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 — START triage (field / mass casualty)
At a mass-casualty incident using START triage, which of the
following patients should be tagged Immediate (Red) and taken
first to the treatment area?
A. A walking wounded adult with minor lacerations and steady
respirations.
B. An adult who is unresponsive, breathing 40 breaths/min,
radial pulse present, and follows simple commands.
C. A conscious adult with a penetrating chest wound, agonal
respirations, and no palpable radial pulse.
D. An adult with a simple fracture, normal respirations, and
oriented.
Correct answer: B
Rationale (stepwise):
, • Why B is correct: START designates patients who are
breathing, have a radial pulse, and can follow commands
but have high respiratory rate as Immediate because they
may deteriorate and require rapid intervention
(airway/ventilatory support). This patient is not walking
wounded and is potentially unstable—priority is rapid
assessment and transport. NCBI+1
• Why A is incorrect: Walking wounded are tagged Minor
(Green) and are lower priority.
• Why C is incorrect: Agonal respirations with no palpable
radial pulse often indicate expectant or immediate
resuscitation attempts in resource-rich settings; however in
START, apneic patients after airway repositioning are often
tagged deceased/expectant when resources are limited —
not the immediate transport category for survivable
injuries.
• Why D is incorrect: Simple fracture with normal vitals is
lower priority (Delayed/Yellow or Green depending on
resource availability).
Question 2 — Primary survey (trauma): airway priority
A 28-year-old involved in a motor vehicle crash arrives with
decreased level of consciousness (GCS 7), abundant facial
burns, singed nasal hairs, and progressive stridor. Which action
should the ED nurse prioritize immediately?
,A. Apply cold compresses to facial burns and observe airway.
B. Prepare for immediate endotracheal intubation (early airway
control).
C. Obtain a portable chest x-ray prior to airway intervention.
D. Start IV fluids via peripheral IV and wait for airway team.
Correct answer: B
Rationale (stepwise):
• Why B is correct: In trauma and burns, signs of inhalation
injury (facial burns, singed nasal hair, hoarseness/stridor)
and reduced consciousness indicate imminent airway loss
— early definitive airway (intubation) is recommended
because airway edema can rapidly progress. Managing the
airway is the first step in the primary survey (A of ABCs).
NCBI+1
• Why A is incorrect: Cooling burns is important, but airway
compromise takes immediate precedence. Delaying airway
control risks complete obstruction.
• Why C is incorrect: Diagnostic imaging should not precede
securing a threatened airway.
• Why D is incorrect: Rapid vascular access is important, but
airway control is the top priority when airway compromise
is imminent.
Question 3 — Burn fluid resuscitation (calculation)
, An 80-kg adult sustains thermal burns estimated at 30% TBSA.
Using the Parkland formula (4 mL × kg × %TBSA), what total
volume of lactated Ringer’s should be given in the first 24 hours
and how much in the first 8 hours?
A. Total 4,800 mL; 2,400 mL in first 8 hours.
B. Total 9,600 mL; 4,800 mL in first 8 hours.
C. Total 12,000 mL; 6,000 mL in first 8 hours.
D. Total 6,400 mL; 3,200 mL in first 8 hours.
Correct answer: B
Rationale (stepwise):
• Calculation: Parkland = 4 mL × weight (kg) × %TBSA → 4 ×
80 × 30 = 9,600 mL in 24 hours. Half of that (4,800 mL) is
given in the first 8 hours from time of burn. This is the
established resuscitation guideline used in adult burn care.
NCBI+1
• Why B is correct: Matches Parkland calculation and timing.
• Why A, C, D are incorrect: They show incorrect arithmetic
or incorrect fractioning of the 24-hour volume.
Question 4 — Anaphylaxis dosing (pediatric)
A 6-year-old child (20 kg) presents with sudden generalized
urticaria, wheezing, hypotension, and altered mental status
after eating peanuts. According to guideline dosing, which of
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Question 1 — START triage (field / mass casualty)
At a mass-casualty incident using START triage, which of the
following patients should be tagged Immediate (Red) and taken
first to the treatment area?
A. A walking wounded adult with minor lacerations and steady
respirations.
B. An adult who is unresponsive, breathing 40 breaths/min,
radial pulse present, and follows simple commands.
C. A conscious adult with a penetrating chest wound, agonal
respirations, and no palpable radial pulse.
D. An adult with a simple fracture, normal respirations, and
oriented.
Correct answer: B
Rationale (stepwise):
, • Why B is correct: START designates patients who are
breathing, have a radial pulse, and can follow commands
but have high respiratory rate as Immediate because they
may deteriorate and require rapid intervention
(airway/ventilatory support). This patient is not walking
wounded and is potentially unstable—priority is rapid
assessment and transport. NCBI+1
• Why A is incorrect: Walking wounded are tagged Minor
(Green) and are lower priority.
• Why C is incorrect: Agonal respirations with no palpable
radial pulse often indicate expectant or immediate
resuscitation attempts in resource-rich settings; however in
START, apneic patients after airway repositioning are often
tagged deceased/expectant when resources are limited —
not the immediate transport category for survivable
injuries.
• Why D is incorrect: Simple fracture with normal vitals is
lower priority (Delayed/Yellow or Green depending on
resource availability).
Question 2 — Primary survey (trauma): airway priority
A 28-year-old involved in a motor vehicle crash arrives with
decreased level of consciousness (GCS 7), abundant facial
burns, singed nasal hairs, and progressive stridor. Which action
should the ED nurse prioritize immediately?
,A. Apply cold compresses to facial burns and observe airway.
B. Prepare for immediate endotracheal intubation (early airway
control).
C. Obtain a portable chest x-ray prior to airway intervention.
D. Start IV fluids via peripheral IV and wait for airway team.
Correct answer: B
Rationale (stepwise):
• Why B is correct: In trauma and burns, signs of inhalation
injury (facial burns, singed nasal hair, hoarseness/stridor)
and reduced consciousness indicate imminent airway loss
— early definitive airway (intubation) is recommended
because airway edema can rapidly progress. Managing the
airway is the first step in the primary survey (A of ABCs).
NCBI+1
• Why A is incorrect: Cooling burns is important, but airway
compromise takes immediate precedence. Delaying airway
control risks complete obstruction.
• Why C is incorrect: Diagnostic imaging should not precede
securing a threatened airway.
• Why D is incorrect: Rapid vascular access is important, but
airway control is the top priority when airway compromise
is imminent.
Question 3 — Burn fluid resuscitation (calculation)
, An 80-kg adult sustains thermal burns estimated at 30% TBSA.
Using the Parkland formula (4 mL × kg × %TBSA), what total
volume of lactated Ringer’s should be given in the first 24 hours
and how much in the first 8 hours?
A. Total 4,800 mL; 2,400 mL in first 8 hours.
B. Total 9,600 mL; 4,800 mL in first 8 hours.
C. Total 12,000 mL; 6,000 mL in first 8 hours.
D. Total 6,400 mL; 3,200 mL in first 8 hours.
Correct answer: B
Rationale (stepwise):
• Calculation: Parkland = 4 mL × weight (kg) × %TBSA → 4 ×
80 × 30 = 9,600 mL in 24 hours. Half of that (4,800 mL) is
given in the first 8 hours from time of burn. This is the
established resuscitation guideline used in adult burn care.
NCBI+1
• Why B is correct: Matches Parkland calculation and timing.
• Why A, C, D are incorrect: They show incorrect arithmetic
or incorrect fractioning of the 24-hour volume.
Question 4 — Anaphylaxis dosing (pediatric)
A 6-year-old child (20 kg) presents with sudden generalized
urticaria, wheezing, hypotension, and altered mental status
after eating peanuts. According to guideline dosing, which of
