Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1. A 54-year-old man arrives by ambulance after a motor-
vehicle crash. He is conscious but has noisy respirations, facial
burns, singed nasal hairs, and hoarseness. Which action should
the emergency nurse perform first?
A. Apply high-flow oxygen by nonrebreather mask.
B. Prepare to intubate with cervical spine precautions.
C. Obtain a portable chest x-ray.
D. Start two large-bore IVs and begin fluid resuscitation.
Answer: B. Prepare to intubate with cervical spine precautions.
Rationale (correct): Facial burns, singed nasal hairs, hoarseness,
and noisy respirations are red flags for inhalation injury with
rapidly progressive airway edema. Securing the airway early
(with c-spine maintenance because of trauma mechanism)
prevents impending loss of airway and is highest priority
(Airway from ABCs).
Why others are incorrect:
,A — Oxygen is important, but if airway will be lost due to
edema, definitive airway takes precedence. Oxygen alone may
be insufficient.
C — Chest x-ray is lower priority and can wait until
airway/ventilation are secured.
D — Fluid resuscitation is required in burns/trauma, but not
before securing airway in potential inhalation injury.
2 (Case). A 28-year-old woman presents to triage complaining
of sudden onset dyspnea and generalized urticaria after eating
at a restaurant. Her vitals: BP 84/50 mm Hg, HR 124, RR 28,
SpO₂ 90% on room air. She is alert but anxious and reports
throat tightness.
2a. Which immediate action should the nurse take?
A. Administer intramuscular epinephrine in the lateral thigh.
B. Give IV diphenhydramine and observe for response.
C. Administer nebulized albuterol and reassess.
D. Start a STAT IV infusion of normal saline only.
Answer: A. Administer intramuscular epinephrine in the lateral
thigh.
Rationale (correct): Anaphylaxis with hypotension, tachycardia,
respiratory compromise and throat tightness requires
immediate IM epinephrine (0.3–0.5 mg in adult lateral thigh) as
first-line therapy. Early epinephrine rapidly reverses airway
edema and vasodilation.
,Why others are incorrect:
B — Antihistamines are adjunctive, not first-line; delaying
epinephrine risks deterioration.
C — Bronchodilator may help bronchospasm but does not treat
systemic vasodilation or airway edema.
D — IV fluids are important for hypotension but should not
delay epinephrine administration.
2b. After giving IM epinephrine, the nurse prepares additional
treatments. Which combination is most appropriate next?
A. IV normal saline bolus, oxygen, IV antihistamine.
B. IV epinephrine infusion and immediate discharge home once
stable.
C. Observation only for 15 minutes then discharge.
D. Administer oral corticosteroids only.
Answer: A. IV normal saline bolus, oxygen, IV antihistamine.
Rationale (correct): After epinephrine, provide oxygen and
aggressive IV fluids for hypotension and adjunctive meds
(H1/H2 blockers, corticosteroids). Monitor for biphasic reaction
and consider ICU if unstable.
Why others are incorrect:
B — IV epinephrine infusion may be required for refractory
shock but not automatically next; discharge is inappropriate
while still requiring monitoring.
C — 15 minutes is insufficient; observation for several hours is
standard.
D — Steroids are adjuncts and not initial sole therapy.
, 3. During triage in a crowded ED, four patients arrive
simultaneously. Which patient should the triage nurse assign
the highest immediate priority?
A. A 32-year-old with kidney stones who rates pain 8/10 and is
diaphoretic.
B. A 70-year-old with sudden left-sided weakness and slurred
speech for 30 minutes.
C. A 19-year-old with a low-grade fever and sore throat.
D. A 45-year-old requesting a refill for chronic hypertension
medication.
Answer: B. A 70-year-old with sudden left-sided weakness and
slurred speech for 30 minutes.
Rationale (correct): Acute neurologic deficits suggest possible
stroke; time-sensitive evaluation and treatment (thrombolysis /
EVT pathways) require immediate priority (preserve brain by
acting quickly). This outranks severe pain without life-
threatening condition.
Why others are incorrect:
A — Severe pain merits urgent attention but not over a
potential stroke.
C — Low-grade fever/sore throat is low priority.
D — Medication refill is nonurgent.
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1. A 54-year-old man arrives by ambulance after a motor-
vehicle crash. He is conscious but has noisy respirations, facial
burns, singed nasal hairs, and hoarseness. Which action should
the emergency nurse perform first?
A. Apply high-flow oxygen by nonrebreather mask.
B. Prepare to intubate with cervical spine precautions.
C. Obtain a portable chest x-ray.
D. Start two large-bore IVs and begin fluid resuscitation.
Answer: B. Prepare to intubate with cervical spine precautions.
Rationale (correct): Facial burns, singed nasal hairs, hoarseness,
and noisy respirations are red flags for inhalation injury with
rapidly progressive airway edema. Securing the airway early
(with c-spine maintenance because of trauma mechanism)
prevents impending loss of airway and is highest priority
(Airway from ABCs).
Why others are incorrect:
,A — Oxygen is important, but if airway will be lost due to
edema, definitive airway takes precedence. Oxygen alone may
be insufficient.
C — Chest x-ray is lower priority and can wait until
airway/ventilation are secured.
D — Fluid resuscitation is required in burns/trauma, but not
before securing airway in potential inhalation injury.
2 (Case). A 28-year-old woman presents to triage complaining
of sudden onset dyspnea and generalized urticaria after eating
at a restaurant. Her vitals: BP 84/50 mm Hg, HR 124, RR 28,
SpO₂ 90% on room air. She is alert but anxious and reports
throat tightness.
2a. Which immediate action should the nurse take?
A. Administer intramuscular epinephrine in the lateral thigh.
B. Give IV diphenhydramine and observe for response.
C. Administer nebulized albuterol and reassess.
D. Start a STAT IV infusion of normal saline only.
Answer: A. Administer intramuscular epinephrine in the lateral
thigh.
Rationale (correct): Anaphylaxis with hypotension, tachycardia,
respiratory compromise and throat tightness requires
immediate IM epinephrine (0.3–0.5 mg in adult lateral thigh) as
first-line therapy. Early epinephrine rapidly reverses airway
edema and vasodilation.
,Why others are incorrect:
B — Antihistamines are adjunctive, not first-line; delaying
epinephrine risks deterioration.
C — Bronchodilator may help bronchospasm but does not treat
systemic vasodilation or airway edema.
D — IV fluids are important for hypotension but should not
delay epinephrine administration.
2b. After giving IM epinephrine, the nurse prepares additional
treatments. Which combination is most appropriate next?
A. IV normal saline bolus, oxygen, IV antihistamine.
B. IV epinephrine infusion and immediate discharge home once
stable.
C. Observation only for 15 minutes then discharge.
D. Administer oral corticosteroids only.
Answer: A. IV normal saline bolus, oxygen, IV antihistamine.
Rationale (correct): After epinephrine, provide oxygen and
aggressive IV fluids for hypotension and adjunctive meds
(H1/H2 blockers, corticosteroids). Monitor for biphasic reaction
and consider ICU if unstable.
Why others are incorrect:
B — IV epinephrine infusion may be required for refractory
shock but not automatically next; discharge is inappropriate
while still requiring monitoring.
C — 15 minutes is insufficient; observation for several hours is
standard.
D — Steroids are adjuncts and not initial sole therapy.
, 3. During triage in a crowded ED, four patients arrive
simultaneously. Which patient should the triage nurse assign
the highest immediate priority?
A. A 32-year-old with kidney stones who rates pain 8/10 and is
diaphoretic.
B. A 70-year-old with sudden left-sided weakness and slurred
speech for 30 minutes.
C. A 19-year-old with a low-grade fever and sore throat.
D. A 45-year-old requesting a refill for chronic hypertension
medication.
Answer: B. A 70-year-old with sudden left-sided weakness and
slurred speech for 30 minutes.
Rationale (correct): Acute neurologic deficits suggest possible
stroke; time-sensitive evaluation and treatment (thrombolysis /
EVT pathways) require immediate priority (preserve brain by
acting quickly). This outranks severe pain without life-
threatening condition.
Why others are incorrect:
A — Severe pain merits urgent attention but not over a
potential stroke.
C — Low-grade fever/sore throat is low priority.
D — Medication refill is nonurgent.
