Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Questions
1. A 54-year-old man is brought to the emergency department
after a motor vehicle crash. He is conscious but has obvious
chest wall deformity and is speaking in short sentences. Vital
signs: RR 32, HR 128, BP 92/56, SpO₂ 86% on room air. Which
action should the triage nurse perform first?
A. Apply oxygen via nonrebreather mask at 15 L/min.
B. Insert a large-bore IV and begin 0.9% NS bolus.
C. Perform a focused chest assessment and prepare for chest
tube insertion.
D. Obtain an immediate portable chest x-ray.
Correct answer: A
Rationale (stepwise):
, • Prioritization: airway and oxygenation are highest priority
(ABCs). The patient has increased work of breathing and
hypoxemia (SpO₂ 86%). Administering high-flow oxygen is
the fastest intervention to correct hypoxia and stabilize the
patient prior to more invasive measures.
• B (IV fluid): Important for hypotension but circulation
interventions follow ensuring oxygenation. Giving fluids
without improving oxygenation may not correct tissue
hypoxia.
• C (chest assessment/chest tube): A chest tube may be
required for tension pneumothorax or hemothorax, but
immediate oxygen delivery is faster and essential while
preparing equipment. If clinical signs of tension
pneumothorax (tracheal deviation, absent breath sounds)
were present, decompression would be emergent — not
described here.
• D (portable chest x-ray): Diagnostic imaging is useful but
should not delay immediate oxygenation and resuscitation.
(Framework: ABCs → immediate O₂, then C and definitive
procedures). NCBI
2. A triage nurse at a mass-casualty incident (MCI) uses START
triage. Which description best matches the “red (immediate)”
category?
,A. Ambulatory patients with minor injuries; can wait several
hours.
B. Patients not breathing after airway repositioning; expectant.
C. Patients with compromised airway, respiratory rate >30, or
uncontrolled hemorrhage but high potential for survival with
immediate care.
D. Patients with serious injuries but stable vital signs who can
have delayed transport.
Correct answer: C
Rationale:
• START defines red/immediate as those who require
immediate intervention to survive (airway compromise, RR
>30, capillary refill >2 sec, inability to follow commands in
some systems, or severe hemorrhage). These patients have
a high potential for survival if treated quickly. REMM+1
• A describes green/minor.
• B describes expectant/black (deceased/expectant) after
failed airway repositioning.
• D describes yellow/delayed.
3. (Case-based) A 28-year-old woman arrives after a house fire.
She is alert and complaining of a sore throat and hoarseness.
Burns: partial-thickness burns to face and neck, 6% TBSA. Vital
, signs: RR 24, HR 110, BP 118/72, SpO₂ 98% on room air. Which
intervention is highest priority?
A. Apply cool compresses and silver sulfadiazine to facial burns.
B. Administer humidified oxygen and prepare for early airway
evaluation (laryngoscopy/ENT consult).
C. Start oral analgesics and discharge with follow-up.
D. Begin intravenous fluids using Parkland formula.
Correct answer: B
Rationale:
• In inhalation injury risk (face/neck burns, hoarseness, soot
around nares), airway edema can progress rapidly. Early
airway evaluation and humidified oxygen are priority to
anticipate airway compromise — establishing airway early
is lifesaving.
• A (topical burn care) is important but secondary to airway
protection.
• C (discharge) is unsafe given airway risk.
• D (IV fluids) is indicated for major burns (>20% TBSA in
adults); 6% TBSA does not usually require Parkland
resuscitation. Thus B is highest priority. (Guiding principle:
airway before other interventions in burns with potential
inhalation injury.) NCBI
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Questions
1. A 54-year-old man is brought to the emergency department
after a motor vehicle crash. He is conscious but has obvious
chest wall deformity and is speaking in short sentences. Vital
signs: RR 32, HR 128, BP 92/56, SpO₂ 86% on room air. Which
action should the triage nurse perform first?
A. Apply oxygen via nonrebreather mask at 15 L/min.
B. Insert a large-bore IV and begin 0.9% NS bolus.
C. Perform a focused chest assessment and prepare for chest
tube insertion.
D. Obtain an immediate portable chest x-ray.
Correct answer: A
Rationale (stepwise):
, • Prioritization: airway and oxygenation are highest priority
(ABCs). The patient has increased work of breathing and
hypoxemia (SpO₂ 86%). Administering high-flow oxygen is
the fastest intervention to correct hypoxia and stabilize the
patient prior to more invasive measures.
• B (IV fluid): Important for hypotension but circulation
interventions follow ensuring oxygenation. Giving fluids
without improving oxygenation may not correct tissue
hypoxia.
• C (chest assessment/chest tube): A chest tube may be
required for tension pneumothorax or hemothorax, but
immediate oxygen delivery is faster and essential while
preparing equipment. If clinical signs of tension
pneumothorax (tracheal deviation, absent breath sounds)
were present, decompression would be emergent — not
described here.
• D (portable chest x-ray): Diagnostic imaging is useful but
should not delay immediate oxygenation and resuscitation.
(Framework: ABCs → immediate O₂, then C and definitive
procedures). NCBI
2. A triage nurse at a mass-casualty incident (MCI) uses START
triage. Which description best matches the “red (immediate)”
category?
,A. Ambulatory patients with minor injuries; can wait several
hours.
B. Patients not breathing after airway repositioning; expectant.
C. Patients with compromised airway, respiratory rate >30, or
uncontrolled hemorrhage but high potential for survival with
immediate care.
D. Patients with serious injuries but stable vital signs who can
have delayed transport.
Correct answer: C
Rationale:
• START defines red/immediate as those who require
immediate intervention to survive (airway compromise, RR
>30, capillary refill >2 sec, inability to follow commands in
some systems, or severe hemorrhage). These patients have
a high potential for survival if treated quickly. REMM+1
• A describes green/minor.
• B describes expectant/black (deceased/expectant) after
failed airway repositioning.
• D describes yellow/delayed.
3. (Case-based) A 28-year-old woman arrives after a house fire.
She is alert and complaining of a sore throat and hoarseness.
Burns: partial-thickness burns to face and neck, 6% TBSA. Vital
, signs: RR 24, HR 110, BP 118/72, SpO₂ 98% on room air. Which
intervention is highest priority?
A. Apply cool compresses and silver sulfadiazine to facial burns.
B. Administer humidified oxygen and prepare for early airway
evaluation (laryngoscopy/ENT consult).
C. Start oral analgesics and discharge with follow-up.
D. Begin intravenous fluids using Parkland formula.
Correct answer: B
Rationale:
• In inhalation injury risk (face/neck burns, hoarseness, soot
around nares), airway edema can progress rapidly. Early
airway evaluation and humidified oxygen are priority to
anticipate airway compromise — establishing airway early
is lifesaving.
• A (topical burn care) is important but secondary to airway
protection.
• C (discharge) is unsafe given airway risk.
• D (IV fluids) is indicated for major burns (>20% TBSA in
adults); 6% TBSA does not usually require Parkland
resuscitation. Thus B is highest priority. (Guiding principle:
airway before other interventions in burns with potential
inhalation injury.) NCBI
