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 62-year-old man arrives to triage after a motor-vehicle
crash. He is conscious but drooling and has visible facial trauma.
Respiratory rate 10/min, speaking in short phrases, oxygen
saturation 88% on room air. Which action should the nurse
perform first?
A. Place the patient on high-flow nasal cannula and obtain chest
x-ray.
B. Assess for an airway obstruction and prepare for definitive
airway (rapid sequence intubation).
C. Control facial bleeding with pressure dressings and obtain
two large bore IVs.
D. Initiate a FAST exam to assess for intra-abdominal bleeding.
Correct answer: B. Assess for an airway obstruction and
prepare for definitive airway (rapid sequence intubation).
,Rationale — correct (B): In trauma care, airway assessment and
maintenance are the top priority (the “A” in ABCs). Drooling,
facial trauma and low SpO₂ with speaking in short phrases
indicate potential airway compromise; securing a definitive
airway (or preparing for it) prevents hypoxia and aspiration. This
is time-sensitive and precedes imaging or IV access.
Why the others are incorrect:
A — Oxygen support is helpful but insufficient if the airway is or
will become compromised; high-flow oxygen without securing
the airway risks aspiration.
C — Hemorrhage control and IV access are high priority but
come secondary to immediate airway threats.
D — FAST is useful for hemorrhage detection but should not
delay airway management.
2. In a multi-casualty incident using START triage, which of the
following victims should be tagged Immediate (Red)?
A. An ambulatory adult with a small laceration and stable vitals.
B. An adult who is breathing spontaneously at 18 breaths/min,
radial pulse present, follows commands, with an open femur
fracture.
C. An adult not breathing until the airway is positioned,
respiratory rate 36/min, radial pulse present.
D. An unresponsive adult with absent respirations after
repositioning and no pulse.
,Correct answer: C. An adult not breathing until the airway is
positioned, respiratory rate 36/min, radial pulse present.
Rationale — correct (C): START triage considers immediate
threats to life. A patient who is not breathing until repositioning
but then has respirations and perfusion may be salvageable
with immediate intervention (airway support) and fits the
Immediate/Red category. High RR and need for airway
maneuvers indicate need for immediate care. REMM+1
Why the others are incorrect:
A — Ambulatory/walking wounded = Minimal/Green.
B — This describes a stable but serious injury — Delay/Yellow
(transport can be delayed).
D — No respirations after repositioning and no pulse =
Expectant/Black (non-salvageable in large MCI when resources
limited).
3. A triage nurse must assign priority to four ED patients
arriving simultaneously. Using Maslow and ABC principles,
which patient is highest priority?
A. A 45-year-old with chest pain 2/10, normal vitals.
B. A 70-year-old with new left-sided weakness and slurred
speech (onset 20 minutes ago).
C. A 30-year-old with ankle sprain, able to bear weight.
D. A 25-year-old with anxiety and hyperventilation.
, Correct answer: B. A 70-year-old with new left-sided weakness
and slurred speech (onset 20 minutes ago).
Rationale — correct (B): Neurologic deficits with recent onset
suggest acute stroke; time-sensitive interventions (e.g.,
thrombolysis or thrombectomy evaluation) are required —
physiologic (airway/circulation/brain perfusion) needs take
precedence. Maslow’s physiological safety (life/function
preservation) outranks comfort or psychosocial needs.
Why the others are incorrect:
A — Chest pain is important but currently mild with normal
vitals; further assessment is needed but not highest priority.
C — Ambulatory sprain = low priority (Maslow:
safety/physiologic needs not imminently threatened).
D — Anxiety requires care but is not immediately life-
threatening compared to possible acute stroke.
4. (Case-based) A 28-year-old woman is brought to ED with
progressive facial swelling, urticaria, and wheezing 20 minutes
after receiving IV ceftriaxone in the ED. BP 88/54 mm Hg, HR
120/min, RR 28/min, SpO₂ 88% on room air. Which is the
nurse’s first action?
A. Administer intramuscular epinephrine 0.3 mg into the lateral
thigh.
B. Start a normal saline bolus via existing IV and elevate legs.
C. Give IV diphenhydramine and methylprednisolone.
D. Prepare for emergent intubation and call anesthesia.
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Questions
1. A 62-year-old man arrives to triage after a motor-vehicle
crash. He is conscious but drooling and has visible facial trauma.
Respiratory rate 10/min, speaking in short phrases, oxygen
saturation 88% on room air. Which action should the nurse
perform first?
A. Place the patient on high-flow nasal cannula and obtain chest
x-ray.
B. Assess for an airway obstruction and prepare for definitive
airway (rapid sequence intubation).
C. Control facial bleeding with pressure dressings and obtain
two large bore IVs.
D. Initiate a FAST exam to assess for intra-abdominal bleeding.
Correct answer: B. Assess for an airway obstruction and
prepare for definitive airway (rapid sequence intubation).
,Rationale — correct (B): In trauma care, airway assessment and
maintenance are the top priority (the “A” in ABCs). Drooling,
facial trauma and low SpO₂ with speaking in short phrases
indicate potential airway compromise; securing a definitive
airway (or preparing for it) prevents hypoxia and aspiration. This
is time-sensitive and precedes imaging or IV access.
Why the others are incorrect:
A — Oxygen support is helpful but insufficient if the airway is or
will become compromised; high-flow oxygen without securing
the airway risks aspiration.
C — Hemorrhage control and IV access are high priority but
come secondary to immediate airway threats.
D — FAST is useful for hemorrhage detection but should not
delay airway management.
2. In a multi-casualty incident using START triage, which of the
following victims should be tagged Immediate (Red)?
A. An ambulatory adult with a small laceration and stable vitals.
B. An adult who is breathing spontaneously at 18 breaths/min,
radial pulse present, follows commands, with an open femur
fracture.
C. An adult not breathing until the airway is positioned,
respiratory rate 36/min, radial pulse present.
D. An unresponsive adult with absent respirations after
repositioning and no pulse.
,Correct answer: C. An adult not breathing until the airway is
positioned, respiratory rate 36/min, radial pulse present.
Rationale — correct (C): START triage considers immediate
threats to life. A patient who is not breathing until repositioning
but then has respirations and perfusion may be salvageable
with immediate intervention (airway support) and fits the
Immediate/Red category. High RR and need for airway
maneuvers indicate need for immediate care. REMM+1
Why the others are incorrect:
A — Ambulatory/walking wounded = Minimal/Green.
B — This describes a stable but serious injury — Delay/Yellow
(transport can be delayed).
D — No respirations after repositioning and no pulse =
Expectant/Black (non-salvageable in large MCI when resources
limited).
3. A triage nurse must assign priority to four ED patients
arriving simultaneously. Using Maslow and ABC principles,
which patient is highest priority?
A. A 45-year-old with chest pain 2/10, normal vitals.
B. A 70-year-old with new left-sided weakness and slurred
speech (onset 20 minutes ago).
C. A 30-year-old with ankle sprain, able to bear weight.
D. A 25-year-old with anxiety and hyperventilation.
, Correct answer: B. A 70-year-old with new left-sided weakness
and slurred speech (onset 20 minutes ago).
Rationale — correct (B): Neurologic deficits with recent onset
suggest acute stroke; time-sensitive interventions (e.g.,
thrombolysis or thrombectomy evaluation) are required —
physiologic (airway/circulation/brain perfusion) needs take
precedence. Maslow’s physiological safety (life/function
preservation) outranks comfort or psychosocial needs.
Why the others are incorrect:
A — Chest pain is important but currently mild with normal
vitals; further assessment is needed but not highest priority.
C — Ambulatory sprain = low priority (Maslow:
safety/physiologic needs not imminently threatened).
D — Anxiety requires care but is not immediately life-
threatening compared to possible acute stroke.
4. (Case-based) A 28-year-old woman is brought to ED with
progressive facial swelling, urticaria, and wheezing 20 minutes
after receiving IV ceftriaxone in the ED. BP 88/54 mm Hg, HR
120/min, RR 28/min, SpO₂ 88% on room air. Which is the
nurse’s first action?
A. Administer intramuscular epinephrine 0.3 mg into the lateral
thigh.
B. Start a normal saline bolus via existing IV and elevate legs.
C. Give IV diphenhydramine and methylprednisolone.
D. Prepare for emergent intubation and call anesthesia.
