Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1 — Prioritization / ABCs (Emergent ED arrival)
A 46-year-old man arrives to the ED after a motor vehicle
collision. He is conscious but reports difficulty breathing. Vital
signs: HR 120, RR 28, BP 96/56, SpO₂ 88% on room air. On
assessment you note asymmetric chest rise and decreased
breath sounds on the left. What should the nurse do first?
A. Obtain a portable chest x-ray.
B. Prepare for immediate needle decompression of the left
chest.
C. Apply a nonrebreather mask at 10–15 L/min.
D. Establish IV access and begin fluid resuscitation.
Correct answer: B. Prepare for immediate needle
decompression of the left chest.
Rationale (stepwise):
, • Why B is correct: Asymmetric chest rise, hypotension,
tachycardia, respiratory distress, and decreased breath
sounds suggest tension pneumothorax — a life-
threatening condition requiring immediate decompression
(needle or finger thoracostomy) to relieve intrathoracic
pressure before imaging or fluids. Emergency
decompression addresses the A (airway/air movement)
and B (breathing/circulation) threats immediately.
• Why A is incorrect: A chest x-ray would confirm diagnosis
but delays a life-saving intervention when clinical signs
indicate tension pneumothorax.
• Why C is incorrect: Oxygen is important, but it does not
relieve intrathoracic pressure causing cardiovascular
collapse; decompression takes priority.
• Why D is incorrect: IV access and fluids help circulation,
but treating the reversible cause (compressed
mediastinum) is higher priority; fluid resuscitation alone
may worsen the hemodynamics in tension pneumothorax
until decompressed.
2 — Maslow & Prioritization (ED triage)
During triage, which patient should be assigned highest priority
based on Maslow’s hierarchy and immediate safety needs?
A. A 28-year-old with a twisted ankle, alert, moderate pain,
vitals stable.
,B. A 62-year-old with chest pain, diaphoresis, and ST-segment
elevations on prehospital ECG.
C. A 40-year-old who requests refills for hypertension
medication and has normal vitals.
D. A 5-year-old with a low-grade fever and sore throat.
Correct answer: B. A 62-year-old with chest pain, diaphoresis,
and ST-segment elevations.
Rationale:
• Why B is correct: Maslow’s safety/physiological needs and
the ABC framework prioritize life-threatening cardiac
ischemia (STEMI) requiring immediate intervention (PCI or
fibrinolysis). This patient has the highest risk of mortality.
• Why A is incorrect: Twisted ankle is painful but not life-
threatening.
• Why C is incorrect: Medication refill is nonurgent.
• Why D is incorrect: Low-grade fever and sore throat in a
child may be urgent for comfort/assessment but far lower
priority than a STEMI.
3 — Triage categories / Disaster triage
In a mass-casualty incident using START triage (Simple Triage
And Rapid Treatment), which label is appropriate for a victim
who is unresponsive, has agonal respirations after repositioning
the airway, and no palpable pulse?
, A. Immediate (red)
B. Delayed (yellow)
C. Minor (green)
D. Deceased/Expectant (black)
Correct answer: D. Deceased/Expectant (black).
Rationale:
• Why D is correct: In START triage, a patient with no
breathing after airway repositioning, apneic/agonal
respirations, and absent pulse is classified as
expectant/deceased (black) in a resource-limited mass-
casualty because the likelihood of survival with available
immediate resources is extremely low.
• Why A is incorrect: Immediate (red) is for those who can
be saved with immediate intervention (e.g., airway
obstruction) — but persistent apnea after repositioning
indicates non-salvageable in MCI context.
• Why B and C are incorrect: Delayed/minor are for patients
who breathe and have perfusion/mental status compatible
with delayed care.
4 — Shock recognition & initial management
A 70-year-old man with GI bleeding is hypotensive (BP 78/42),
tachycardic, cool/clammy skin, and urine output 10 mL/hr.
Which action should the nurse perform first?
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
1 — Prioritization / ABCs (Emergent ED arrival)
A 46-year-old man arrives to the ED after a motor vehicle
collision. He is conscious but reports difficulty breathing. Vital
signs: HR 120, RR 28, BP 96/56, SpO₂ 88% on room air. On
assessment you note asymmetric chest rise and decreased
breath sounds on the left. What should the nurse do first?
A. Obtain a portable chest x-ray.
B. Prepare for immediate needle decompression of the left
chest.
C. Apply a nonrebreather mask at 10–15 L/min.
D. Establish IV access and begin fluid resuscitation.
Correct answer: B. Prepare for immediate needle
decompression of the left chest.
Rationale (stepwise):
, • Why B is correct: Asymmetric chest rise, hypotension,
tachycardia, respiratory distress, and decreased breath
sounds suggest tension pneumothorax — a life-
threatening condition requiring immediate decompression
(needle or finger thoracostomy) to relieve intrathoracic
pressure before imaging or fluids. Emergency
decompression addresses the A (airway/air movement)
and B (breathing/circulation) threats immediately.
• Why A is incorrect: A chest x-ray would confirm diagnosis
but delays a life-saving intervention when clinical signs
indicate tension pneumothorax.
• Why C is incorrect: Oxygen is important, but it does not
relieve intrathoracic pressure causing cardiovascular
collapse; decompression takes priority.
• Why D is incorrect: IV access and fluids help circulation,
but treating the reversible cause (compressed
mediastinum) is higher priority; fluid resuscitation alone
may worsen the hemodynamics in tension pneumothorax
until decompressed.
2 — Maslow & Prioritization (ED triage)
During triage, which patient should be assigned highest priority
based on Maslow’s hierarchy and immediate safety needs?
A. A 28-year-old with a twisted ankle, alert, moderate pain,
vitals stable.
,B. A 62-year-old with chest pain, diaphoresis, and ST-segment
elevations on prehospital ECG.
C. A 40-year-old who requests refills for hypertension
medication and has normal vitals.
D. A 5-year-old with a low-grade fever and sore throat.
Correct answer: B. A 62-year-old with chest pain, diaphoresis,
and ST-segment elevations.
Rationale:
• Why B is correct: Maslow’s safety/physiological needs and
the ABC framework prioritize life-threatening cardiac
ischemia (STEMI) requiring immediate intervention (PCI or
fibrinolysis). This patient has the highest risk of mortality.
• Why A is incorrect: Twisted ankle is painful but not life-
threatening.
• Why C is incorrect: Medication refill is nonurgent.
• Why D is incorrect: Low-grade fever and sore throat in a
child may be urgent for comfort/assessment but far lower
priority than a STEMI.
3 — Triage categories / Disaster triage
In a mass-casualty incident using START triage (Simple Triage
And Rapid Treatment), which label is appropriate for a victim
who is unresponsive, has agonal respirations after repositioning
the airway, and no palpable pulse?
, A. Immediate (red)
B. Delayed (yellow)
C. Minor (green)
D. Deceased/Expectant (black)
Correct answer: D. Deceased/Expectant (black).
Rationale:
• Why D is correct: In START triage, a patient with no
breathing after airway repositioning, apneic/agonal
respirations, and absent pulse is classified as
expectant/deceased (black) in a resource-limited mass-
casualty because the likelihood of survival with available
immediate resources is extremely low.
• Why A is incorrect: Immediate (red) is for those who can
be saved with immediate intervention (e.g., airway
obstruction) — but persistent apnea after repositioning
indicates non-salvageable in MCI context.
• Why B and C are incorrect: Delayed/minor are for patients
who breathe and have perfusion/mental status compatible
with delayed care.
4 — Shock recognition & initial management
A 70-year-old man with GI bleeding is hypotensive (BP 78/42),
tachycardic, cool/clammy skin, and urine output 10 mL/hr.
Which action should the nurse perform first?
