Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Basic triage priority (single best answer)
A 56-year-old male arrives by ambulance after a motor vehicle
crash. He is conscious but noisy respirations and has obvious
chest deformity. Vital signs: RR 34, SpO₂ 86% on room air, HR
122, BP 88/56. According to immediate triage priorities
(ABCs/ESI), which action should the triage nurse perform first?
A. Obtain a detailed trauma history while keeping him on the
stretcher.
B. Apply high-flow oxygen and prepare for airway intervention
with cervical spine stabilization.
C. Start two large-bore IVs and begin fluid resuscitation.
D. Conduct a FAST exam to evaluate for blunt abdominal injury.
E. Place the patient in a monitored ED bed and call the trauma
team after triage is complete.
Correct answer: B.
Rationale (correct): Airway and breathing take priority in the
ABC approach. Noisy respirations, low SpO₂, and chest
,deformity indicate a threatened airway and compromised
ventilation; immediate oxygen and preparation for airway
management with c-spine protection are essential. (Triage/ESI
principles prioritize airway/respiratory compromise.) ENA
Rationale (incorrect):
A — Detailed history is important but not before securing
airway/oxygenation.
C — IV access and fluids are important for hypotension, but
airway takes precedence.
D — FAST is a secondary survey tool; not first when
airway/respiration compromise exists.
E — Waiting to call the trauma team delays critical airway care.
2 — Maslow’s/priority setting (single best answer)
Which statement best applies Maslow’s hierarchy to nursing
priorities during a multiple-casualty incident?
A. Address psychological needs first to reduce panic among
victims.
B. Provide wound care before airway management if bleeding is
visible.
C. Prioritize airway, breathing, and circulation before advanced
psychosocial interventions.
D. Ensure patients feel respected before performing any life-
saving procedures.
E. Triage according to who can communicate their needs best.
,Correct answer: C.
Rationale (correct): Maslow places physiological needs (airway,
breathing, circulation) at the base—these must be addressed
before higher-order psychosocial needs. In emergency triage,
life-saving physiologic interventions take precedence.
Rationale (incorrect):
A — Psychological care is important but secondary to
physiologic stabilization.
B — Visible bleeding may be life-threatening but airway beats
local wound care if airway is compromised.
D — Respect is important but cannot override urgent life-saving
actions.
E — Communication ability does not equate to clinical acuity;
triage must be objective.
3 — START triage application (case)
During a mass casualty incident, a triage officer directs
ambulatory patients to a green zone. One patient in the green
group later develops progressive shortness of breath and
confusion. What is the most appropriate immediate action?
A. Re-label the patient as black (expectant) and leave for
secondary triage later.
B. Move the patient to the red (immediate) treatment area and
initiate reassessment and interventions.
C. Keep the patient in green but give oral fluids and re-evaluate
, in 2 hours.
D. Send the patient to the hospital outpatient clinic for follow-
up.
E. Document findings and continue triaging remaining victims.
Correct answer: B.
Rationale (correct): Triage is dynamic. Deterioration requires
immediate re-triage to a higher acuity category
(red/immediate) and urgent interventions. START emphasizes
rapid re-assessment and escalation for worsening patients.
CHEMM
Rationale (incorrect):
A — Black/expectant is for deceased or non-survivable injuries
when resources are limited; confusion with dyspnea suggests
treatable deterioration.
C — Waiting is unsafe given acute decline.
D — Outpatient referral is inappropriate for acute deterioration.
E — Documenting without acting risks preventable morbidity.
4 — Shock recognition (single best answer)
A 72-year-old woman with a history of myocardial infarction
presents with hypotension, cool clammy skin, oliguria, and
altered mental status. Which type of shock is most likely?
A. Hypovolemic shock
B. Distributive (septic) shock
C. Cardiogenic shock
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Basic triage priority (single best answer)
A 56-year-old male arrives by ambulance after a motor vehicle
crash. He is conscious but noisy respirations and has obvious
chest deformity. Vital signs: RR 34, SpO₂ 86% on room air, HR
122, BP 88/56. According to immediate triage priorities
(ABCs/ESI), which action should the triage nurse perform first?
A. Obtain a detailed trauma history while keeping him on the
stretcher.
B. Apply high-flow oxygen and prepare for airway intervention
with cervical spine stabilization.
C. Start two large-bore IVs and begin fluid resuscitation.
D. Conduct a FAST exam to evaluate for blunt abdominal injury.
E. Place the patient in a monitored ED bed and call the trauma
team after triage is complete.
Correct answer: B.
Rationale (correct): Airway and breathing take priority in the
ABC approach. Noisy respirations, low SpO₂, and chest
,deformity indicate a threatened airway and compromised
ventilation; immediate oxygen and preparation for airway
management with c-spine protection are essential. (Triage/ESI
principles prioritize airway/respiratory compromise.) ENA
Rationale (incorrect):
A — Detailed history is important but not before securing
airway/oxygenation.
C — IV access and fluids are important for hypotension, but
airway takes precedence.
D — FAST is a secondary survey tool; not first when
airway/respiration compromise exists.
E — Waiting to call the trauma team delays critical airway care.
2 — Maslow’s/priority setting (single best answer)
Which statement best applies Maslow’s hierarchy to nursing
priorities during a multiple-casualty incident?
A. Address psychological needs first to reduce panic among
victims.
B. Provide wound care before airway management if bleeding is
visible.
C. Prioritize airway, breathing, and circulation before advanced
psychosocial interventions.
D. Ensure patients feel respected before performing any life-
saving procedures.
E. Triage according to who can communicate their needs best.
,Correct answer: C.
Rationale (correct): Maslow places physiological needs (airway,
breathing, circulation) at the base—these must be addressed
before higher-order psychosocial needs. In emergency triage,
life-saving physiologic interventions take precedence.
Rationale (incorrect):
A — Psychological care is important but secondary to
physiologic stabilization.
B — Visible bleeding may be life-threatening but airway beats
local wound care if airway is compromised.
D — Respect is important but cannot override urgent life-saving
actions.
E — Communication ability does not equate to clinical acuity;
triage must be objective.
3 — START triage application (case)
During a mass casualty incident, a triage officer directs
ambulatory patients to a green zone. One patient in the green
group later develops progressive shortness of breath and
confusion. What is the most appropriate immediate action?
A. Re-label the patient as black (expectant) and leave for
secondary triage later.
B. Move the patient to the red (immediate) treatment area and
initiate reassessment and interventions.
C. Keep the patient in green but give oral fluids and re-evaluate
, in 2 hours.
D. Send the patient to the hospital outpatient clinic for follow-
up.
E. Document findings and continue triaging remaining victims.
Correct answer: B.
Rationale (correct): Triage is dynamic. Deterioration requires
immediate re-triage to a higher acuity category
(red/immediate) and urgent interventions. START emphasizes
rapid re-assessment and escalation for worsening patients.
CHEMM
Rationale (incorrect):
A — Black/expectant is for deceased or non-survivable injuries
when resources are limited; confusion with dyspnea suggests
treatable deterioration.
C — Waiting is unsafe given acute decline.
D — Outpatient referral is inappropriate for acute deterioration.
E — Documenting without acting risks preventable morbidity.
4 — Shock recognition (single best answer)
A 72-year-old woman with a history of myocardial infarction
presents with hypotension, cool clammy skin, oliguria, and
altered mental status. Which type of shock is most likely?
A. Hypovolemic shock
B. Distributive (septic) shock
C. Cardiogenic shock
