Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1) (Prioritization / ABCs)
A 58-year-old man arrives at triage after falling at home. He is
conscious but drooling and making gurgling sounds; respiratory
rate 10/min; pulse 110/min; BP 130/86 mm Hg. Which action
has the highest immediate priority?
A. Obtain a 12-lead ECG.
B. Prepare for immediate endotracheal intubation
(oropharyngeal suctioning and positioning while awaiting
advanced airway).
C. Start two large-bore IVs and give 0.9% sodium chloride bolus.
D. Assess pain using a numeric pain scale.
Correct answer: B
Rationale (stepwise):
• Priority reasoning: airway compromise (drooling, gurgling)
indicates partial airway obstruction — per basic emergency
airway principles the airway takes priority over breathing,
, circulation, and diagnostics. Secure the airway: position,
suction to clear secretions, and prepare for definitive
airway if needed. (ABC rule = Airway first). cpr.heart.org
• Why A is incorrect: ECG is important for cardiac
assessment but not more urgent than clearing an
obstructed airway.
• Why C is incorrect: IV access and fluids are important for
circulation, but airway intervention is higher priority.
• Why D is incorrect: Pain assessment is lower priority when
airway compromise exists.
2) (Triage categories / START)
During a mass-casualty incident, you encounter four walking
patients with minor abrasions who can follow commands and
have radial pulses. According to START triage principles, these
patients should be tagged as:
A. Black (expectant).
B. Red (immediate).
C. Yellow (delayed).
D. Green (minor/walking wounded).
Correct answer: D
Rationale (stepwise):
• START triage quickly sorts victims: those who can walk and
have minor injuries are tagged Green (minor) — “walking
, wounded.” This allows limited resources to be directed to
higher-acuity patients. NCBI+1
• Why A is incorrect: Black/expectant is for those not
expected to survive given resources (no spontaneous
respirations after repositioning or obviously fatal injuries).
• Why B is incorrect: Red/immediate is reserved for life- or
limb-threatening injuries needing immediate intervention.
• Why C is incorrect: Yellow/delayed applies to patients
needing care but not immediate life-saving interventions.
3) (Acute condition — Anaphylaxis)
A 24-year-old woman develops sudden generalized urticaria,
wheezing, hypotension (BP 78/50 mm Hg), and stridor 5
minutes after receiving a medication in the ED. The nurse’s first
action should be:
A. Administer intramuscular epinephrine into the lateral thigh.
B. Give intravenous hydrocortisone.
C. Start nebulized albuterol treatment.
D. Administer oral antihistamine (diphenhydramine) via NG
tube.
Correct answer: A
Rationale (stepwise):
• First-line therapy for anaphylaxis is intramuscular
epinephrine (anterolateral thigh) because it rapidly
, reverses bronchospasm, vasodilation, and laryngeal
edema; its early administration saves lives. International
and specialty guidelines emphasize prompt IM
epinephrine. PMC+1
• Why B is incorrect: Steroids are adjunctive and may
prevent biphasic reactions but do not treat immediate
airway/circulatory collapse.
• Why C is incorrect: Nebulized albuterol can help
bronchospasm but is not a substitute for epinephrine in
systemic anaphylaxis.
• Why D is incorrect: Oral antihistamines act too slowly and
are insufficient for life-threatening anaphylaxis.
4) (Cardiac arrest — ACLS priorities)
A patient is found pulseless and apneic in an ED waiting area.
Which sequence of actions follows current high-quality
resuscitation priorities?
A. Start chest compressions immediately, call for
help/defibrillator, attach monitor/defibrillator, and follow
rhythm-based algorithm.
B. Check for a pulse for 60–90 seconds, then start CPR if no
pulse.
C. Begin rescue breathing only, then chest compressions after
advanced airway arrives.
D. Obtain a rapid 12-lead ECG, then begin chest compressions.
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1) (Prioritization / ABCs)
A 58-year-old man arrives at triage after falling at home. He is
conscious but drooling and making gurgling sounds; respiratory
rate 10/min; pulse 110/min; BP 130/86 mm Hg. Which action
has the highest immediate priority?
A. Obtain a 12-lead ECG.
B. Prepare for immediate endotracheal intubation
(oropharyngeal suctioning and positioning while awaiting
advanced airway).
C. Start two large-bore IVs and give 0.9% sodium chloride bolus.
D. Assess pain using a numeric pain scale.
Correct answer: B
Rationale (stepwise):
• Priority reasoning: airway compromise (drooling, gurgling)
indicates partial airway obstruction — per basic emergency
airway principles the airway takes priority over breathing,
, circulation, and diagnostics. Secure the airway: position,
suction to clear secretions, and prepare for definitive
airway if needed. (ABC rule = Airway first). cpr.heart.org
• Why A is incorrect: ECG is important for cardiac
assessment but not more urgent than clearing an
obstructed airway.
• Why C is incorrect: IV access and fluids are important for
circulation, but airway intervention is higher priority.
• Why D is incorrect: Pain assessment is lower priority when
airway compromise exists.
2) (Triage categories / START)
During a mass-casualty incident, you encounter four walking
patients with minor abrasions who can follow commands and
have radial pulses. According to START triage principles, these
patients should be tagged as:
A. Black (expectant).
B. Red (immediate).
C. Yellow (delayed).
D. Green (minor/walking wounded).
Correct answer: D
Rationale (stepwise):
• START triage quickly sorts victims: those who can walk and
have minor injuries are tagged Green (minor) — “walking
, wounded.” This allows limited resources to be directed to
higher-acuity patients. NCBI+1
• Why A is incorrect: Black/expectant is for those not
expected to survive given resources (no spontaneous
respirations after repositioning or obviously fatal injuries).
• Why B is incorrect: Red/immediate is reserved for life- or
limb-threatening injuries needing immediate intervention.
• Why C is incorrect: Yellow/delayed applies to patients
needing care but not immediate life-saving interventions.
3) (Acute condition — Anaphylaxis)
A 24-year-old woman develops sudden generalized urticaria,
wheezing, hypotension (BP 78/50 mm Hg), and stridor 5
minutes after receiving a medication in the ED. The nurse’s first
action should be:
A. Administer intramuscular epinephrine into the lateral thigh.
B. Give intravenous hydrocortisone.
C. Start nebulized albuterol treatment.
D. Administer oral antihistamine (diphenhydramine) via NG
tube.
Correct answer: A
Rationale (stepwise):
• First-line therapy for anaphylaxis is intramuscular
epinephrine (anterolateral thigh) because it rapidly
, reverses bronchospasm, vasodilation, and laryngeal
edema; its early administration saves lives. International
and specialty guidelines emphasize prompt IM
epinephrine. PMC+1
• Why B is incorrect: Steroids are adjunctive and may
prevent biphasic reactions but do not treat immediate
airway/circulatory collapse.
• Why C is incorrect: Nebulized albuterol can help
bronchospasm but is not a substitute for epinephrine in
systemic anaphylaxis.
• Why D is incorrect: Oral antihistamines act too slowly and
are insufficient for life-threatening anaphylaxis.
4) (Cardiac arrest — ACLS priorities)
A patient is found pulseless and apneic in an ED waiting area.
Which sequence of actions follows current high-quality
resuscitation priorities?
A. Start chest compressions immediately, call for
help/defibrillator, attach monitor/defibrillator, and follow
rhythm-based algorithm.
B. Check for a pulse for 60–90 seconds, then start CPR if no
pulse.
C. Begin rescue breathing only, then chest compressions after
advanced airway arrives.
D. Obtain a rapid 12-lead ECG, then begin chest compressions.
