Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Mass-casualty triage: first action
A 3-patient MVA arrives at the ED triage area
minutes after a multi-vehicle collision. You must
assign START triage tags quickly. Which patient
should receive a red (immediate) tag?
A. 24-year-old breathing 28/min, capillary refill
brisk, complaining of leg pain only.
B. 45-year-old with penetrating chest wound,
respiratory rate 8/min, weak radial pulses.
C. 60-year-old with open femur fracture, alert, RR
20, stable vitals.
D. 16-year-old with partial-thickness burns to both
arms, crying, airway intact.
Correct answer: B
,Rationale — correct (B):
START triage prioritizes immediate life threats:
airway, breathing, circulation (ABCs). RR 8
(bradypnea) and weak pulses indicate compromised
ventilation and perfusion — immediate threat to
life; therefore red (immediate). Assessment should
prompt airway support and rapid transfer to
resuscitation.
Why A is incorrect: RR 28 is tachypneic but
perfusion intact and only isolated extremity pain →
yellow/green depending on reassessment. Not
immediate.
Why C is incorrect: Open femur fracture is serious
but not immediately life-threatening if vitals stable
→ yellow (delayed).
Why D is incorrect: Partial-thickness burns to arms
with intact airway are important but not immediate
unless inhalation injury suspected → yellow/green.
2 — Cardiac arrest in ED: initial priority
,A 58-year-old with sudden collapse becomes
pulseless while in the ED. You arrive first and
confirm unresponsiveness and no pulse. What is the
nurse’s first action?
A. Start chest compressions at 100–120/min.
B. Deliver one shock with the defibrillator.
C. Administer IV epinephrine immediately.
D. Check blood glucose level.
Correct answer: A
Rationale — correct (A):
Basic Life Support (BLS) directives: immediately
initiate high-quality chest compressions (depth, rate
100–120/min, minimal interruptions) when
pulseless. Early compressions maintain perfusion
while team prepares defibrillator/airway.
Why B is incorrect: Defibrillation only for shockable
rhythms (VF/pulseless VT) after rhythm analysis —
compressions come first if no immediate
defibrillator.
Why C is incorrect: Epinephrine is given after initial
compressions/defibrillation per ACLS algorithm; not
, the very first action.
Why D is incorrect: Checking glucose is important
but not prior to initiating chest compressions in a
pulseless patient.
3 — Anaphylaxis in triage: prioritization & actions
A 30-year-old arrives after a bee sting with facial
swelling, stridor, hypotension (BP 80/50), and
tachycardia. Which action is highest priority?
A. Give oral antihistamine (diphenhydramine) and
observe.
B. Administer intramuscular epinephrine and call for
airway support.
C. Start a peripheral IV and give a 250 mL normal
saline bolus only.
D. Apply a cold compress to the sting site and
reassure the patient.
Correct answer: B
Rationale — correct (B):
Anaphylaxis with airway compromise (stridor) and
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1 — Mass-casualty triage: first action
A 3-patient MVA arrives at the ED triage area
minutes after a multi-vehicle collision. You must
assign START triage tags quickly. Which patient
should receive a red (immediate) tag?
A. 24-year-old breathing 28/min, capillary refill
brisk, complaining of leg pain only.
B. 45-year-old with penetrating chest wound,
respiratory rate 8/min, weak radial pulses.
C. 60-year-old with open femur fracture, alert, RR
20, stable vitals.
D. 16-year-old with partial-thickness burns to both
arms, crying, airway intact.
Correct answer: B
,Rationale — correct (B):
START triage prioritizes immediate life threats:
airway, breathing, circulation (ABCs). RR 8
(bradypnea) and weak pulses indicate compromised
ventilation and perfusion — immediate threat to
life; therefore red (immediate). Assessment should
prompt airway support and rapid transfer to
resuscitation.
Why A is incorrect: RR 28 is tachypneic but
perfusion intact and only isolated extremity pain →
yellow/green depending on reassessment. Not
immediate.
Why C is incorrect: Open femur fracture is serious
but not immediately life-threatening if vitals stable
→ yellow (delayed).
Why D is incorrect: Partial-thickness burns to arms
with intact airway are important but not immediate
unless inhalation injury suspected → yellow/green.
2 — Cardiac arrest in ED: initial priority
,A 58-year-old with sudden collapse becomes
pulseless while in the ED. You arrive first and
confirm unresponsiveness and no pulse. What is the
nurse’s first action?
A. Start chest compressions at 100–120/min.
B. Deliver one shock with the defibrillator.
C. Administer IV epinephrine immediately.
D. Check blood glucose level.
Correct answer: A
Rationale — correct (A):
Basic Life Support (BLS) directives: immediately
initiate high-quality chest compressions (depth, rate
100–120/min, minimal interruptions) when
pulseless. Early compressions maintain perfusion
while team prepares defibrillator/airway.
Why B is incorrect: Defibrillation only for shockable
rhythms (VF/pulseless VT) after rhythm analysis —
compressions come first if no immediate
defibrillator.
Why C is incorrect: Epinephrine is given after initial
compressions/defibrillation per ACLS algorithm; not
, the very first action.
Why D is incorrect: Checking glucose is important
but not prior to initiating chest compressions in a
pulseless patient.
3 — Anaphylaxis in triage: prioritization & actions
A 30-year-old arrives after a bee sting with facial
swelling, stridor, hypotension (BP 80/50), and
tachycardia. Which action is highest priority?
A. Give oral antihistamine (diphenhydramine) and
observe.
B. Administer intramuscular epinephrine and call for
airway support.
C. Start a peripheral IV and give a 250 mL normal
saline bolus only.
D. Apply a cold compress to the sting site and
reassure the patient.
Correct answer: B
Rationale — correct (B):
Anaphylaxis with airway compromise (stridor) and
