RELIAS ED RN A COMPLETE TEST 2026 UPDATED |
100% Correct & Verified Answers | Emergency
Department RN Assessment | Pass Guaranteed - A+
Graded
Part I: Triage & Rapid Patient Assessment (20 questions)
Q1: A 34-year-old male walks into triage stating he has "bad indigestion" and mild
chest discomfort. He is diaphoretic, clutching his chest, and his skin is pale. Vital
signs: BP 88/52, HR 118, RR 24, SpO2 91% on room air. What is the correct ESI level
and immediate action?
A. ESI 3 — obtain a full cardiac history and 12-lead EKG before moving him to a bed
B. ESI 4 — give him an antacid and have him wait in the lobby since he described
indigestion
C. ESI 1 — immediate bed assignment and activation of the cardiac team;
hypotension, tachycardia, and hypoxia indicate high risk of death [CORRECT]
D. ESI 2 — place him in a hallway bed and start a saline lock while waiting for a room
Correct Answer: C
Rationale: This patient meets ESI 1 criteria — a high-risk situation requiring
immediate life-saving intervention. Hypotension, tachycardia, and hypoxia with chest
pain suggest cardiogenic shock or massive MI. A delays critical care for assessment. B
is a dangerous mis-triage based on the patient's self-description. D delays definitive
care in a hallway when a monitored bed is needed now.
Q2: Triage Scenario: The waiting room has four patients who have just checked in.
Who should be brought back first?
, • Patient A: 67-year-old female, chief complaint "weakness," vitals BP 198/110, HR
92, RR 18, SpO2 97%, pain 2/10
• Patient B: 8-year-old male, chief complaint "earache," vitals stable, afebrile, pain
5/10
• Patient C: 45-year-old male, chief complaint "chest pressure," vitals BP 102/68,
HR 128, RR 26, SpO2 89%, pain 9/10, diaphoretic
• Patient D: 22-year-old female, chief complaint "ankle sprain," vitals stable, pain
6/10
A. Patient A, because severely elevated blood pressure indicates a hypertensive
emergency
B. Patient C, because hypotension, tachycardia, hypoxia, and diaphoresis with chest
pain indicate a high-risk cardiac event requiring immediate intervention [CORRECT]
C. Patient B, because pediatric patients should always be prioritized in triage
D. Patient D, because musculoskeletal injuries can deteriorate quickly if not splinted
promptly
Correct Answer: B
Rationale: Patient C meets ESI 1 criteria with vital sign abnormalities indicating
hemodynamic compromise and respiratory failure. A has elevated BP but is stable. B
and D are non-urgent complaints. A misidentifies the priority — while hypertensive
urgency needs evaluation, it is not immediately life-threatening. C incorrectly
prioritizes all pediatric patients regardless of acuity. D is inappropriate for a stable
sprain.
Q3: A 56-year-old female arrives via EMS with sudden onset of the "worst headache
of my life," accompanied by nausea, vomiting, and photophobia. She is alert and
oriented but rates her pain 10/10. Her BP is 220/130, HR 58, RR 14. What is the most
appropriate ESI level?
A. ESI 3 — she is alert and oriented, so she can wait for a CT scan in the queue
B. ESI 2 — she needs rapid assessment and neuroimaging due to thunderclap
headache with severe hypertension and bradycardia, concerning for subarachnoid
hemorrhage [CORRECT]
,C. ESI 4 — headache with nausea is a common presentation and typically non-
emergent
D. ESI 1 — she is not in cardiac arrest or respiratory failure, so immediate life-saving
intervention is not needed
Correct Answer: B
Rationale: Thunderclap headache with hypertension, bradycardia (Cushing's triad
indicator), and neuro symptoms meets ESI 2 — a high-risk patient needing rapid
evaluation and intervention. A dangerously underestimates the presentation. C is
inappropriate given the classic SAH presentation. D is incorrect because while she is
not in arrest, she has a high-risk condition requiring prompt workup to prevent
deterioration.
Q4: Which vital sign combination in a 70-year-old patient with pneumonia most
strongly indicates the need for immediate escalation to a higher level of care?
A. BP 142/88, HR 96, RR 18, SpO2 94% on 2L NC
B. BP 98/56, HR 128, RR 32, SpO2 86% on 15L NRB, altered mental status [CORRECT]
C. BP 118/72, HR 104, RR 24, SpO2 91% on room air
D. BP 134/80, HR 88, RR 20, SpO2 96% on room air
Correct Answer: B
Rationale: Hypotension, tachycardia, tachypnea, severe hypoxemia despite high-flow
oxygen, and altered mental status indicate septic shock with respiratory failure —
requiring immediate ICU-level intervention. A shows mild hypoxemia but is otherwise
stable. C needs oxygen but is not in shock. D is essentially normal.
Q5: A triage nurse is assessing a 4-year-old brought in by parents for fever and rash.
The child is irritable, has a non-blanching petechial rash on the trunk, and capillary
refill is 4 seconds. Temperature is 39.8°C (103.6°F). What is the priority action?
A. Obtain a detailed vaccination history before proceeding with assessment
B. Place the child in the waiting room with a mask and reassess in 30 minutes
, C. Immediately escort to a treatment room, initiate sepsis protocol, and notify the
physician — petechiae with fever and delayed capillary refill indicates possible
meningococcemia [CORRECT]
D. Give acetaminophen per protocol and discharge with return precautions for viral
exanthem
Correct Answer: C
Rationale: Non-blanching petechial rash with high fever and poor perfusion is classic
for meningococcemia — a time-critical, life-threatening infection. A delays critical
care. B is dangerous given the high risk of rapid deterioration. D misses the life-
threatening presentation entirely.
Q6: During triage, a patient states they have abdominal pain rated 3/10 that started
two days ago. Vitals are stable, and the patient is ambulatory with normal skin color.
According to ESI triage principles, which resource prediction is most appropriate?
A. ESI 1 — all abdominal pain requires immediate evaluation for surgical emergencies
B. ESI 2 — abdominal pain always warrants rapid placement and labs
C. ESI 3 — likely to require multiple resources (labs, imaging, IV fluids) but is stable
with normal vitals [CORRECT]
D. ESI 4 — abdominal pain is typically self-limiting and requires no resources
Correct Answer: C
Rationale: Stable vitals, low pain score, and chronicity suggest ESI 3 — multiple
resources likely needed but not a high-risk, immediate threat. A over-triages all
abdominal pain. B assumes all abdominal pain is urgent regardless of presentation. D
under-triages by assuming no workup is needed.
Q7: A 28-year-old female presents after a motor vehicle collision. She is ambulatory,
complaining of neck pain and a headache. She denies loss of consciousness. Her GCS
is 15, vitals are stable, and she has no midline cervical tenderness. What is the
appropriate next step?
100% Correct & Verified Answers | Emergency
Department RN Assessment | Pass Guaranteed - A+
Graded
Part I: Triage & Rapid Patient Assessment (20 questions)
Q1: A 34-year-old male walks into triage stating he has "bad indigestion" and mild
chest discomfort. He is diaphoretic, clutching his chest, and his skin is pale. Vital
signs: BP 88/52, HR 118, RR 24, SpO2 91% on room air. What is the correct ESI level
and immediate action?
A. ESI 3 — obtain a full cardiac history and 12-lead EKG before moving him to a bed
B. ESI 4 — give him an antacid and have him wait in the lobby since he described
indigestion
C. ESI 1 — immediate bed assignment and activation of the cardiac team;
hypotension, tachycardia, and hypoxia indicate high risk of death [CORRECT]
D. ESI 2 — place him in a hallway bed and start a saline lock while waiting for a room
Correct Answer: C
Rationale: This patient meets ESI 1 criteria — a high-risk situation requiring
immediate life-saving intervention. Hypotension, tachycardia, and hypoxia with chest
pain suggest cardiogenic shock or massive MI. A delays critical care for assessment. B
is a dangerous mis-triage based on the patient's self-description. D delays definitive
care in a hallway when a monitored bed is needed now.
Q2: Triage Scenario: The waiting room has four patients who have just checked in.
Who should be brought back first?
, • Patient A: 67-year-old female, chief complaint "weakness," vitals BP 198/110, HR
92, RR 18, SpO2 97%, pain 2/10
• Patient B: 8-year-old male, chief complaint "earache," vitals stable, afebrile, pain
5/10
• Patient C: 45-year-old male, chief complaint "chest pressure," vitals BP 102/68,
HR 128, RR 26, SpO2 89%, pain 9/10, diaphoretic
• Patient D: 22-year-old female, chief complaint "ankle sprain," vitals stable, pain
6/10
A. Patient A, because severely elevated blood pressure indicates a hypertensive
emergency
B. Patient C, because hypotension, tachycardia, hypoxia, and diaphoresis with chest
pain indicate a high-risk cardiac event requiring immediate intervention [CORRECT]
C. Patient B, because pediatric patients should always be prioritized in triage
D. Patient D, because musculoskeletal injuries can deteriorate quickly if not splinted
promptly
Correct Answer: B
Rationale: Patient C meets ESI 1 criteria with vital sign abnormalities indicating
hemodynamic compromise and respiratory failure. A has elevated BP but is stable. B
and D are non-urgent complaints. A misidentifies the priority — while hypertensive
urgency needs evaluation, it is not immediately life-threatening. C incorrectly
prioritizes all pediatric patients regardless of acuity. D is inappropriate for a stable
sprain.
Q3: A 56-year-old female arrives via EMS with sudden onset of the "worst headache
of my life," accompanied by nausea, vomiting, and photophobia. She is alert and
oriented but rates her pain 10/10. Her BP is 220/130, HR 58, RR 14. What is the most
appropriate ESI level?
A. ESI 3 — she is alert and oriented, so she can wait for a CT scan in the queue
B. ESI 2 — she needs rapid assessment and neuroimaging due to thunderclap
headache with severe hypertension and bradycardia, concerning for subarachnoid
hemorrhage [CORRECT]
,C. ESI 4 — headache with nausea is a common presentation and typically non-
emergent
D. ESI 1 — she is not in cardiac arrest or respiratory failure, so immediate life-saving
intervention is not needed
Correct Answer: B
Rationale: Thunderclap headache with hypertension, bradycardia (Cushing's triad
indicator), and neuro symptoms meets ESI 2 — a high-risk patient needing rapid
evaluation and intervention. A dangerously underestimates the presentation. C is
inappropriate given the classic SAH presentation. D is incorrect because while she is
not in arrest, she has a high-risk condition requiring prompt workup to prevent
deterioration.
Q4: Which vital sign combination in a 70-year-old patient with pneumonia most
strongly indicates the need for immediate escalation to a higher level of care?
A. BP 142/88, HR 96, RR 18, SpO2 94% on 2L NC
B. BP 98/56, HR 128, RR 32, SpO2 86% on 15L NRB, altered mental status [CORRECT]
C. BP 118/72, HR 104, RR 24, SpO2 91% on room air
D. BP 134/80, HR 88, RR 20, SpO2 96% on room air
Correct Answer: B
Rationale: Hypotension, tachycardia, tachypnea, severe hypoxemia despite high-flow
oxygen, and altered mental status indicate septic shock with respiratory failure —
requiring immediate ICU-level intervention. A shows mild hypoxemia but is otherwise
stable. C needs oxygen but is not in shock. D is essentially normal.
Q5: A triage nurse is assessing a 4-year-old brought in by parents for fever and rash.
The child is irritable, has a non-blanching petechial rash on the trunk, and capillary
refill is 4 seconds. Temperature is 39.8°C (103.6°F). What is the priority action?
A. Obtain a detailed vaccination history before proceeding with assessment
B. Place the child in the waiting room with a mask and reassess in 30 minutes
, C. Immediately escort to a treatment room, initiate sepsis protocol, and notify the
physician — petechiae with fever and delayed capillary refill indicates possible
meningococcemia [CORRECT]
D. Give acetaminophen per protocol and discharge with return precautions for viral
exanthem
Correct Answer: C
Rationale: Non-blanching petechial rash with high fever and poor perfusion is classic
for meningococcemia — a time-critical, life-threatening infection. A delays critical
care. B is dangerous given the high risk of rapid deterioration. D misses the life-
threatening presentation entirely.
Q6: During triage, a patient states they have abdominal pain rated 3/10 that started
two days ago. Vitals are stable, and the patient is ambulatory with normal skin color.
According to ESI triage principles, which resource prediction is most appropriate?
A. ESI 1 — all abdominal pain requires immediate evaluation for surgical emergencies
B. ESI 2 — abdominal pain always warrants rapid placement and labs
C. ESI 3 — likely to require multiple resources (labs, imaging, IV fluids) but is stable
with normal vitals [CORRECT]
D. ESI 4 — abdominal pain is typically self-limiting and requires no resources
Correct Answer: C
Rationale: Stable vitals, low pain score, and chronicity suggest ESI 3 — multiple
resources likely needed but not a high-risk, immediate threat. A over-triages all
abdominal pain. B assumes all abdominal pain is urgent regardless of presentation. D
under-triages by assuming no workup is needed.
Q7: A 28-year-old female presents after a motor vehicle collision. She is ambulatory,
complaining of neck pain and a headache. She denies loss of consciousness. Her GCS
is 15, vitals are stable, and she has no midline cervical tenderness. What is the
appropriate next step?
