SAUNDERS COMPREHENSIVE REVIEW FOR THE
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1 — Mass-casualty triage (START vs SALT)
A multiple-vehicle highway collision with 12 victims. You are the
first trained healthcare responder on scene. You perform a
rapid survey: one patient is unresponsive, not breathing after
opening the airway; five are breathing and following
commands; three are confused and have weak radial pulses;
three are walking wounded. According to START triage
principles, which action is the highest priority?
A. Tag the unresponsive non-breathing patient as
deceased/expectant and move on.
B. Perform a jaw thrust and 2 rescue breaths on the
unresponsive patient; if still not breathing, tag as deceased and
continue triage.
,C. Begin immediate transport of the walking wounded to clear
scene capacity.
D. Provide high-flow oxygen to confused patients with weak
pulses before further triage.
Correct answer: B
Rationale — correct (B): START requires opening the airway to
determine if a non-breathing victim will breathe with airway
opening. If the patient remains apneic after a simple airway
maneuver and is judged to have no chance of survival with
available resources, they may be tagged deceased/expectant —
but only after attempting airway opening and brief
reassessment. This immediate airway maneuver is the correct
first action. (START principle: assess respirations, perfusion,
mental status; open airway if apneic). CHEMM
Why the others are incorrect:
A — Tagging without attempting airway opening violates START
protocol.
C — Walking wounded are lowest priority (minor) and moving
them first is not the highest priority during initial triage.
D — While oxygen is important, immediate airway
assessment/intervention on an apneic patient is higher priority
than treating those with weak pulses.
2 — ESI triage: immediate life threat
,A 62-year-old male arrives by private vehicle with severe
shortness of breath, audible stridor, accessory muscle use, SpO₂
82% on room air, and is diaphoretic. He is able to speak only 1–
2 words at a time. Using the Emergency Severity Index (ESI),
what triage level should the nurse assign?
A. ESI level 1
B. ESI level 2
C. ESI level 3
D. ESI level 4
Correct answer: A
Rationale — correct (A): ESI level 1 = immediate, life-
threatening need for resuscitation or unstable (e.g., severe
respiratory distress, hypoxia, impending airway compromise).
This patient is unstable and requires immediate life-saving
interventions (airway/oxygen/possible intubation). EMSC
Improvement Center+1
Why the others are incorrect:
B — Level 2 is for high-risk or confused/lethargic patients who
are not yet in immediate need of resuscitation; this patient
requires immediate resuscitative action.
C/D — Resource-based lower acuity levels; not appropriate for
impending respiratory failure.
3 — Chemical exposure (decontamination)
, Emergency department receives multiple victims from an
industrial chlorine release. A conscious ambulatory patient
arrives complaining of eye burning and cough. What is the
nurse’s most appropriate immediate action?
A. Put the patient on a nonrebreather mask to prevent
inhalation injury.
B. Remove clothing and irrigate exposed skin and eyes with
water while isolating the patient.
C. Administer nebulized albuterol immediately in triage.
D. Wait for physician orders before removing clothing to avoid
medicolegal issues.
Correct answer: B
Rationale — correct (B): Primary decontamination principle:
“Get away, get it off, get clean.” Immediate removal of
contaminated clothing and copious irrigation of exposed
skin/eyes reduces further chemical absorption and decreases
injury. Patients should be isolated/contained to protect
staff/others. For chlorine — remove clothing and flush eyes/skin
with water. CDC+1
Why the others are incorrect:
A — Oxygen therapy may be needed, but preventing further
dermal/ocular exposure by removing clothing and irrigation is
higher priority for decontamination.
C — Nebulized bronchodilators may help bronchospasm but
only after decontamination and initial assessment; they do not
replace decontamination.
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1 — Mass-casualty triage (START vs SALT)
A multiple-vehicle highway collision with 12 victims. You are the
first trained healthcare responder on scene. You perform a
rapid survey: one patient is unresponsive, not breathing after
opening the airway; five are breathing and following
commands; three are confused and have weak radial pulses;
three are walking wounded. According to START triage
principles, which action is the highest priority?
A. Tag the unresponsive non-breathing patient as
deceased/expectant and move on.
B. Perform a jaw thrust and 2 rescue breaths on the
unresponsive patient; if still not breathing, tag as deceased and
continue triage.
,C. Begin immediate transport of the walking wounded to clear
scene capacity.
D. Provide high-flow oxygen to confused patients with weak
pulses before further triage.
Correct answer: B
Rationale — correct (B): START requires opening the airway to
determine if a non-breathing victim will breathe with airway
opening. If the patient remains apneic after a simple airway
maneuver and is judged to have no chance of survival with
available resources, they may be tagged deceased/expectant —
but only after attempting airway opening and brief
reassessment. This immediate airway maneuver is the correct
first action. (START principle: assess respirations, perfusion,
mental status; open airway if apneic). CHEMM
Why the others are incorrect:
A — Tagging without attempting airway opening violates START
protocol.
C — Walking wounded are lowest priority (minor) and moving
them first is not the highest priority during initial triage.
D — While oxygen is important, immediate airway
assessment/intervention on an apneic patient is higher priority
than treating those with weak pulses.
2 — ESI triage: immediate life threat
,A 62-year-old male arrives by private vehicle with severe
shortness of breath, audible stridor, accessory muscle use, SpO₂
82% on room air, and is diaphoretic. He is able to speak only 1–
2 words at a time. Using the Emergency Severity Index (ESI),
what triage level should the nurse assign?
A. ESI level 1
B. ESI level 2
C. ESI level 3
D. ESI level 4
Correct answer: A
Rationale — correct (A): ESI level 1 = immediate, life-
threatening need for resuscitation or unstable (e.g., severe
respiratory distress, hypoxia, impending airway compromise).
This patient is unstable and requires immediate life-saving
interventions (airway/oxygen/possible intubation). EMSC
Improvement Center+1
Why the others are incorrect:
B — Level 2 is for high-risk or confused/lethargic patients who
are not yet in immediate need of resuscitation; this patient
requires immediate resuscitative action.
C/D — Resource-based lower acuity levels; not appropriate for
impending respiratory failure.
3 — Chemical exposure (decontamination)
, Emergency department receives multiple victims from an
industrial chlorine release. A conscious ambulatory patient
arrives complaining of eye burning and cough. What is the
nurse’s most appropriate immediate action?
A. Put the patient on a nonrebreather mask to prevent
inhalation injury.
B. Remove clothing and irrigate exposed skin and eyes with
water while isolating the patient.
C. Administer nebulized albuterol immediately in triage.
D. Wait for physician orders before removing clothing to avoid
medicolegal issues.
Correct answer: B
Rationale — correct (B): Primary decontamination principle:
“Get away, get it off, get clean.” Immediate removal of
contaminated clothing and copious irrigation of exposed
skin/eyes reduces further chemical absorption and decreases
injury. Patients should be isolated/contained to protect
staff/others. For chlorine — remove clothing and flush eyes/skin
with water. CDC+1
Why the others are incorrect:
A — Oxygen therapy may be needed, but preventing further
dermal/ocular exposure by removing clothing and irrigation is
higher priority for decontamination.
C — Nebulized bronchodilators may help bronchospasm but
only after decontamination and initial assessment; they do not
replace decontamination.
