Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1) Basic-priority (ABCs) triage — multiple choice
A 54-year-old male is brought to triage after a motor-vehicle
collision. He is conscious but pale, has a weak, rapid pulse
(pulse 132/min), respiratory rate 26/min, blood pressure 82/52
mm Hg, and cool, clammy skin. Which action should the triage
nurse perform first?
A. Obtain two large-bore IVs and begin isotonic crystalloid
bolus.
B. Apply a cervical spine collar and immobilize the spine.
C. Give 100% oxygen by nonrebreather mask.
D. Obtain a focused secondary survey including FAST exam
(focused assessment with sonography in trauma).
Correct answer: A. Obtain two large-bore IVs and begin
isotonic crystalloid bolus.
Rationale — stepwise (correct):
, 1. Patient shows signs of hypovolemic/hemorrhagic shock
(tachycardia, hypotension, cool/clammy skin). Restoring
circulating volume is immediately life-saving. Large-bore IV
access (two 16–18 gauge) and isotonic crystalloid bolus
(e.g., normal saline or lactated Ringer’s) are priority
interventions to improve perfusion.
2. This is consistent with ABCs — airway and breathing are
currently present (RR 26, patient conscious) whereas
circulation is critically compromised; treat the circulation
first.
3. After rapid IV access and bolus initiation, continue
simultaneous airway/immobilization and notify trauma
team for definitive hemorrhage control.
Why other options are less appropriate:
B. Cervical spine immobilization is essential in blunt trauma, but
immediate resuscitation of hypotension that is life-threatening
takes precedence — immobilize concurrently, but the first
active life-saving step is vascular access and resuscitation.
C. Oxygen supports breathing; however, hypovolemia is the
immediate life threat. Oxygen may be applied concurrently but
should not delay IV access and fluid resuscitation.
D. FAST exam and secondary survey are important but should
follow initial resuscitation and stabilization.
2) Maslow & prioritization — multiple choice
,Which patient requires the nurse’s assessment first on a busy
emergency unit, based on Maslow’s hierarchy and immediate
risk?
A. A 29-year-old with severe anxiety after a panic attack,
breathing at 28/min, oxygen saturation 96% on room air.
B. A 72-year-old with end-stage COPD in mild respiratory
distress, oxygen saturation 88% on 2 L via nasal cannula.
C. A 45-year-old scheduled for discharge after sutures,
requesting pain medication for site discomfort.
D. A 60-year-old with a history of dementia, accompanied by
family, reporting mild confusion and urinary frequency.
Correct answer: B. A 72-year-old with end-stage COPD in mild
respiratory distress, O₂ sat 88% on 2 L NC.
Rationale — stepwise (correct):
1. Maslow and ABC prioritization place physiological needs
(airway/breathing/circulation) highest. An O₂ saturation
of 88% is below acceptable levels (usually <92%
concerning in COPD patient depending on baseline) — this
requires immediate assessment/intervention (increase O₂
per protocol, monitor ABGs, consider noninvasive
ventilation).
2. The anxiety patient (A) has relatively intact oxygenation.
The discharge pain request (C) and confusion (D) are lower
in immediate physiological priority.
, Why other options are less appropriate:
A. Anxiety with normal oxygenation is important but not
emergent.
C. Pain after suture removal is lower priority and can wait
briefly.
D. Confusion warrants assessment but not before correcting
hypoxia risk.
3) Shock recognition and stages — multiple choice
A patient in the ED after GI hemorrhage has pale, cool skin,
oliguria, increased lactic acid, and narrowed pulse pressure.
Which stage of shock is most consistent with these findings?
A. Compensatory (early) shock
B. Progressive (intermediate) shock
C. Refractory (late) shock
D. Pre-shock (initial) stage
Correct answer: B. Progressive (intermediate) shock.
Rationale — stepwise (correct):
1. Progressive shock is characterized by failing compensatory
mechanisms — hypotension, oliguria, lactic acidosis
(anaerobic metabolism), cool/clammy skin, narrowing
pulse pressure — indicating inadequate perfusion and
organ dysfunction. Prompt intervention is required to
prevent irreversible damage.
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1) Basic-priority (ABCs) triage — multiple choice
A 54-year-old male is brought to triage after a motor-vehicle
collision. He is conscious but pale, has a weak, rapid pulse
(pulse 132/min), respiratory rate 26/min, blood pressure 82/52
mm Hg, and cool, clammy skin. Which action should the triage
nurse perform first?
A. Obtain two large-bore IVs and begin isotonic crystalloid
bolus.
B. Apply a cervical spine collar and immobilize the spine.
C. Give 100% oxygen by nonrebreather mask.
D. Obtain a focused secondary survey including FAST exam
(focused assessment with sonography in trauma).
Correct answer: A. Obtain two large-bore IVs and begin
isotonic crystalloid bolus.
Rationale — stepwise (correct):
, 1. Patient shows signs of hypovolemic/hemorrhagic shock
(tachycardia, hypotension, cool/clammy skin). Restoring
circulating volume is immediately life-saving. Large-bore IV
access (two 16–18 gauge) and isotonic crystalloid bolus
(e.g., normal saline or lactated Ringer’s) are priority
interventions to improve perfusion.
2. This is consistent with ABCs — airway and breathing are
currently present (RR 26, patient conscious) whereas
circulation is critically compromised; treat the circulation
first.
3. After rapid IV access and bolus initiation, continue
simultaneous airway/immobilization and notify trauma
team for definitive hemorrhage control.
Why other options are less appropriate:
B. Cervical spine immobilization is essential in blunt trauma, but
immediate resuscitation of hypotension that is life-threatening
takes precedence — immobilize concurrently, but the first
active life-saving step is vascular access and resuscitation.
C. Oxygen supports breathing; however, hypovolemia is the
immediate life threat. Oxygen may be applied concurrently but
should not delay IV access and fluid resuscitation.
D. FAST exam and secondary survey are important but should
follow initial resuscitation and stabilization.
2) Maslow & prioritization — multiple choice
,Which patient requires the nurse’s assessment first on a busy
emergency unit, based on Maslow’s hierarchy and immediate
risk?
A. A 29-year-old with severe anxiety after a panic attack,
breathing at 28/min, oxygen saturation 96% on room air.
B. A 72-year-old with end-stage COPD in mild respiratory
distress, oxygen saturation 88% on 2 L via nasal cannula.
C. A 45-year-old scheduled for discharge after sutures,
requesting pain medication for site discomfort.
D. A 60-year-old with a history of dementia, accompanied by
family, reporting mild confusion and urinary frequency.
Correct answer: B. A 72-year-old with end-stage COPD in mild
respiratory distress, O₂ sat 88% on 2 L NC.
Rationale — stepwise (correct):
1. Maslow and ABC prioritization place physiological needs
(airway/breathing/circulation) highest. An O₂ saturation
of 88% is below acceptable levels (usually <92%
concerning in COPD patient depending on baseline) — this
requires immediate assessment/intervention (increase O₂
per protocol, monitor ABGs, consider noninvasive
ventilation).
2. The anxiety patient (A) has relatively intact oxygenation.
The discharge pain request (C) and confusion (D) are lower
in immediate physiological priority.
, Why other options are less appropriate:
A. Anxiety with normal oxygenation is important but not
emergent.
C. Pain after suture removal is lower priority and can wait
briefly.
D. Confusion warrants assessment but not before correcting
hypoxia risk.
3) Shock recognition and stages — multiple choice
A patient in the ED after GI hemorrhage has pale, cool skin,
oliguria, increased lactic acid, and narrowed pulse pressure.
Which stage of shock is most consistent with these findings?
A. Compensatory (early) shock
B. Progressive (intermediate) shock
C. Refractory (late) shock
D. Pre-shock (initial) stage
Correct answer: B. Progressive (intermediate) shock.
Rationale — stepwise (correct):
1. Progressive shock is characterized by failing compensatory
mechanisms — hypotension, oliguria, lactic acidosis
(anaerobic metabolism), cool/clammy skin, narrowing
pulse pressure — indicating inadequate perfusion and
organ dysfunction. Prompt intervention is required to
prevent irreversible damage.
