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.
Question 1
A 34-year-old male is brought to the ED after a multi-vehicle
crash. He is unconscious, respirations are 6/min, he has no
radial pulse, and he does not respond to voice. Using START
triage at a mass-casualty incident, into which category should
the triage nurse place him?
A. Minor (Green)
B. Delayed (Yellow)
C. Immediate (Red)
D. Expectant (Black)
E. Ambulatory (Blue)
Answer: D. Expectant (Black)
,Rationale: START triage uses airway/breathing, respiratory rate
(>30 or <30), perfusion (radial pulse), and mental status (obeys
commands) to prioritize. An unresponsive patient with
respirations <10 (or apnea without immediate response) and
absent peripheral pulse who is unlikely to survive with available
resources is categorized Expectant (Black) in conventional
START to conserve resources for salvageable patients. This is
consistent with START guidance used in mass-casualty triage.
REMM+1
• A (Green) Incorrect — ambulatory/minor patients are
stable and can walk; not applicable.
• B (Yellow) Incorrect — delayed means serious but not
immediately life-threatening.
• C (Red) Incorrect — immediate indicates salvageable with
immediate intervention (breathing and pulse present).
• E (Blue) Incorrect — not a START color; distractor.
Question 2
During a hospital triage using the Emergency Severity Index (ESI
v5), which patient should receive ESI level 1 triage?
A. Chest pain radiating to jaw with hypotension and
diaphoresis.
B. Stable fever and sore throat, wants antibiotics.
C. Sprained ankle, able to bear weight.
,D. Anxious patient requesting immediate reassurance.
E. Minor laceration requiring 3–4 sutures.
Answer: A. Chest pain radiating to jaw with hypotension and
diaphoresis.
Rationale: ESI level 1 is for unstable patients who require
immediate life-saving interventions (eg, airway, circulation,
major resuscitation). Chest pain with hypotension and
diaphoresis suggests acute coronary syndrome with
hemodynamic instability — immediate intervention required.
ESI uses acuity and expected resource needs to assign levels.
EMSC Improvement Center+1
• B (Level 5) Incorrect — non-urgent, low resources.
• C (Level 4 or 5) Incorrect — low acuity, likely low resources.
• D Incorrect — anxiety alone without physiological
instability is lower acuity.
• E Incorrect — requires some resources but not immediate
life-saving interventions.
Question 3
A chemical tanker overturns, exposing a crowd to an unknown
liquid. Several ambulatory patients arrive at the ED by foot.
Which initial action should ED nursing leadership direct?
A. Triage and treat in the ED waiting room.
B. Direct ambulatory patients to a decontamination (decon)
, area to remove outer clothing and rinse.
C. Bring the patients into the resuscitation bay immediately for
full triage.
D. Administer activated charcoal to all exposed patients.
E. Begin full weight-based antidote administration for all.
Answer: B. Direct ambulatory patients to a decontamination
(decon) area to remove outer clothing and rinse.
Rationale: In mass chemical exposures, rapid gross
decontamination (remove clothing, copious water rinse) for
ambulatory patients reduces further contamination and
secondary exposure to staff; CHEMM and federal decon
guidance recommend disrobing and water decontamination as
first steps. Triage/treatment should occur after decon or in
designated clean zones. Activated charcoal and antidotes are
agent-specific and should not be given indiscriminately.
CHEMM+1
• A Incorrect — waiting room increases risk of secondary
contamination to ED and staff.
• C Incorrect — bringing contaminated patients into
resuscitation bays risks contaminating clean treatment
areas.
• D Incorrect — activated charcoal is for certain ingested
toxins, not general first step for unknown dermal exposure.
• E Incorrect — antidotes are agent-specific; mass antidote
administration without identification is inappropriate.
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
Question 1
A 34-year-old male is brought to the ED after a multi-vehicle
crash. He is unconscious, respirations are 6/min, he has no
radial pulse, and he does not respond to voice. Using START
triage at a mass-casualty incident, into which category should
the triage nurse place him?
A. Minor (Green)
B. Delayed (Yellow)
C. Immediate (Red)
D. Expectant (Black)
E. Ambulatory (Blue)
Answer: D. Expectant (Black)
,Rationale: START triage uses airway/breathing, respiratory rate
(>30 or <30), perfusion (radial pulse), and mental status (obeys
commands) to prioritize. An unresponsive patient with
respirations <10 (or apnea without immediate response) and
absent peripheral pulse who is unlikely to survive with available
resources is categorized Expectant (Black) in conventional
START to conserve resources for salvageable patients. This is
consistent with START guidance used in mass-casualty triage.
REMM+1
• A (Green) Incorrect — ambulatory/minor patients are
stable and can walk; not applicable.
• B (Yellow) Incorrect — delayed means serious but not
immediately life-threatening.
• C (Red) Incorrect — immediate indicates salvageable with
immediate intervention (breathing and pulse present).
• E (Blue) Incorrect — not a START color; distractor.
Question 2
During a hospital triage using the Emergency Severity Index (ESI
v5), which patient should receive ESI level 1 triage?
A. Chest pain radiating to jaw with hypotension and
diaphoresis.
B. Stable fever and sore throat, wants antibiotics.
C. Sprained ankle, able to bear weight.
,D. Anxious patient requesting immediate reassurance.
E. Minor laceration requiring 3–4 sutures.
Answer: A. Chest pain radiating to jaw with hypotension and
diaphoresis.
Rationale: ESI level 1 is for unstable patients who require
immediate life-saving interventions (eg, airway, circulation,
major resuscitation). Chest pain with hypotension and
diaphoresis suggests acute coronary syndrome with
hemodynamic instability — immediate intervention required.
ESI uses acuity and expected resource needs to assign levels.
EMSC Improvement Center+1
• B (Level 5) Incorrect — non-urgent, low resources.
• C (Level 4 or 5) Incorrect — low acuity, likely low resources.
• D Incorrect — anxiety alone without physiological
instability is lower acuity.
• E Incorrect — requires some resources but not immediate
life-saving interventions.
Question 3
A chemical tanker overturns, exposing a crowd to an unknown
liquid. Several ambulatory patients arrive at the ED by foot.
Which initial action should ED nursing leadership direct?
A. Triage and treat in the ED waiting room.
B. Direct ambulatory patients to a decontamination (decon)
, area to remove outer clothing and rinse.
C. Bring the patients into the resuscitation bay immediately for
full triage.
D. Administer activated charcoal to all exposed patients.
E. Begin full weight-based antidote administration for all.
Answer: B. Direct ambulatory patients to a decontamination
(decon) area to remove outer clothing and rinse.
Rationale: In mass chemical exposures, rapid gross
decontamination (remove clothing, copious water rinse) for
ambulatory patients reduces further contamination and
secondary exposure to staff; CHEMM and federal decon
guidance recommend disrobing and water decontamination as
first steps. Triage/treatment should occur after decon or in
designated clean zones. Activated charcoal and antidotes are
agent-specific and should not be given indiscriminately.
CHEMM+1
• A Incorrect — waiting room increases risk of secondary
contamination to ED and staff.
• C Incorrect — bringing contaminated patients into
resuscitation bays risks contaminating clean treatment
areas.
• D Incorrect — activated charcoal is for certain ingested
toxins, not general first step for unknown dermal exposure.
• E Incorrect — antidotes are agent-specific; mass antidote
administration without identification is inappropriate.
