Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Triage priority (ESI / ABCs)
A 42-year-old man arrives to triage after a motor
vehicle crash. He is unconscious, snoring
respirations, heart rate 122, BP 88/52 mm Hg, and
obvious deformity of the left femur with heavy
bleeding. According to immediate triage priorities,
which action should the triage nurse perform first?
A. Apply direct pressure to the femoral wound.
B. Open and maintain the airway using jaw-thrust
and evaluate breathing.
C. Insert a large-bore IV and begin normal saline
bolus.
D. Prepare for immediate rapid sequence intubation
(RSI).
,Answer: B. Open and maintain the airway using
jaw-thrust and evaluate breathing.
Rationale (Clinical Judgment steps):
• Recognize cues: unconscious patient with
snoring respirations (airway compromise) and
hypotension.
• Analyze: Airway patency is the highest priority
(A of ABCs); other interventions depend on
airway protection.
• Decide: Secure/maintain airway before
significant interventions for circulation or
hemorrhage.
• Act: Perform jaw-thrust/manually open airway;
prepare for definitive airway if needed.
• Evaluate: Reassess respirations, oxygenation,
and responsiveness; if airway remains
compromised, escalate to intubation.
Why other options are incorrect: A (direct
pressure) addresses circulation but not the
immediately life-threatening airway. C (IV/fluids)
, is important but secondary to airway. D (RSI)
may be required, but initial airway opening and
assessment come first; RSI requires preparation
and personnel.
(References: ABC priority in emergency/trauma
primary survey; ATLS principles applied in triage.)
2 — Maslow & prioritization
A triage nurse must prioritize four patients waiting
to be seen. Which patient should be seen first based
on Maslow’s hierarchy and immediate clinical risk?
A. A 26-year-old with anxiety requesting a COVID
test.
B. A 70-year-old with chest pain and diaphoresis.
C. A 45-year-old seeking antibiotics for sinus
congestion.
D. A 19-year-old with intact open fracture of the
index finger.
Answer: B. A 70-year-old with chest pain and
diaphoresis.
, Rationale:
• Recognize: Chest pain + diaphoresis suggests
possible ACS → threat to physiologic safety
(Maslow: basic physiological needs).
• Analyze: Immediate life-threatening condition;
must be assessed and monitored first.
• Decide/Act: Rapid ECG, oxygen if needed,
aspirin per protocol, notify ED provider.
• Evaluate: Reassess pain, vitals, ECG results.
Incorrect options: A and C are low acuity
(psych/social or minor infection). D is urgent but
likely not immediately life-threatening
compared to potential cardiac ischemia.
(Triage decisions prioritize physiologic threats over
lower-level needs.)
3 — ESI triage level identification
Using the Emergency Severity Index (ESI), which
patient is ESI level 1 (immediate)?
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Triage priority (ESI / ABCs)
A 42-year-old man arrives to triage after a motor
vehicle crash. He is unconscious, snoring
respirations, heart rate 122, BP 88/52 mm Hg, and
obvious deformity of the left femur with heavy
bleeding. According to immediate triage priorities,
which action should the triage nurse perform first?
A. Apply direct pressure to the femoral wound.
B. Open and maintain the airway using jaw-thrust
and evaluate breathing.
C. Insert a large-bore IV and begin normal saline
bolus.
D. Prepare for immediate rapid sequence intubation
(RSI).
,Answer: B. Open and maintain the airway using
jaw-thrust and evaluate breathing.
Rationale (Clinical Judgment steps):
• Recognize cues: unconscious patient with
snoring respirations (airway compromise) and
hypotension.
• Analyze: Airway patency is the highest priority
(A of ABCs); other interventions depend on
airway protection.
• Decide: Secure/maintain airway before
significant interventions for circulation or
hemorrhage.
• Act: Perform jaw-thrust/manually open airway;
prepare for definitive airway if needed.
• Evaluate: Reassess respirations, oxygenation,
and responsiveness; if airway remains
compromised, escalate to intubation.
Why other options are incorrect: A (direct
pressure) addresses circulation but not the
immediately life-threatening airway. C (IV/fluids)
, is important but secondary to airway. D (RSI)
may be required, but initial airway opening and
assessment come first; RSI requires preparation
and personnel.
(References: ABC priority in emergency/trauma
primary survey; ATLS principles applied in triage.)
2 — Maslow & prioritization
A triage nurse must prioritize four patients waiting
to be seen. Which patient should be seen first based
on Maslow’s hierarchy and immediate clinical risk?
A. A 26-year-old with anxiety requesting a COVID
test.
B. A 70-year-old with chest pain and diaphoresis.
C. A 45-year-old seeking antibiotics for sinus
congestion.
D. A 19-year-old with intact open fracture of the
index finger.
Answer: B. A 70-year-old with chest pain and
diaphoresis.
, Rationale:
• Recognize: Chest pain + diaphoresis suggests
possible ACS → threat to physiologic safety
(Maslow: basic physiological needs).
• Analyze: Immediate life-threatening condition;
must be assessed and monitored first.
• Decide/Act: Rapid ECG, oxygen if needed,
aspirin per protocol, notify ED provider.
• Evaluate: Reassess pain, vitals, ECG results.
Incorrect options: A and C are low acuity
(psych/social or minor infection). D is urgent but
likely not immediately life-threatening
compared to potential cardiac ischemia.
(Triage decisions prioritize physiologic threats over
lower-level needs.)
3 — ESI triage level identification
Using the Emergency Severity Index (ESI), which
patient is ESI level 1 (immediate)?
