Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1 (Single-best-answer — Triage / ESI)
A 67-year-old male arrives to the ED by ambulance with chest
pain, diaphoresis, and shortness of breath. He is pale and
diaphoretic, says “I feel like I’m going to die,” and has mildly
labored respirations. Vital signs: HR 110, BP 90/56, RR 24, SpO₂
92% on room air. According to the Emergency Severity Index
(ESI) 5-level triage algorithm, what ESI level should the nurse
assign?
A. ESI level 1 — immediate lifesaving intervention required
B. ESI level 2 — high risk or severe pain/distress
C. ESI level 3 — urgent but not high-risk
D. ESI level 4 — needs one resource
Correct answer: B
Rationale (correct):
, • ESI level 2 is appropriate for patients who are high-risk,
appear very ill, or have severe pain or distress and do not
require an immediate life-saving intervention. This patient
is hypotensive (BP 90/56), tachycardic, diaphoretic and
reports severe distress — all indicators of high risk
requiring rapid evaluation. The ESI aims to rapidly identify
such high-risk patients for expedited care.
media.emscimprovement.center
Rationale (incorrect options):
• A: ESI level 1 is reserved for patients requiring immediate
lifesaving interventions (e.g., active CPR, open airway with
need for immediate intubation, ongoing major
hemorrhage). Although this patient is unstable, there is
not an immediate documented need for a lifesaving
procedure at triage.
• C: ESI level 3 is for patients who are stable enough to wait
and whose expected resource needs are multiple; this
patient is higher risk.
• D: ESI level 4 signals a single resource needed (e.g., simple
X-ray) — clearly inappropriate for this unstable
presentation.
2 (Single-best-answer — START triage / mass casualty)
During a mass casualty incident, a nurse performing START
triage encounters an adult who is not breathing. The nurse
,opens the airway — the patient remains apneic. What is the
correct triage category under START?
A. Minor (green) — delayed
B. Immediate (red) — needs early intervention
C. Deceased/Expectant (black) — not breathing after airway
opening
D. Ambulatory (walkie-wounded) — can move to collection
point
Correct answer: C
Rationale (correct):
• START triage instructs rescuers that if an adult is not
breathing and does not start breathing after opening the
airway, the patient is tagged deceased/expectant (black) in
the mass casualty context because resources are focused
on salvageable patients. This preserves limited resources
during MCIs. CHEMM+1
Rationale (incorrect options):
• A & D: Minor/ambulatory are for patients who can walk or
have minor injuries — not applicable.
• B: Immediate (red) is for patients who are breathing but
have compromised RPM parameters (e.g., RR >30, absent
radial pulse, or unable to follow commands). A patient
apneic after airway opening is considered non-salvageable
in START unless resources permit advanced resuscitation.
, 3 (Case/NGN — Prioritization / ABCs — Rank order)
A 24-year-old male is brought to the ED after a motor vehicle
collision. At triage he is conscious but has the following
problems (place these interventions in order of priority — 1 =
highest to 4 = lowest):
A. Apply cervical collar and immobilize spine.
B. Control active external hemorrhage from a femoral wound.
C. Establish two large bore IVs and begin fluid resuscitation.
D. Assess airway for patency and protect airway as indicated.
Correct order: D → B → C → A
Rationale (stepwise):
1. D — Airway: ABCs — airway patency takes absolute
priority. If airway compromise is present, immediate
actions (jaw thrust, suction, advanced airway) precede
other interventions.
2. B — Control hemorrhage: Massive external hemorrhage
can rapidly lead to hypovolemic arrest and should be
controlled next (direct pressure, tourniquet if indicated).
Hemorrhage control ties closely to airway and breathing
priorities in trauma.
3. C — IV access / fluids: After airway and hemorrhage
control, secure vascular access for blood and fluids; with
ongoing bleeding, rapid infusion is necessary.
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1 (Single-best-answer — Triage / ESI)
A 67-year-old male arrives to the ED by ambulance with chest
pain, diaphoresis, and shortness of breath. He is pale and
diaphoretic, says “I feel like I’m going to die,” and has mildly
labored respirations. Vital signs: HR 110, BP 90/56, RR 24, SpO₂
92% on room air. According to the Emergency Severity Index
(ESI) 5-level triage algorithm, what ESI level should the nurse
assign?
A. ESI level 1 — immediate lifesaving intervention required
B. ESI level 2 — high risk or severe pain/distress
C. ESI level 3 — urgent but not high-risk
D. ESI level 4 — needs one resource
Correct answer: B
Rationale (correct):
, • ESI level 2 is appropriate for patients who are high-risk,
appear very ill, or have severe pain or distress and do not
require an immediate life-saving intervention. This patient
is hypotensive (BP 90/56), tachycardic, diaphoretic and
reports severe distress — all indicators of high risk
requiring rapid evaluation. The ESI aims to rapidly identify
such high-risk patients for expedited care.
media.emscimprovement.center
Rationale (incorrect options):
• A: ESI level 1 is reserved for patients requiring immediate
lifesaving interventions (e.g., active CPR, open airway with
need for immediate intubation, ongoing major
hemorrhage). Although this patient is unstable, there is
not an immediate documented need for a lifesaving
procedure at triage.
• C: ESI level 3 is for patients who are stable enough to wait
and whose expected resource needs are multiple; this
patient is higher risk.
• D: ESI level 4 signals a single resource needed (e.g., simple
X-ray) — clearly inappropriate for this unstable
presentation.
2 (Single-best-answer — START triage / mass casualty)
During a mass casualty incident, a nurse performing START
triage encounters an adult who is not breathing. The nurse
,opens the airway — the patient remains apneic. What is the
correct triage category under START?
A. Minor (green) — delayed
B. Immediate (red) — needs early intervention
C. Deceased/Expectant (black) — not breathing after airway
opening
D. Ambulatory (walkie-wounded) — can move to collection
point
Correct answer: C
Rationale (correct):
• START triage instructs rescuers that if an adult is not
breathing and does not start breathing after opening the
airway, the patient is tagged deceased/expectant (black) in
the mass casualty context because resources are focused
on salvageable patients. This preserves limited resources
during MCIs. CHEMM+1
Rationale (incorrect options):
• A & D: Minor/ambulatory are for patients who can walk or
have minor injuries — not applicable.
• B: Immediate (red) is for patients who are breathing but
have compromised RPM parameters (e.g., RR >30, absent
radial pulse, or unable to follow commands). A patient
apneic after airway opening is considered non-salvageable
in START unless resources permit advanced resuscitation.
, 3 (Case/NGN — Prioritization / ABCs — Rank order)
A 24-year-old male is brought to the ED after a motor vehicle
collision. At triage he is conscious but has the following
problems (place these interventions in order of priority — 1 =
highest to 4 = lowest):
A. Apply cervical collar and immobilize spine.
B. Control active external hemorrhage from a femoral wound.
C. Establish two large bore IVs and begin fluid resuscitation.
D. Assess airway for patency and protect airway as indicated.
Correct order: D → B → C → A
Rationale (stepwise):
1. D — Airway: ABCs — airway patency takes absolute
priority. If airway compromise is present, immediate
actions (jaw thrust, suction, advanced airway) precede
other interventions.
2. B — Control hemorrhage: Massive external hemorrhage
can rapidly lead to hypovolemic arrest and should be
controlled next (direct pressure, tourniquet if indicated).
Hemorrhage control ties closely to airway and breathing
priorities in trauma.
3. C — IV access / fluids: After airway and hemorrhage
control, secure vascular access for blood and fluids; with
ongoing bleeding, rapid infusion is necessary.
