Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Prioritization / ABCs (single-best-answer)
A 68-year-old male arrives by ambulance after
syncope at home. He is unconscious, snoring
respirations, pulse 52/min, BP 88/54 mm Hg. Which
intervention should the ED nurse perform first?
A. Start IV normal saline bolus.
B. Open airway and position for ventilation.
C. Obtain 12-lead ECG.
D. Give 0.4 mg sublingual nitroglycerin.
Answer: (B)
Rationale — stepwise:
, 1. Airway and breathing take priority in ABC
approach; snoring respirations indicate partial
airway obstruction. Opening airway (chin-
lift/jaw thrust if not suspected C-spine injury)
and preparing to ventilate if needed is
immediate.
2. IV fluid (A) is important for hypotension but
secondary to securing airway/ventilation.
3. ECG (C) is urgent in syncope/bradycardia but
comes after airway stabilization.
4. Nitroglycerin (D) is contraindicated for
hypotension and bradycardia.
Clinical principle: Always address airway before
circulation/other interventions (ABCs). (NCLEX
priority and emergency practice.)
2 — Triage categories / ESI (single-best-answer)
At triage an adult complains of severe shortness of
breath, pulse 130/min, speaking only single words,
,accessory muscle use. Using a 5-level triage system
(ESI/similar), which category is most appropriate?
A. ESI Level 1 — immediate life-saving intervention
required.
B. ESI Level 2 — high risk or
confused/lethargic/disoriented.
C. ESI Level 3 — urgent, likely to need multiple
resources.
D. ESI Level 4 — nonurgent, one resource expected.
Answer: (A)
Rationale — stepwise:
1. Patient is in respiratory distress, only able to
speak single words → suggests respiratory
failure and need for immediate life-saving
interventions (e.g., airway support, oxygen,
possible intubation).
2. ESI Level 1 is assigned when immediate
lifesaving interventions are required. ESI Level 2
(B) applies to high risk but not necessarily
requiring immediate lifesaving action.
, 3. Levels 3–4 (C,D) are lower acuity.
Reference: Emergency Severity Index guidance
for identifying patients needing immediate
intervention. media.emscimprovement.center
3 — Mass-casualty triage (case-based, single-best-
answer)
In a mass-casualty incident, a triage nurse uses a
rapid system asking ambulatory victims to move to
one area; those not moving are then assessed for
respirations, perfusion, and mental status. Which
triage system is being used?
A. ESI (Emergency Severity Index)
B. START (Simple Triage and Rapid Treatment)
C. SALT (Sort, Assess, Lifesaving interventions,
Treatment/Transport)
D. Manchester Triage System
Answer: (B)
Rationale — stepwise:
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Prioritization / ABCs (single-best-answer)
A 68-year-old male arrives by ambulance after
syncope at home. He is unconscious, snoring
respirations, pulse 52/min, BP 88/54 mm Hg. Which
intervention should the ED nurse perform first?
A. Start IV normal saline bolus.
B. Open airway and position for ventilation.
C. Obtain 12-lead ECG.
D. Give 0.4 mg sublingual nitroglycerin.
Answer: (B)
Rationale — stepwise:
, 1. Airway and breathing take priority in ABC
approach; snoring respirations indicate partial
airway obstruction. Opening airway (chin-
lift/jaw thrust if not suspected C-spine injury)
and preparing to ventilate if needed is
immediate.
2. IV fluid (A) is important for hypotension but
secondary to securing airway/ventilation.
3. ECG (C) is urgent in syncope/bradycardia but
comes after airway stabilization.
4. Nitroglycerin (D) is contraindicated for
hypotension and bradycardia.
Clinical principle: Always address airway before
circulation/other interventions (ABCs). (NCLEX
priority and emergency practice.)
2 — Triage categories / ESI (single-best-answer)
At triage an adult complains of severe shortness of
breath, pulse 130/min, speaking only single words,
,accessory muscle use. Using a 5-level triage system
(ESI/similar), which category is most appropriate?
A. ESI Level 1 — immediate life-saving intervention
required.
B. ESI Level 2 — high risk or
confused/lethargic/disoriented.
C. ESI Level 3 — urgent, likely to need multiple
resources.
D. ESI Level 4 — nonurgent, one resource expected.
Answer: (A)
Rationale — stepwise:
1. Patient is in respiratory distress, only able to
speak single words → suggests respiratory
failure and need for immediate life-saving
interventions (e.g., airway support, oxygen,
possible intubation).
2. ESI Level 1 is assigned when immediate
lifesaving interventions are required. ESI Level 2
(B) applies to high risk but not necessarily
requiring immediate lifesaving action.
, 3. Levels 3–4 (C,D) are lower acuity.
Reference: Emergency Severity Index guidance
for identifying patients needing immediate
intervention. media.emscimprovement.center
3 — Mass-casualty triage (case-based, single-best-
answer)
In a mass-casualty incident, a triage nurse uses a
rapid system asking ambulatory victims to move to
one area; those not moving are then assessed for
respirations, perfusion, and mental status. Which
triage system is being used?
A. ESI (Emergency Severity Index)
B. START (Simple Triage and Rapid Treatment)
C. SALT (Sort, Assess, Lifesaving interventions,
Treatment/Transport)
D. Manchester Triage System
Answer: (B)
Rationale — stepwise:
