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
Scenario: EMS brings a 58-year-old male found unresponsive at
home. He has no pulse and is not breathing. Bystander CPR in
progress with 2-person compressions. A monitor shows coarse
ventricular fibrillation. What is the first action the ED nurse
should take on arrival?
A. Defibrillate immediately with highest available biphasic
charge.
B. Continue compressions and prepare for 2 minutes then
defibrillate.
C. Pause compressions to secure advanced airway before
defibrillation.
D. Give epinephrine 1 mg IV immediately then defibrillate.
,Correct answer: A
Rationale: For a shockable rhythm (ventricular fibrillation),
immediate defibrillation is the highest-priority intervention to
restore perfusing rhythm—ideally minimizing interruptions to
chest compressions (shock delivery should be coordinated to
minimize pause). The AHA 2025 guidelines emphasize prompt
defibrillation for VF/pulseless VT while maintaining high-quality
CPR. cpr.heart.org
• B incorrect: Delaying defibrillation to wait a full 2 minutes
is not indicated for an immediately available shockable
rhythm.
• C incorrect: Securing an advanced airway is important but
not before delivering a shock for VF when defibrillator and
pads are ready—airway can be addressed while
preparations continue.
• D incorrect: Epinephrine is given after initial defibrillation
attempts per ACLS sequence; it is not the first step when
defibrillation is immediately available.
2
Scenario: During triage, a patient with chest pain is assessed
using the ESI. He is on high-flow oxygen, diaphoretic,
hypotensive, and appears unstable. According to ESI principles,
what ESI level is most appropriate?
A. ESI level 1 (Immediate life-saving intervention required)
,B. ESI level 2 (High risk or severe pain)
C. ESI level 3 (Multiple resources anticipated)
D. ESI level 4 (One resource anticipated)
Correct answer: A
Rationale: ESI level 1 is for patients who need immediate life-
saving interventions (e.g., unstable ABCs, hypotension with
signs of shock). This patient demonstrates hemodynamic
instability and needs immediate resuscitation rather than
resource counting. The ESI handbook guides triage assignment
by first determining whether immediate life-saving
interventions are required. California Emergency Nurses
Association
• B incorrect: Level 2 is for high risk or severe pain but not
necessarily immediate life-saving interventions;
hypotension with instability escalates to Level 1.
• C/D incorrect: These levels are for stable patients where
resource estimation is primary.
3
Scenario (NGN style — case snapshot + task): A 30-year-old
man arrives after suspected inhalational chlorine exposure in an
industrial spill. He is coughing, has tachypnea, SpO₂ 90% on
room air, and mild wheeze. You are the triage RN. List the
priority initial nursing actions in order (best sequence). Options
show sequences — pick the best sequence:
, A. Move patient to fresh air → remove contaminated clothing
→ apply oxygen via non-rebreather → notify poison
control/activate hazmat.
B. Apply oxygen → remove clothing → move to fresh air →
decontaminate with water → notify poison control.
C. Move patient to fresh air → apply oxygen → remove
contaminated clothing → notify poison control/activate
CHEMM.
D. Move patient to decontamination tent → immediate
intubation → administer bronchodilator → notify authorities.
Correct answer: C
Rationale: For inhalational chemical exposure, immediate
removal from exposure (move to fresh air) is first, then support
oxygenation (apply oxygen) and remove contaminated clothing
to limit ongoing exposure; notify CHEMM/poison control and
activate hazmat resources for decontamination guidance. The
CDC recommends “get away from the area, get it off and get
clean,” and first responders should move patients to fresh air
and support oxygenation early. Active decontamination follows
scene/hazmat protocols; intubation is reserved for respiratory
failure. CDC+1
• A incorrect: Decontamination (removing clothing) should
occur as early as possible but after moving to safety;
oxygen support is higher priority than decontamination if
patient is hypoxic.
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1
Scenario: EMS brings a 58-year-old male found unresponsive at
home. He has no pulse and is not breathing. Bystander CPR in
progress with 2-person compressions. A monitor shows coarse
ventricular fibrillation. What is the first action the ED nurse
should take on arrival?
A. Defibrillate immediately with highest available biphasic
charge.
B. Continue compressions and prepare for 2 minutes then
defibrillate.
C. Pause compressions to secure advanced airway before
defibrillation.
D. Give epinephrine 1 mg IV immediately then defibrillate.
,Correct answer: A
Rationale: For a shockable rhythm (ventricular fibrillation),
immediate defibrillation is the highest-priority intervention to
restore perfusing rhythm—ideally minimizing interruptions to
chest compressions (shock delivery should be coordinated to
minimize pause). The AHA 2025 guidelines emphasize prompt
defibrillation for VF/pulseless VT while maintaining high-quality
CPR. cpr.heart.org
• B incorrect: Delaying defibrillation to wait a full 2 minutes
is not indicated for an immediately available shockable
rhythm.
• C incorrect: Securing an advanced airway is important but
not before delivering a shock for VF when defibrillator and
pads are ready—airway can be addressed while
preparations continue.
• D incorrect: Epinephrine is given after initial defibrillation
attempts per ACLS sequence; it is not the first step when
defibrillation is immediately available.
2
Scenario: During triage, a patient with chest pain is assessed
using the ESI. He is on high-flow oxygen, diaphoretic,
hypotensive, and appears unstable. According to ESI principles,
what ESI level is most appropriate?
A. ESI level 1 (Immediate life-saving intervention required)
,B. ESI level 2 (High risk or severe pain)
C. ESI level 3 (Multiple resources anticipated)
D. ESI level 4 (One resource anticipated)
Correct answer: A
Rationale: ESI level 1 is for patients who need immediate life-
saving interventions (e.g., unstable ABCs, hypotension with
signs of shock). This patient demonstrates hemodynamic
instability and needs immediate resuscitation rather than
resource counting. The ESI handbook guides triage assignment
by first determining whether immediate life-saving
interventions are required. California Emergency Nurses
Association
• B incorrect: Level 2 is for high risk or severe pain but not
necessarily immediate life-saving interventions;
hypotension with instability escalates to Level 1.
• C/D incorrect: These levels are for stable patients where
resource estimation is primary.
3
Scenario (NGN style — case snapshot + task): A 30-year-old
man arrives after suspected inhalational chlorine exposure in an
industrial spill. He is coughing, has tachypnea, SpO₂ 90% on
room air, and mild wheeze. You are the triage RN. List the
priority initial nursing actions in order (best sequence). Options
show sequences — pick the best sequence:
, A. Move patient to fresh air → remove contaminated clothing
→ apply oxygen via non-rebreather → notify poison
control/activate hazmat.
B. Apply oxygen → remove clothing → move to fresh air →
decontaminate with water → notify poison control.
C. Move patient to fresh air → apply oxygen → remove
contaminated clothing → notify poison control/activate
CHEMM.
D. Move patient to decontamination tent → immediate
intubation → administer bronchodilator → notify authorities.
Correct answer: C
Rationale: For inhalational chemical exposure, immediate
removal from exposure (move to fresh air) is first, then support
oxygenation (apply oxygen) and remove contaminated clothing
to limit ongoing exposure; notify CHEMM/poison control and
activate hazmat resources for decontamination guidance. The
CDC recommends “get away from the area, get it off and get
clean,” and first responders should move patients to fresh air
and support oxygenation early. Active decontamination follows
scene/hazmat protocols; intubation is reserved for respiratory
failure. CDC+1
• A incorrect: Decontamination (removing clothing) should
occur as early as possible but after moving to safety;
oxygen support is higher priority than decontamination if
patient is hypoxic.
