Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Questions (1–20)
1. A 58-year-old man is brought to the ED after a motor-vehicle
crash. He is conscious, complaining of chest pain and shortness
of breath. Vital signs: HR 120, RR 28, BP 86/50, SpO₂ 88% on
room air. Which action has the highest priority?
A. Obtain a 12-lead ECG.
B. Start large-bore IV access and begin isotonic crystalloid bolus.
C. Apply high-flow oxygen via nonrebreather mask.
D. Perform a focused secondary survey.
Correct answer: C
Rationale — correct (C): Airway and oxygenation come before
circulation when a patient has signs of hypoxia and respiratory
distress. Applying high-flow oxygen (nonrebreather) is the
fastest action to improve SpO₂ and tissue oxygenation and
reduces immediate risk while other interventions are arranged.
This follows ABC prioritization (Airway/Breathing/Circulation).
,Rationales — incorrect:
A. ECG is important for chest pain but not the immediate first
action when SpO₂ is low and the patient is tachypneic;
oxygenation must be addressed first.
B. IV access and fluids address circulation (C) and are high
priority, but improving oxygenation is prioritized when SpO₂ is
88% and respiratory distress is present.
D. Secondary survey is performed after life-threatening ABC
issues are addressed.
2. (Case-based) A 24-year-old woman arrives by ambulance
after anaphylaxis following a bee sting. She is anxious,
wheezing, and hypotensive (BP 74/40). Which medication and
route should the ED nurse administer first?
A. Diphenhydramine IV bolus.
B. Epinephrine 0.3–0.5 mg IM (1:1,000).
C. Albuterol nebulizer treatment.
D. Epinephrine 1 mg IV push (1:10,000).
Correct answer: B
Rationale — correct (B): For anaphylaxis the first-line
medication is intramuscular epinephrine (1:1,000
concentration) 0.3–0.5 mg in adults IM (anterolateral thigh)
because it rapidly reverses bronchospasm, vasodilation, and
mucosal edema. IM route provides rapid absorption with lower
risk than IV push in most cases.
,Rationales — incorrect:
A. Diphenhydramine is an adjunct antihistamine but slower
onset; not first-line for life-threatening anaphylaxis.
C. Albuterol treats bronchospasm but does not address
vasodilation and shock; it is adjunctive.
D. IV epinephrine (1:10,000) is reserved for cardiac arrest or
when patient is in extremis with appropriate expertise—IV
bolus carries higher risk and is not the standard first immediate
route for most anaphylaxis presentations outside of cardiac
arrest or when IM failed and IV access with continuous
monitoring is available.
3. During triage of a mass-casualty incident, a patient with a
penetrating abdominal wound and decreased level of
consciousness is encountered. According to standard triage
color categories (START/simple triage), what category should
this patient receive?
A. Green (minor/delayed).
B. Yellow (urgent/observation).
C. Red (immediate).
D. Black (expectant/deceased).
Correct answer: C
Rationale — correct (C): Penetrating abdominal wounds with
decreased level of consciousness suggest immediate life-
threatening injury requiring rapid intervention — triage
category RED (immediate). START triage prioritizes those with
, compromised airway/breathing/circulation or significant
potential for deterioration as immediate.
Rationales — incorrect:
A. Green is for ambulatory/minor injuries — not appropriate.
B. Yellow is for serious but not immediately life-threatening
injuries; decreased LOC and penetrating abdomen indicate
higher urgency.
D. Black (expectant) is for those unlikely to survive given
available resources (e.g., absent respirations after airway
repositioning); this patient is salvageable.
4. (Select all that apply) A nurse is triaging four ED arrivals.
Which patients should be assigned immediate (red) priority?
1. A 65-year-old with sudden left-sided weakness and facial
droop, onset 30 minutes.
2. A 45-year-old with controlled epistaxis and stable vitals.
3. A 28-year-old with tracheal deviation after blunt chest
trauma.
4. A 50-year-old with abdominal pain and fever 100.6°F.
A. 1 and 3 only
B. 1, 2, and 3
C. 2 and 4 only
D. 1, 3, and 4
Correct answer: A (1 and 3 only)
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Questions (1–20)
1. A 58-year-old man is brought to the ED after a motor-vehicle
crash. He is conscious, complaining of chest pain and shortness
of breath. Vital signs: HR 120, RR 28, BP 86/50, SpO₂ 88% on
room air. Which action has the highest priority?
A. Obtain a 12-lead ECG.
B. Start large-bore IV access and begin isotonic crystalloid bolus.
C. Apply high-flow oxygen via nonrebreather mask.
D. Perform a focused secondary survey.
Correct answer: C
Rationale — correct (C): Airway and oxygenation come before
circulation when a patient has signs of hypoxia and respiratory
distress. Applying high-flow oxygen (nonrebreather) is the
fastest action to improve SpO₂ and tissue oxygenation and
reduces immediate risk while other interventions are arranged.
This follows ABC prioritization (Airway/Breathing/Circulation).
,Rationales — incorrect:
A. ECG is important for chest pain but not the immediate first
action when SpO₂ is low and the patient is tachypneic;
oxygenation must be addressed first.
B. IV access and fluids address circulation (C) and are high
priority, but improving oxygenation is prioritized when SpO₂ is
88% and respiratory distress is present.
D. Secondary survey is performed after life-threatening ABC
issues are addressed.
2. (Case-based) A 24-year-old woman arrives by ambulance
after anaphylaxis following a bee sting. She is anxious,
wheezing, and hypotensive (BP 74/40). Which medication and
route should the ED nurse administer first?
A. Diphenhydramine IV bolus.
B. Epinephrine 0.3–0.5 mg IM (1:1,000).
C. Albuterol nebulizer treatment.
D. Epinephrine 1 mg IV push (1:10,000).
Correct answer: B
Rationale — correct (B): For anaphylaxis the first-line
medication is intramuscular epinephrine (1:1,000
concentration) 0.3–0.5 mg in adults IM (anterolateral thigh)
because it rapidly reverses bronchospasm, vasodilation, and
mucosal edema. IM route provides rapid absorption with lower
risk than IV push in most cases.
,Rationales — incorrect:
A. Diphenhydramine is an adjunct antihistamine but slower
onset; not first-line for life-threatening anaphylaxis.
C. Albuterol treats bronchospasm but does not address
vasodilation and shock; it is adjunctive.
D. IV epinephrine (1:10,000) is reserved for cardiac arrest or
when patient is in extremis with appropriate expertise—IV
bolus carries higher risk and is not the standard first immediate
route for most anaphylaxis presentations outside of cardiac
arrest or when IM failed and IV access with continuous
monitoring is available.
3. During triage of a mass-casualty incident, a patient with a
penetrating abdominal wound and decreased level of
consciousness is encountered. According to standard triage
color categories (START/simple triage), what category should
this patient receive?
A. Green (minor/delayed).
B. Yellow (urgent/observation).
C. Red (immediate).
D. Black (expectant/deceased).
Correct answer: C
Rationale — correct (C): Penetrating abdominal wounds with
decreased level of consciousness suggest immediate life-
threatening injury requiring rapid intervention — triage
category RED (immediate). START triage prioritizes those with
, compromised airway/breathing/circulation or significant
potential for deterioration as immediate.
Rationales — incorrect:
A. Green is for ambulatory/minor injuries — not appropriate.
B. Yellow is for serious but not immediately life-threatening
injuries; decreased LOC and penetrating abdomen indicate
higher urgency.
D. Black (expectant) is for those unlikely to survive given
available resources (e.g., absent respirations after airway
repositioning); this patient is salvageable.
4. (Select all that apply) A nurse is triaging four ED arrivals.
Which patients should be assigned immediate (red) priority?
1. A 65-year-old with sudden left-sided weakness and facial
droop, onset 30 minutes.
2. A 45-year-old with controlled epistaxis and stable vitals.
3. A 28-year-old with tracheal deviation after blunt chest
trauma.
4. A 50-year-old with abdominal pain and fever 100.6°F.
A. 1 and 3 only
B. 1, 2, and 3
C. 2 and 4 only
D. 1, 3, and 4
Correct answer: A (1 and 3 only)
