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.
Questions (1–25)
Q1
A 54-year-old man arrives at triage complaining of sudden,
severe chest pain radiating to his jaw and diaphoresis. Vitals: BP
86/56 mmHg, HR 118, RR 24, SpO₂ 94% on room air. Which
triage category is most appropriate?
A. Non-urgent
B. Urgent
C. Emergent (immediate)
D. Fast-track
Answer: C — Emergent (immediate)
NGN focus: Recognize cues / Prioritize
,Rationale (correct): Hypotension with chest pain and
diaphoresis indicate possible cardiogenic shock or acute
myocardial infarction with hemodynamic instability; immediate
attention is required (emergent). Emergent = needs immediate
life-saving interventions.
Why others are incorrect:
A: Non-urgent — wrong; delays could be fatal.
B: Urgent — indicates serious condition but not immediate
threat; vitals show hemodynamic instability, so emergent.
D: Fast-track — reserved for minor problems; not appropriate.
Q2
During a multiple-victim motor vehicle crash, four victims arrive
simultaneously. Which victim should be triaged first using START
principles?
1. Victim A: Respirations 6/min, no palpable carotid pulse.
2. Victim B: Respirations 28/min, radial pulse present, follows
commands.
3. Victim C: Respirations 8/min after manual repositioning,
capillary refill delayed, does not follow commands.
4. Victim D: Respirations 18/min, radial pulse present,
oriented.
Select the patient to treat first.
,A. Victim A
B. Victim B
C. Victim C
D. Victim D
Answer: C — Victim C
NGN focus: Analyze / Prioritize
Rationale (correct): START triage: immediate (red) includes
patients with respiratory compromise that respond to basic
maneuvers (e.g., repositioning) but have signs of shock or
altered mental status — these need rapid transport/treatment.
Victim C improved respirations after repositioning (indicates
patent airway with compromise), has poor perfusion and
altered mental status — highest priority.
Why others incorrect:
A: Respirations 6/min + no carotid pulse suggests
deceased/expectant or needs immediate CPR but if no pulse
likely expectant in mass casualty triage (or requires
resuscitation if resources allow). In START, apneic after airway
repositioning often categorized as deceased/expectant if no
respirations.
B: Resp 28/min >30 is immediate; 28/min with good perfusion
and following commands often delayed (yellow) compared to C.
D: Stable, lower priority (green).
Q3
, A patient with suspected organophosphate poisoning is brought
in after farm exposure. The patient is diaphoretic, bradycardic
46/min, bronchorrheic, pinpoint pupils, and has muscle
fasciculations. Which intervention should the nurse prioritize?
A. Apply cardiac monitor and prepare for atropine and
pralidoxime (2-PAM) administration.
B. Give activated charcoal PO.
C. Start broad-spectrum antibiotics.
D. Administer IV naloxone.
Answer: A — Apply cardiac monitor and prepare for atropine
and pralidoxime (2-PAM) administration.
NGN focus: Recognize cues / Implement
Rationale (correct): Organophosphate causes cholinergic excess
(DUMBBELSS): bradycardia, bronchorrhea, bronchospasm —
atropine (blocks muscarinic effects) and 2-PAM (reactivates
acetylcholinesterase) are life-saving. Cardiac monitor because
bradyarrhythmias possible.
Why others incorrect:
B: Activated charcoal may be considered if ingestion and airway
protected, but not the priority compared with atropine/2-PAM
for cholinergic crisis.
C: Antibiotics are not indicated.
D: Naloxone treats opioid overdose, not organophosphate
poisoning.
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
Questions (1–25)
Q1
A 54-year-old man arrives at triage complaining of sudden,
severe chest pain radiating to his jaw and diaphoresis. Vitals: BP
86/56 mmHg, HR 118, RR 24, SpO₂ 94% on room air. Which
triage category is most appropriate?
A. Non-urgent
B. Urgent
C. Emergent (immediate)
D. Fast-track
Answer: C — Emergent (immediate)
NGN focus: Recognize cues / Prioritize
,Rationale (correct): Hypotension with chest pain and
diaphoresis indicate possible cardiogenic shock or acute
myocardial infarction with hemodynamic instability; immediate
attention is required (emergent). Emergent = needs immediate
life-saving interventions.
Why others are incorrect:
A: Non-urgent — wrong; delays could be fatal.
B: Urgent — indicates serious condition but not immediate
threat; vitals show hemodynamic instability, so emergent.
D: Fast-track — reserved for minor problems; not appropriate.
Q2
During a multiple-victim motor vehicle crash, four victims arrive
simultaneously. Which victim should be triaged first using START
principles?
1. Victim A: Respirations 6/min, no palpable carotid pulse.
2. Victim B: Respirations 28/min, radial pulse present, follows
commands.
3. Victim C: Respirations 8/min after manual repositioning,
capillary refill delayed, does not follow commands.
4. Victim D: Respirations 18/min, radial pulse present,
oriented.
Select the patient to treat first.
,A. Victim A
B. Victim B
C. Victim C
D. Victim D
Answer: C — Victim C
NGN focus: Analyze / Prioritize
Rationale (correct): START triage: immediate (red) includes
patients with respiratory compromise that respond to basic
maneuvers (e.g., repositioning) but have signs of shock or
altered mental status — these need rapid transport/treatment.
Victim C improved respirations after repositioning (indicates
patent airway with compromise), has poor perfusion and
altered mental status — highest priority.
Why others incorrect:
A: Respirations 6/min + no carotid pulse suggests
deceased/expectant or needs immediate CPR but if no pulse
likely expectant in mass casualty triage (or requires
resuscitation if resources allow). In START, apneic after airway
repositioning often categorized as deceased/expectant if no
respirations.
B: Resp 28/min >30 is immediate; 28/min with good perfusion
and following commands often delayed (yellow) compared to C.
D: Stable, lower priority (green).
Q3
, A patient with suspected organophosphate poisoning is brought
in after farm exposure. The patient is diaphoretic, bradycardic
46/min, bronchorrheic, pinpoint pupils, and has muscle
fasciculations. Which intervention should the nurse prioritize?
A. Apply cardiac monitor and prepare for atropine and
pralidoxime (2-PAM) administration.
B. Give activated charcoal PO.
C. Start broad-spectrum antibiotics.
D. Administer IV naloxone.
Answer: A — Apply cardiac monitor and prepare for atropine
and pralidoxime (2-PAM) administration.
NGN focus: Recognize cues / Implement
Rationale (correct): Organophosphate causes cholinergic excess
(DUMBBELSS): bradycardia, bronchorrhea, bronchospasm —
atropine (blocks muscarinic effects) and 2-PAM (reactivates
acetylcholinesterase) are life-saving. Cardiac monitor because
bradyarrhythmias possible.
Why others incorrect:
B: Activated charcoal may be considered if ingestion and airway
protected, but not the priority compared with atropine/2-PAM
for cholinergic crisis.
C: Antibiotics are not indicated.
D: Naloxone treats opioid overdose, not organophosphate
poisoning.
