Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Prioritization / ABCs (Multiple choice)
A 58-year-old man arrives at triage after a motor
vehicle collision. He is able to speak but complains
of chest pain and shortness of breath. Vital signs: RR
32, SpO₂ 88% on room air, HR 120, BP 90/60. Which
is the nurse’s highest priority action?
A. Obtain a 12-lead ECG.
B. Administer high-flow oxygen and assess
airway/breathing.
C. Establish IV access and begin fluid bolus.
D. Move patient to radiology for chest X-ray.
Correct answer: B.
,Rationale (stepwise):
1. ABCs: airway and oxygenation take priority
when SpO₂ is low and RR is high — address
breathing immediately.
2. Give high-flow O₂ (or prepare for assisted
ventilation) and reassess. This stabilizes
oxygenation prior to diagnostics.
3. ECG and IV/fluids are important but second to
ensuring adequate oxygenation. Chest X-ray is
diagnostic and should follow stabilization.
(Primary survey/ATLS and emergency nursing
prioritize airway/breathing before other
interventions). NCBI
2 — Maslow / Prioritization (Multiple choice)
Which patient requires the nurse’s immediate
attention on a mixed-acuity medical–surgical unit?
A. A postoperative patient requesting pain
medication for incisional pain.
B. A patient who is anxious about discharge
,teaching.
C. A patient on telemetry with sudden loss of
consciousness and no palpable pulse.
D. A patient asking about financial concerns related
to medications.
Correct answer: C.
Rationale (stepwise):
1. Maslow and clinical priority place physiological
and life-threatening needs first; an
unresponsive, pulseless patient requires
immediate resuscitation (CAB/ACLS algorithm).
2. Pain, anxiety, and psychosocial/financial
concerns are important but lower priority than
cardiac arrest.
(Life-threatening physiologic problems
supersede safety and psychosocial needs.)
NCSBN+1
3 — START Triage (Mass casualty) (Case)
, During a multi-vehicle crash in the field, four victims
are brought to the triage area. Which patient is
tagged Immediate (Red) under START triage?
A. Alert, breathing 22/min, minor lacerations, can
walk.
B. Not breathing; after repositioning airway, still
apneic.
C. Breathing 8/min, radial pulse present, responds
to verbal commands.
D. Breathing 20/min, capillary refill >4 sec, confused
when spoken to.
Correct answer: D.
Rationale (stepwise):
1. START uses RPM (Respiration, Perfusion, Mental
status). Immediate/red includes patients with
respiratory compromise (too slow/fast), poor
perfusion, or altered mental status but who are
salvageable.
2. Choice D: capillary refill >4 sec (poor perfusion)
and confusion (altered mental status) →
immediate.
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Prioritization / ABCs (Multiple choice)
A 58-year-old man arrives at triage after a motor
vehicle collision. He is able to speak but complains
of chest pain and shortness of breath. Vital signs: RR
32, SpO₂ 88% on room air, HR 120, BP 90/60. Which
is the nurse’s highest priority action?
A. Obtain a 12-lead ECG.
B. Administer high-flow oxygen and assess
airway/breathing.
C. Establish IV access and begin fluid bolus.
D. Move patient to radiology for chest X-ray.
Correct answer: B.
,Rationale (stepwise):
1. ABCs: airway and oxygenation take priority
when SpO₂ is low and RR is high — address
breathing immediately.
2. Give high-flow O₂ (or prepare for assisted
ventilation) and reassess. This stabilizes
oxygenation prior to diagnostics.
3. ECG and IV/fluids are important but second to
ensuring adequate oxygenation. Chest X-ray is
diagnostic and should follow stabilization.
(Primary survey/ATLS and emergency nursing
prioritize airway/breathing before other
interventions). NCBI
2 — Maslow / Prioritization (Multiple choice)
Which patient requires the nurse’s immediate
attention on a mixed-acuity medical–surgical unit?
A. A postoperative patient requesting pain
medication for incisional pain.
B. A patient who is anxious about discharge
,teaching.
C. A patient on telemetry with sudden loss of
consciousness and no palpable pulse.
D. A patient asking about financial concerns related
to medications.
Correct answer: C.
Rationale (stepwise):
1. Maslow and clinical priority place physiological
and life-threatening needs first; an
unresponsive, pulseless patient requires
immediate resuscitation (CAB/ACLS algorithm).
2. Pain, anxiety, and psychosocial/financial
concerns are important but lower priority than
cardiac arrest.
(Life-threatening physiologic problems
supersede safety and psychosocial needs.)
NCSBN+1
3 — START Triage (Mass casualty) (Case)
, During a multi-vehicle crash in the field, four victims
are brought to the triage area. Which patient is
tagged Immediate (Red) under START triage?
A. Alert, breathing 22/min, minor lacerations, can
walk.
B. Not breathing; after repositioning airway, still
apneic.
C. Breathing 8/min, radial pulse present, responds
to verbal commands.
D. Breathing 20/min, capillary refill >4 sec, confused
when spoken to.
Correct answer: D.
Rationale (stepwise):
1. START uses RPM (Respiration, Perfusion, Mental
status). Immediate/red includes patients with
respiratory compromise (too slow/fast), poor
perfusion, or altered mental status but who are
salvageable.
2. Choice D: capillary refill >4 sec (poor perfusion)
and confusion (altered mental status) →
immediate.
