,
can reduce anxiety, and improve cooperation with care—
appropriate unless family presence compromises care.
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1 — Triage categorization (ESI-style)
A 58-year-old man arrives to the ED with sudden, severe
shortness of breath. He is sitting upright, using accessory
muscles, pulse 120, SpO₂ 84% on room air. He is diaphoretic and
reports chest tightness. According to standard ED triage
categories (ESI/typical triage logic), which triage level is most
appropriate?
A. ESI level 1 — immediate life-saving intervention required
B. ESI level 2 — high risk or confused/lethargic/disoriented or
severe pain/distress
C. ESI level 3 — urgent; multiple resources expected
D. ESI level 4 — less urgent; 1 resource needed
Correct: A
Rationale (correct):
, 1. The patient is in respiratory distress with hypoxia (SpO₂
84%), tachycardia, and severe work of breathing — this
suggests imminent threat to life and requires immediate
life-saving interventions (oxygen, airway support, possible
intubation). Under ESI, patients who need immediate life-
saving interventions are ESI level 1.
media.emscimprovement.center
Why other options are wrong:
• B (ESI 2): Appropriate for high-risk patients who are not yet
requiring immediate life-saving intervention; this patient
already meets criteria for immediate intervention.
• C/D: Underestimate acuity — not acceptable given hypoxia
and respiratory distress.
2 — ABC prioritization in polytrauma
A motor vehicle crash victim arrives alert but pale. Primary
survey: airway patent, RR 28, breath sounds diminished on the
left, BP 86/48, HR 134, GCS 14. Which action should the nurse
perform first?
A. Secure two large-bore IVs and begin fluid resuscitation.
B. Prep for emergent chest tube insertion on the left.
C. Administer high-flow oxygen via non-rebreather mask.
D. Obtain portable chest x-ray.
Correct: C
,Rationale (correct):
1. ABC priority: Airway → Breathing → Circulation. The
airway is patent but breathing is compromised (tachypnea,
diminished left breath sounds, hypotension — possible
tension/large hemothorax). Immediate oxygen supports
oxygenation while preparing definitive interventions. High-
flow oxygen is rapid and lifesaving and can be started
immediately.
2. After oxygen, simultaneous actions include rapid IV access
and preparing chest tube/emergent decompression
depending on assessment. ATLS emphasizes rapid
stabilization and simultaneous life-saving interventions.
store.facs.org
Why other options are wrong:
• A: Important and should be started quickly, but
oxygenation must be ensured first; IV access can be
established concurrently after oxygen is applied.
• B: If tension pneumothorax suspected with hemodynamic
compromise, immediate decompression (needle
decompression) could be needed; however, initial step by
the nurse is to apply oxygen while mobilizing the team and
chest decompression equipment. If the scenario indicated
absent breath sounds and severe distention with tracheal
deviation, chest decompression would be first.
, • D: Imaging should not precede immediate stabilization in
the hypotensive, unstable trauma patient.
3 — Maslow & prioritization (psychosocial element)
A 32-year-old woman with multiple lacerations is crying and
requests that her mother be allowed into the treatment area
immediately. She is hemodynamically stable, GCS 15, no airway
compromise. Using Maslow’s hierarchy in prioritization of
needs, the nurse should:
A. Deny the request — family are not allowed until treatment
complete.
B. Allow mother to accompany patient to reduce anxiety
(safety/belonging needs).
C. Defer to provider decision; do nothing until physician asks.
D. Explain that family may join later after discharge planning
(esteem needs).
Correct: B
Rationale (correct):
1. Maslow’s hierarchy places physiologic and safety needs
first. This patient’s physiologic needs are currently met and
she is stable; next level includes belonging and emotional
support. Allowing the mother provides emotional support,
can reduce anxiety, and improve cooperation with care—
appropriate unless family presence compromises care.
