Saunders NCLEX-RN Test Bank: 250+ Emergency
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1. (Triage — single best answer)
A 34-year-old man arrives at the ED after a motor
vehicle crash. He is breathing spontaneously at 10
breaths per minute, is pale and diaphoretic, and has
a weak, rapid radial pulse. He follows commands.
According to START triage principles, which triage
category should this patient be assigned?
A. Green (Minor)
B. Yellow (Delayed)
C. Red (Immediate)
D. Black (Expectant)
Answer: C. Red (Immediate)
Rationale (stepwise):
, • Correct: The patient has abnormal respiratory
rate (<30? but breathing), signs of poor
perfusion (weak rapid pulse, pale, diaphoretic)
and requires immediate intervention to prevent
deterioration — START/field triage places
patients with compromised
perfusion/respiration or altered circulation into
Immediate/Red. REMM
• A (Green) incorrect: “Walking wounded” with
minor injuries — not applicable.
• B (Yellow) incorrect: Used for serious injuries
that can tolerate short delay; this patient’s
perfusion suggests imminent instability.
• D (Black) incorrect: Expectant/deceased — not
appropriate when signs of life and potential to
benefit from immediate care exist.
2. (Triage — single best answer)
During a multi-victim incident, which initial step is
central to the SALT triage framework and helps
,quickly prioritize patients for more detailed
assessment?
A. Start life-saving interventions immediately for all
patients.
B. Sort — ask ambulatory patients to move to a
collection point.
C. Assess full vitals on every patient before sorting.
D. Transport all patients to the nearest ED
immediately.
Answer: B. Sort — ask ambulatory patients to
move to a collection point.
Rationale:
• Correct: SALT begins with Sort (global sorting)
— asking ambulatory patients to walk to a
designated area to quickly separate the walking
wounded from those needing immediate
assessment. This preserves resources and
speeds triage. PMC
• A incorrect: Life-saving interventions are
important but SALT’s first step is sorting, not
performing interventions universally.
, • C incorrect: Detailed assessment/vitals are
subsequent steps; requiring full vitals first
delays prioritization in mass casualty.
• D incorrect: Transport without triage wastes
resources and risks taking low-priority patients
ahead of immediate needs.
3. (Prioritization — case-based)
Case: A patient in triage complains of shortness of
breath. Vital signs: RR 34, SpO₂ 86% on room air, HR
120, BP 100/60. Which immediate nursing action
has the highest priority?
A. Obtain a 12-lead ECG.
B. Administer high-flow oxygen (non-rebreather)
and reassess.
C. Insert two IV lines for possible fluid resuscitation.
D. Complete a full respiratory assessment and order
ABGs.
Answer: B. Administer high-flow oxygen (non-
rebreather) and reassess.
Nursing & Triage Questions with Rationales (2025
Edition)
TEST BANK
1. (Triage — single best answer)
A 34-year-old man arrives at the ED after a motor
vehicle crash. He is breathing spontaneously at 10
breaths per minute, is pale and diaphoretic, and has
a weak, rapid radial pulse. He follows commands.
According to START triage principles, which triage
category should this patient be assigned?
A. Green (Minor)
B. Yellow (Delayed)
C. Red (Immediate)
D. Black (Expectant)
Answer: C. Red (Immediate)
Rationale (stepwise):
, • Correct: The patient has abnormal respiratory
rate (<30? but breathing), signs of poor
perfusion (weak rapid pulse, pale, diaphoretic)
and requires immediate intervention to prevent
deterioration — START/field triage places
patients with compromised
perfusion/respiration or altered circulation into
Immediate/Red. REMM
• A (Green) incorrect: “Walking wounded” with
minor injuries — not applicable.
• B (Yellow) incorrect: Used for serious injuries
that can tolerate short delay; this patient’s
perfusion suggests imminent instability.
• D (Black) incorrect: Expectant/deceased — not
appropriate when signs of life and potential to
benefit from immediate care exist.
2. (Triage — single best answer)
During a multi-victim incident, which initial step is
central to the SALT triage framework and helps
,quickly prioritize patients for more detailed
assessment?
A. Start life-saving interventions immediately for all
patients.
B. Sort — ask ambulatory patients to move to a
collection point.
C. Assess full vitals on every patient before sorting.
D. Transport all patients to the nearest ED
immediately.
Answer: B. Sort — ask ambulatory patients to
move to a collection point.
Rationale:
• Correct: SALT begins with Sort (global sorting)
— asking ambulatory patients to walk to a
designated area to quickly separate the walking
wounded from those needing immediate
assessment. This preserves resources and
speeds triage. PMC
• A incorrect: Life-saving interventions are
important but SALT’s first step is sorting, not
performing interventions universally.
, • C incorrect: Detailed assessment/vitals are
subsequent steps; requiring full vitals first
delays prioritization in mass casualty.
• D incorrect: Transport without triage wastes
resources and risks taking low-priority patients
ahead of immediate needs.
3. (Prioritization — case-based)
Case: A patient in triage complains of shortness of
breath. Vital signs: RR 34, SpO₂ 86% on room air, HR
120, BP 100/60. Which immediate nursing action
has the highest priority?
A. Obtain a 12-lead ECG.
B. Administer high-flow oxygen (non-rebreather)
and reassess.
C. Insert two IV lines for possible fluid resuscitation.
D. Complete a full respiratory assessment and order
ABGs.
Answer: B. Administer high-flow oxygen (non-
rebreather) and reassess.
