Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Question 1 — Triage priority (START)
A mass-casualty incident brings five ambulatory casualties to
the ED. A nurse at the entrance asks, “If you can walk, go to the
green area.” One patient remains supine, breathing 36/min, has
an absent radial pulse, and does not follow commands.
According to START triage, what tag/priority should the nurse
assign?
A. Minor (green)
B. Delayed (yellow)
C. Immediate (red)
D. Deceased/expectant (black)
Correct answer: C. Immediate (red)
Rationale — Stepwise:
, 1. START uses the “RPM” decision points — Respirations (>30
= immediate), Perfusion (no radial pulse or cap refill >2 sec
= immediate), Mental status (cannot follow commands =
immediate). This patient meets criteria for immediate.
CHEMM+1
2. Immediate (red) means needs rapid life-saving
interventions/urgent transport.
3. Other options: Minor (A) is for ambulatory/walking;
Delayed (B) is for stable injuries not immediately life-
threatening; Deceased/expectant (D) reserved for apnea or
unsalvageable injuries after appropriate attempts. Hence C
is correct.
Question 2 — ABC prioritization (ED arrival)
A 64-year-old male arrives after an MVC. He is conscious but
speaking only a few words (dyspneic), has obvious chest wall
deformity on the right, pulse 128, BP 88/56, respirations 30, O₂
sat 86% on room air. Which action should the ED nurse perform
first?
A. Apply high-flow oxygen via nonrebreather and prepare for
needle decompression.
B. Obtain a 12-lead ECG.
C. Start two large-bore IVs and begin fluid bolus.
D. Immobilize the cervical spine and logroll to assess for other
injuries.
,Correct answer: A. Apply high-flow oxygen via nonrebreather
and prepare for needle decompression.
Rationale — Stepwise:
1. ABCs — Airway and adequate oxygenation override other
interventions. The patient is hypoxic (SpO₂ 86%) and
dyspneic with chest deformity suggestive of possible
tension pneumothorax or flail chest. Immediate oxygen
and preparation for life-saving thoracic intervention
(needle decompression) are top priority. cpr.heart.org
2. Next priorities: establish IV access (C) and fluid
resuscitation are important for hypotension, but
airway/oxygenation comes first. 12-lead ECG (B) is
secondary. Cervical immobilization (D) is important in
trauma but not before addressing an immediately life-
threatening compromised oxygenation.
Why other answers incorrect: B delays treatment of hypoxia; C
addresses circulation but not the immediate airway/oxygen
deficit; D may be appropriate but not the first action when
airway/oxygenation are unstable.
Question 3 — Anaphylaxis immediate action
A 23-year-old with known peanut allergy develops diffuse
urticaria, wheeze, hypotension (BP 74/40), and altered mental
status in triage. What is the nurse’s most appropriate initial
action?
, A. Give intramuscular epinephrine immediately and call for
help.
B. Start IV diphenhydramine and monitor for improvement.
C. Obtain blood for tryptase levels and wait for results before
giving epinephrine.
D. Administer nebulized albuterol only.
Correct answer: A. Give intramuscular epinephrine
immediately and call for help.
Rationale — Stepwise:
1. Epinephrine IM is the first-line, life-saving treatment for
anaphylaxis and should be given immediately (dose per
protocol). Delays increase risk of cardiovascular collapse.
NCBI
2. Antihistamines (B) and labs (C) are adjuncts or diagnostic
but never first actions. Nebulized albuterol (D) may help
bronchospasm but is insufficient alone when
hypotension/altered mental status indicate severe
anaphylaxis.
Why other answers incorrect: B, C, and D delay the primary,
evidence-based lifesaving intervention.
Question 4 — Shock recognition (case-based)
A 58-year-old woman is admitted with vomiting and bloody
diarrhea for 24 hours. On assessment: decreased skin turgor,
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Question 1 — Triage priority (START)
A mass-casualty incident brings five ambulatory casualties to
the ED. A nurse at the entrance asks, “If you can walk, go to the
green area.” One patient remains supine, breathing 36/min, has
an absent radial pulse, and does not follow commands.
According to START triage, what tag/priority should the nurse
assign?
A. Minor (green)
B. Delayed (yellow)
C. Immediate (red)
D. Deceased/expectant (black)
Correct answer: C. Immediate (red)
Rationale — Stepwise:
, 1. START uses the “RPM” decision points — Respirations (>30
= immediate), Perfusion (no radial pulse or cap refill >2 sec
= immediate), Mental status (cannot follow commands =
immediate). This patient meets criteria for immediate.
CHEMM+1
2. Immediate (red) means needs rapid life-saving
interventions/urgent transport.
3. Other options: Minor (A) is for ambulatory/walking;
Delayed (B) is for stable injuries not immediately life-
threatening; Deceased/expectant (D) reserved for apnea or
unsalvageable injuries after appropriate attempts. Hence C
is correct.
Question 2 — ABC prioritization (ED arrival)
A 64-year-old male arrives after an MVC. He is conscious but
speaking only a few words (dyspneic), has obvious chest wall
deformity on the right, pulse 128, BP 88/56, respirations 30, O₂
sat 86% on room air. Which action should the ED nurse perform
first?
A. Apply high-flow oxygen via nonrebreather and prepare for
needle decompression.
B. Obtain a 12-lead ECG.
C. Start two large-bore IVs and begin fluid bolus.
D. Immobilize the cervical spine and logroll to assess for other
injuries.
,Correct answer: A. Apply high-flow oxygen via nonrebreather
and prepare for needle decompression.
Rationale — Stepwise:
1. ABCs — Airway and adequate oxygenation override other
interventions. The patient is hypoxic (SpO₂ 86%) and
dyspneic with chest deformity suggestive of possible
tension pneumothorax or flail chest. Immediate oxygen
and preparation for life-saving thoracic intervention
(needle decompression) are top priority. cpr.heart.org
2. Next priorities: establish IV access (C) and fluid
resuscitation are important for hypotension, but
airway/oxygenation comes first. 12-lead ECG (B) is
secondary. Cervical immobilization (D) is important in
trauma but not before addressing an immediately life-
threatening compromised oxygenation.
Why other answers incorrect: B delays treatment of hypoxia; C
addresses circulation but not the immediate airway/oxygen
deficit; D may be appropriate but not the first action when
airway/oxygenation are unstable.
Question 3 — Anaphylaxis immediate action
A 23-year-old with known peanut allergy develops diffuse
urticaria, wheeze, hypotension (BP 74/40), and altered mental
status in triage. What is the nurse’s most appropriate initial
action?
, A. Give intramuscular epinephrine immediately and call for
help.
B. Start IV diphenhydramine and monitor for improvement.
C. Obtain blood for tryptase levels and wait for results before
giving epinephrine.
D. Administer nebulized albuterol only.
Correct answer: A. Give intramuscular epinephrine
immediately and call for help.
Rationale — Stepwise:
1. Epinephrine IM is the first-line, life-saving treatment for
anaphylaxis and should be given immediately (dose per
protocol). Delays increase risk of cardiovascular collapse.
NCBI
2. Antihistamines (B) and labs (C) are adjuncts or diagnostic
but never first actions. Nebulized albuterol (D) may help
bronchospasm but is insufficient alone when
hypotension/altered mental status indicate severe
anaphylaxis.
Why other answers incorrect: B, C, and D delay the primary,
evidence-based lifesaving intervention.
Question 4 — Shock recognition (case-based)
A 58-year-old woman is admitted with vomiting and bloody
diarrhea for 24 hours. On assessment: decreased skin turgor,
