SAUNDERS COMPREHENSIVE REVIEW FOR THE
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1) (Triage—ED acuity)
A 57-year-old male arrives to the ED triage desk with sudden
onset chest pressure radiating to the left arm that began 20
minutes ago, diaphoresis, and nausea. Vital signs: BP 86/56 mm
Hg, HR 122 bpm, RR 22, O₂ 92% on room air. On ESI triage,
which level is most appropriate?
A. ESI Level 1
B. ESI Level 2
C. ESI Level 3
D. ESI Level 4
Correct answer: B. ESI Level 2
Rationale:
, • B correct: ESI Level 2 is for patients who are high risk or
confused/lethargic/disoriented, or in severe pain/distress
— and those with signs of potential life-threatening
conditions who require rapid evaluation (e.g., suspected
acute coronary syndrome with hypotension/tachycardia).
Immediate attention required. EMSC Improvement Centre
• A incorrect: Level 1 is for patients requiring immediate life-
saving interventions (e.g., cardiac arrest, airway
obstruction). This patient is unstable but not currently in
arrest.
• C/D incorrect: Levels 3–4 are for lower acuity patients who
are stable and can wait; this patient is high risk and
unstable.
2) (START triage / mass casualty)
During a mass casualty incident, a first responder uses START
triage. You are asked to categorize a walking, alert adult who
cannot follow commands and has a respiratory rate of 32/min.
According to START, this patient should be tagged:
A. Minor (Green)
B. Delayed (Yellow)
C. Immediate (Red)
D. Deceased/Expectant (Black)
Correct answer: C. Immediate (Red)
,Rationale:
• C correct: START uses RPM (Respirations, Perfusion,
Mental status). RR >30 is an immediate criterion. Inability
to follow commands (altered mental status) also suggests
high acuity. Thus immediate (red) for life-threatening
problems that need rapid intervention/transport. NCBI
• A/B incorrect: Walking patients often initially sorted as
“walking wounded” (green) during the global sort, but the
individual assessment (RR >30, altered mental status)
upgrades to immediate.
• D incorrect: Deceased/expectant is for no respirations
after repositioning or obviously non-survivable injuries.
3) (SALT triage—mass casualty)
In SALT triage, which of these is considered a life-saving
intervention that can be performed at triage to change a
patient’s triage category?
A. Complete head-to-toe secondary survey
B. Application of a tourniquet to control severe extremity
hemorrhage
C. Intravenous heparin for suspected pulmonary embolism
D. Full radiographic imaging
Correct answer: B. Application of a tourniquet to control
severe extremity hemorrhage
, Rationale:
• B correct: SALT includes life-saving interventions at triage
(e.g., hemorrhage control, opening airway, rescue breaths
in children, antidote autoinjectors). Tourniquet for
uncontrolled extremity hemorrhage is a canonical field life-
saving action. CHEMM+1
• A incorrect: Secondary survey is comprehensive
assessment—not a brief triage life-saving intervention.
• C incorrect: IV heparin is definitive care requiring
diagnostics and monitoring; not a field triage life-saving
maneuver.
• D incorrect: Imaging is diagnostic/definitive care, not a
triage life-saving action.
4) (Prioritization—multiple patients in ED)
You are the triage RN. Which patient should be brought back to
the treatment area first?
A. 28-year-old with uncomplicated ankle sprain, tolerating PO,
stable vitals.
B. 65-year-old with sudden slurred speech and right-sided
weakness for 40 minutes.
C. 40-year-old with fever 100.6°F and sore throat.
D. 22-year-old with simple laceration on forearm that needs
suturing.
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1) (Triage—ED acuity)
A 57-year-old male arrives to the ED triage desk with sudden
onset chest pressure radiating to the left arm that began 20
minutes ago, diaphoresis, and nausea. Vital signs: BP 86/56 mm
Hg, HR 122 bpm, RR 22, O₂ 92% on room air. On ESI triage,
which level is most appropriate?
A. ESI Level 1
B. ESI Level 2
C. ESI Level 3
D. ESI Level 4
Correct answer: B. ESI Level 2
Rationale:
, • B correct: ESI Level 2 is for patients who are high risk or
confused/lethargic/disoriented, or in severe pain/distress
— and those with signs of potential life-threatening
conditions who require rapid evaluation (e.g., suspected
acute coronary syndrome with hypotension/tachycardia).
Immediate attention required. EMSC Improvement Centre
• A incorrect: Level 1 is for patients requiring immediate life-
saving interventions (e.g., cardiac arrest, airway
obstruction). This patient is unstable but not currently in
arrest.
• C/D incorrect: Levels 3–4 are for lower acuity patients who
are stable and can wait; this patient is high risk and
unstable.
2) (START triage / mass casualty)
During a mass casualty incident, a first responder uses START
triage. You are asked to categorize a walking, alert adult who
cannot follow commands and has a respiratory rate of 32/min.
According to START, this patient should be tagged:
A. Minor (Green)
B. Delayed (Yellow)
C. Immediate (Red)
D. Deceased/Expectant (Black)
Correct answer: C. Immediate (Red)
,Rationale:
• C correct: START uses RPM (Respirations, Perfusion,
Mental status). RR >30 is an immediate criterion. Inability
to follow commands (altered mental status) also suggests
high acuity. Thus immediate (red) for life-threatening
problems that need rapid intervention/transport. NCBI
• A/B incorrect: Walking patients often initially sorted as
“walking wounded” (green) during the global sort, but the
individual assessment (RR >30, altered mental status)
upgrades to immediate.
• D incorrect: Deceased/expectant is for no respirations
after repositioning or obviously non-survivable injuries.
3) (SALT triage—mass casualty)
In SALT triage, which of these is considered a life-saving
intervention that can be performed at triage to change a
patient’s triage category?
A. Complete head-to-toe secondary survey
B. Application of a tourniquet to control severe extremity
hemorrhage
C. Intravenous heparin for suspected pulmonary embolism
D. Full radiographic imaging
Correct answer: B. Application of a tourniquet to control
severe extremity hemorrhage
, Rationale:
• B correct: SALT includes life-saving interventions at triage
(e.g., hemorrhage control, opening airway, rescue breaths
in children, antidote autoinjectors). Tourniquet for
uncontrolled extremity hemorrhage is a canonical field life-
saving action. CHEMM+1
• A incorrect: Secondary survey is comprehensive
assessment—not a brief triage life-saving intervention.
• C incorrect: IV heparin is definitive care requiring
diagnostics and monitoring; not a field triage life-saving
maneuver.
• D incorrect: Imaging is diagnostic/definitive care, not a
triage life-saving action.
4) (Prioritization—multiple patients in ED)
You are the triage RN. Which patient should be brought back to
the treatment area first?
A. 28-year-old with uncomplicated ankle sprain, tolerating PO,
stable vitals.
B. 65-year-old with sudden slurred speech and right-sided
weakness for 40 minutes.
C. 40-year-old with fever 100.6°F and sore throat.
D. 22-year-old with simple laceration on forearm that needs
suturing.
