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 — SBA (Triage level)
A 68-year-old man arrives at the ED walking and alert. He
complains of crushing chest pain for 20 minutes, diaphoresis,
and shortness of breath. Vital signs: HR 110, BP 88/56, RR 24,
SpO₂ 92% on room air. Which triage category (ESI/triage level) is
most appropriate?
A. Non-urgent (ESI 5)
B. Urgent (ESI 4)
C. Emergent (ESI 2)
D. Immediate (ESI 1)
Correct answer: C. Emergent (ESI 2)
,Rationale: This patient has unstable vital signs (hypotension)
and symptoms concerning for acute coronary syndrome. ESI
level 1 is for immediate life-saving interventions (e.g., cardiac
arrest). ESI 2 (emergent) is appropriate for high-risk situations
or those with threatened vital functions requiring rapid
evaluation/intervention. ESI 4–5 represent lower
acuity/resource needs. Undertriaging ACS increases
morbidity/mortality risk. California Emergency Nurses
Association+1
• Why A/B incorrect: non-urgent and urgent categories
understate acuity and delay timely interventions.
• Why D incorrect: ESI 1 denotes need for immediate
resuscitation (e.g., ongoing CPR, airway loss), which is not
present in this scenario.
2 — SBA (Mass casualty triage)
A multi-vehicle highway collision results in >30 casualties. As
the first EMS team arrives, which initial mass-casualty triage
approach is recommended for rapid sorting of patients by most
likely survivable need?
A. Use individual hospital admission criteria for each patient
B. START (Simple Triage and Rapid Treatment) or SALT triage for
field sorting
C. Admit all walking wounded to local hospital immediately
,D. Evaluate each patient with a full primary and secondary
survey before tagging
Correct answer: B. START or SALT triage for field sorting
Rationale: For MCIs, START and SALT are widely used field triage
systems to rapidly sort many patients by priority for
treatment/transport. They allow rescuers to categorize patients
quickly (RPM or SALT steps). Performing full primary/secondary
surveys for every patient at scene is impractical and delays care.
Local hospital admission criteria are irrelevant at initial scene
sorting. CHEMM+2CHEMM+2
• Why A, C, D incorrect: They are either impractical or unsafe
at initial scene triage and can lead to delays or
misallocation of scarce resources.
3 — SBA (CPR/defibrillation priority)
A 55-year-old man collapses in the ED waiting area and is found
unresponsive and pulseless. Bystander CPR has already been
started. As the ED nurse, what is the immediate priority?
A. Continue chest compressions and attach
defibrillator/monitor to check rhythm
B. Move patient to resuscitation bay before continuing
compressions
C. Give 1 mg epinephrine IV push immediately
D. Attempt rapid airway intubation while chest compressions
continue
, Correct answer: A. Continue chest compressions and attach
defibrillator/monitor to check rhythm
Rationale: Immediate high-quality chest compressions and
prompt rhythm analysis/defibrillation (if indicated) are core
priorities per AHA guidelines. Early defibrillation for shockable
rhythms significantly improves survival. Epinephrine
administration and advanced airway come after establishing
compressions/defibrillation according to current ACLS
sequence. Moving patient may delay interventions.
professional.heart.org+1
• Why B incorrect: Moving the patient may interrupt
compressions and delay defibrillation.
• Why C incorrect: Epinephrine is important but secondary
to early defibrillation/compressions in initial
seconds/minutes.
• Why D incorrect: Advanced airway should not supersede
immediate compressions/defibrillation.
4 — MR (Chemical exposure — immediate actions) — Select
all that apply
A closed-warehouse leak exposes multiple workers to an
unknown liquid chemical. As ED triage nurse receiving these
patients, which actions are immediate priorities? (Select all that
apply.)
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1 — SBA (Triage level)
A 68-year-old man arrives at the ED walking and alert. He
complains of crushing chest pain for 20 minutes, diaphoresis,
and shortness of breath. Vital signs: HR 110, BP 88/56, RR 24,
SpO₂ 92% on room air. Which triage category (ESI/triage level) is
most appropriate?
A. Non-urgent (ESI 5)
B. Urgent (ESI 4)
C. Emergent (ESI 2)
D. Immediate (ESI 1)
Correct answer: C. Emergent (ESI 2)
,Rationale: This patient has unstable vital signs (hypotension)
and symptoms concerning for acute coronary syndrome. ESI
level 1 is for immediate life-saving interventions (e.g., cardiac
arrest). ESI 2 (emergent) is appropriate for high-risk situations
or those with threatened vital functions requiring rapid
evaluation/intervention. ESI 4–5 represent lower
acuity/resource needs. Undertriaging ACS increases
morbidity/mortality risk. California Emergency Nurses
Association+1
• Why A/B incorrect: non-urgent and urgent categories
understate acuity and delay timely interventions.
• Why D incorrect: ESI 1 denotes need for immediate
resuscitation (e.g., ongoing CPR, airway loss), which is not
present in this scenario.
2 — SBA (Mass casualty triage)
A multi-vehicle highway collision results in >30 casualties. As
the first EMS team arrives, which initial mass-casualty triage
approach is recommended for rapid sorting of patients by most
likely survivable need?
A. Use individual hospital admission criteria for each patient
B. START (Simple Triage and Rapid Treatment) or SALT triage for
field sorting
C. Admit all walking wounded to local hospital immediately
,D. Evaluate each patient with a full primary and secondary
survey before tagging
Correct answer: B. START or SALT triage for field sorting
Rationale: For MCIs, START and SALT are widely used field triage
systems to rapidly sort many patients by priority for
treatment/transport. They allow rescuers to categorize patients
quickly (RPM or SALT steps). Performing full primary/secondary
surveys for every patient at scene is impractical and delays care.
Local hospital admission criteria are irrelevant at initial scene
sorting. CHEMM+2CHEMM+2
• Why A, C, D incorrect: They are either impractical or unsafe
at initial scene triage and can lead to delays or
misallocation of scarce resources.
3 — SBA (CPR/defibrillation priority)
A 55-year-old man collapses in the ED waiting area and is found
unresponsive and pulseless. Bystander CPR has already been
started. As the ED nurse, what is the immediate priority?
A. Continue chest compressions and attach
defibrillator/monitor to check rhythm
B. Move patient to resuscitation bay before continuing
compressions
C. Give 1 mg epinephrine IV push immediately
D. Attempt rapid airway intubation while chest compressions
continue
, Correct answer: A. Continue chest compressions and attach
defibrillator/monitor to check rhythm
Rationale: Immediate high-quality chest compressions and
prompt rhythm analysis/defibrillation (if indicated) are core
priorities per AHA guidelines. Early defibrillation for shockable
rhythms significantly improves survival. Epinephrine
administration and advanced airway come after establishing
compressions/defibrillation according to current ACLS
sequence. Moving patient may delay interventions.
professional.heart.org+1
• Why B incorrect: Moving the patient may interrupt
compressions and delay defibrillation.
• Why C incorrect: Epinephrine is important but secondary
to early defibrillation/compressions in initial
seconds/minutes.
• Why D incorrect: Advanced airway should not supersede
immediate compressions/defibrillation.
4 — MR (Chemical exposure — immediate actions) — Select
all that apply
A closed-warehouse leak exposes multiple workers to an
unknown liquid chemical. As ED triage nurse receiving these
patients, which actions are immediate priorities? (Select all that
apply.)
