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.
Questions (1–25)
1. (SBA — Triage category / ED triage)
A 42-year-old male arrives to the ED with sudden onset left-
sided weakness and slurred speech that began 20 minutes ago.
Vital signs: HR 92, BP 168/96, RR 18, O₂ sat 97% on room air.
According to emergency triage categories
(emergent/urgent/non-urgent), how should the nurse triage
this patient?
A. Emergent — immediate evaluation/transfer to resuscitation
area
B. Urgent — evaluation within 30–60 minutes
,C. Non-urgent — evaluation within 2–4 hours
D. Minor — fast track evaluation
Answer: A. Emergent
Rationale — correct: Sudden focal neurologic deficits (possible
acute stroke) are time-sensitive and require immediate
evaluation for reperfusion therapy and stroke team activation.
This meets emergent criteria because delay can cause
irreversible brain injury; triage must prioritize immediate clinical
evaluation. (Aligns with ED triage principles in START/ED triage
literature.) NCBI+1
Rationale — incorrect:
B. Urgent is for non-life-threatening but prompt needs (e.g.,
moderate pain, minor fractures) — inappropriate for suspected
stroke.
C/D. Non-urgent/minor are for non-time-sensitive complaints
— unsafe here.
2. (SBA — START triage for mass casualty)
During a mass casualty incident, a triage nurse assesses a
walking wounded patient who can follow commands, is
breathing, and has radial pulses but is pale and reports
dizziness. Using START triage, which color tag/category is
appropriate?
A. Immediate (Red)
B. Delayed (Yellow)
,C. Minor (Green)
D. Deceased/Expectant (Black)
Answer: B. Delayed (Yellow)
Rationale — correct: The walking wounded who can follow
commands and has a pulse but with non-life-threatening signs
(pallor/dizziness suggesting possible moderate blood loss but
stable airway/breathing) are categorized as delayed—treatment
can be deferred until immediate casualties are stabilized. START
assigns red for immediate airway/breathing/circulation
compromise. NCBI+1
Rationale — incorrect:
A. Red is for immediate life-threatening conditions (e.g., apnea
after repositioning, uncontrolled hemorrhage).
C. Green is for minor ambulatory injuries — not appropriate
given dizziness/pallor suggesting circulatory compromise.
D. Black is for deceased/expectant—clearly not appropriate.
3. (SBA — CPR/ROSC management)
A 60-year-old man in the ED has a witnessed ventricular
fibrillation arrest. ROSC achieved after defibrillation. Post-ROSC
the patient is comatose; BP 85/50 despite fluid bolus. According
to current ALS/ROSC guidance, which is the priority immediate
action?
A. Start therapeutic hypothermia (targeted temperature
management) immediately at bedside
, B. Obtain a 12-lead ECG and prepare for possible coronary
reperfusion while stabilizing hemodynamics
C. Extubate to allow neurological exam
D. Give aspirin 325 mg PO
Answer: B. Obtain a 12-lead ECG and prepare for possible
coronary reperfusion while stabilizing hemodynamics
Rationale — correct: After ROSC, the priority is stabilization
(airway/ventilation, hemodynamics) and identifying reversible
causes. Immediate 12-lead ECG is recommended to look for
STEMI and guide emergent coronary reperfusion; meanwhile
manage hypotension (vasopressors if needed) and airway. TTM
may be considered but immediate coronary assessment is
crucial in VF arrests due to likely cardiac etiology. cpr.heart.org
Rationale — incorrect:
A. TTM (targeted temperature management) can be considered
after stabilization and ROSC but is not the single immediate
priority over diagnosis and hemodynamic stabilization.
C. Extubation in comatose post-ROSC is contraindicated.
D. Aspirin PO may be indicated if ACS is suspected but is not the
immediate action ahead of ECG and hemodynamic
management in an unstable post-arrest patient.
4. (SATA — Chemical exposure decontamination steps)
Select all appropriate immediate nursing actions for an adult
patient who presents after a suspected industrial liquid
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
Questions (1–25)
1. (SBA — Triage category / ED triage)
A 42-year-old male arrives to the ED with sudden onset left-
sided weakness and slurred speech that began 20 minutes ago.
Vital signs: HR 92, BP 168/96, RR 18, O₂ sat 97% on room air.
According to emergency triage categories
(emergent/urgent/non-urgent), how should the nurse triage
this patient?
A. Emergent — immediate evaluation/transfer to resuscitation
area
B. Urgent — evaluation within 30–60 minutes
,C. Non-urgent — evaluation within 2–4 hours
D. Minor — fast track evaluation
Answer: A. Emergent
Rationale — correct: Sudden focal neurologic deficits (possible
acute stroke) are time-sensitive and require immediate
evaluation for reperfusion therapy and stroke team activation.
This meets emergent criteria because delay can cause
irreversible brain injury; triage must prioritize immediate clinical
evaluation. (Aligns with ED triage principles in START/ED triage
literature.) NCBI+1
Rationale — incorrect:
B. Urgent is for non-life-threatening but prompt needs (e.g.,
moderate pain, minor fractures) — inappropriate for suspected
stroke.
C/D. Non-urgent/minor are for non-time-sensitive complaints
— unsafe here.
2. (SBA — START triage for mass casualty)
During a mass casualty incident, a triage nurse assesses a
walking wounded patient who can follow commands, is
breathing, and has radial pulses but is pale and reports
dizziness. Using START triage, which color tag/category is
appropriate?
A. Immediate (Red)
B. Delayed (Yellow)
,C. Minor (Green)
D. Deceased/Expectant (Black)
Answer: B. Delayed (Yellow)
Rationale — correct: The walking wounded who can follow
commands and has a pulse but with non-life-threatening signs
(pallor/dizziness suggesting possible moderate blood loss but
stable airway/breathing) are categorized as delayed—treatment
can be deferred until immediate casualties are stabilized. START
assigns red for immediate airway/breathing/circulation
compromise. NCBI+1
Rationale — incorrect:
A. Red is for immediate life-threatening conditions (e.g., apnea
after repositioning, uncontrolled hemorrhage).
C. Green is for minor ambulatory injuries — not appropriate
given dizziness/pallor suggesting circulatory compromise.
D. Black is for deceased/expectant—clearly not appropriate.
3. (SBA — CPR/ROSC management)
A 60-year-old man in the ED has a witnessed ventricular
fibrillation arrest. ROSC achieved after defibrillation. Post-ROSC
the patient is comatose; BP 85/50 despite fluid bolus. According
to current ALS/ROSC guidance, which is the priority immediate
action?
A. Start therapeutic hypothermia (targeted temperature
management) immediately at bedside
, B. Obtain a 12-lead ECG and prepare for possible coronary
reperfusion while stabilizing hemodynamics
C. Extubate to allow neurological exam
D. Give aspirin 325 mg PO
Answer: B. Obtain a 12-lead ECG and prepare for possible
coronary reperfusion while stabilizing hemodynamics
Rationale — correct: After ROSC, the priority is stabilization
(airway/ventilation, hemodynamics) and identifying reversible
causes. Immediate 12-lead ECG is recommended to look for
STEMI and guide emergent coronary reperfusion; meanwhile
manage hypotension (vasopressors if needed) and airway. TTM
may be considered but immediate coronary assessment is
crucial in VF arrests due to likely cardiac etiology. cpr.heart.org
Rationale — incorrect:
A. TTM (targeted temperature management) can be considered
after stabilization and ROSC but is not the single immediate
priority over diagnosis and hemodynamic stabilization.
C. Extubation in comatose post-ROSC is contraindicated.
D. Aspirin PO may be indicated if ACS is suspected but is not the
immediate action ahead of ECG and hemodynamic
management in an unstable post-arrest patient.
4. (SATA — Chemical exposure decontamination steps)
Select all appropriate immediate nursing actions for an adult
patient who presents after a suspected industrial liquid
