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.
Item 1 — Emergent vs Urgent vs Non-urgent (single best
answer)
A 56-year-old man arrives via private vehicle to the emergency
department complaining of sudden, severe chest pressure
radiating to the left arm and jaw. He appears diaphoretic and
pale, blood pressure 88/56 mm Hg, heart rate 112/min,
respiratory rate 24/min, oxygen saturation 89% on room air.
Using standard triage categories (emergent/urgent/non-
urgent), which triage category is most appropriate?
A. Non-urgent
B. Urgent
C. Emergent
D. Fast-track
,Correct answer: C. Emergent
Rationale (correct):
This patient has signs and symptoms consistent with acute
coronary syndrome with hemodynamic instability (hypotension,
hypoxemia, diaphoresis) and requires immediate evaluation
and treatment to preserve life/limb/function. Emergent =
immediate threat to life or limb; this meets that threshold.
NCSBN+1
Rationale (incorrect options):
A. Non-urgent — Incorrect: Non-urgent applies to stable
conditions that can safely wait (e.g., minor rashes). This patient
is unstable.
B. Urgent — Incorrect: Urgent indicates a serious condition
requiring timely care but not immediate life-saving
interventions. The patient’s hypotension and hypoxia require
immediate action.
D. Fast-track — Incorrect: Fast-track is for low-acuity, rapid-
turnover cases (sprains, minor wounds). Not appropriate.
References: NCSBN NCLEX-RN Test Plan (content alignment);
ESI/triage guidance on identification of unstable patients.
NCSBN+1
Item 2 — ESI Level Identification (single best answer)
,In the Emergency Severity Index (ESI) 5-level triage, which level
would a patient who requires immediate life-saving
intervention be assigned?
A. ESI 1
B. ESI 2
C. ESI 3
D. ESI 4
Correct answer: A. ESI 1
Rationale (correct):
ESI Level 1 identifies patients who need immediate life-saving
interventions (e.g., intubation, immediate cardioversion, active
hemorrhage control). ESI is a validated 5-level system that
prioritizes life-threatening needs first. EMSC Improvement
Center+1
Rationale (incorrect options):
B. ESI 2 — High risk but not necessarily immediate life-saving
interventions (e.g., severe pain, potential for deterioration).
C. ESI 3 — Requires multiple resources but can wait for a short
time.
D. ESI 4 — Requires one resource (e.g., single X-ray).
Reference: ESI Handbook; ENA triage resources. EMSC
Improvement Center+1
Item 3 — START Mass Casualty Triage (single best answer)
, During an outdoor explosion with many casualties, first
responders use START triage. A victim is breathing after airway
repositioning, respiratory rate 36/min, has a radial pulse, and
follows commands. According to START rules, how should this
patient be triaged?
A. Immediate (red)
B. Delayed (yellow)
C. Minimal (green)
D. Expectant (black)
Correct answer: A. Immediate (red)
Rationale (correct):
In START, breathing rate >30/min after airway repositioning is an
immediate (red) criterion because tachypnea >30 indicates
significant physiologic compromise. Even if pulse and mental
status are present, the respiratory criterion drives the
classification as immediate. CHEMM+1
Rationale (incorrect options):
B. Delayed — Incorrect: Delayed if breathing rate ≤30, adequate
perfusion, and follow commands.
C. Minimal — Incorrect: Ambulatory/minor injuries only.
D. Expectant — Incorrect: For unsurvivable injuries or no signs
of life.
References: START algorithm summary; StatPearls review of
mass casualty triage. CHEMM+1
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
Item 1 — Emergent vs Urgent vs Non-urgent (single best
answer)
A 56-year-old man arrives via private vehicle to the emergency
department complaining of sudden, severe chest pressure
radiating to the left arm and jaw. He appears diaphoretic and
pale, blood pressure 88/56 mm Hg, heart rate 112/min,
respiratory rate 24/min, oxygen saturation 89% on room air.
Using standard triage categories (emergent/urgent/non-
urgent), which triage category is most appropriate?
A. Non-urgent
B. Urgent
C. Emergent
D. Fast-track
,Correct answer: C. Emergent
Rationale (correct):
This patient has signs and symptoms consistent with acute
coronary syndrome with hemodynamic instability (hypotension,
hypoxemia, diaphoresis) and requires immediate evaluation
and treatment to preserve life/limb/function. Emergent =
immediate threat to life or limb; this meets that threshold.
NCSBN+1
Rationale (incorrect options):
A. Non-urgent — Incorrect: Non-urgent applies to stable
conditions that can safely wait (e.g., minor rashes). This patient
is unstable.
B. Urgent — Incorrect: Urgent indicates a serious condition
requiring timely care but not immediate life-saving
interventions. The patient’s hypotension and hypoxia require
immediate action.
D. Fast-track — Incorrect: Fast-track is for low-acuity, rapid-
turnover cases (sprains, minor wounds). Not appropriate.
References: NCSBN NCLEX-RN Test Plan (content alignment);
ESI/triage guidance on identification of unstable patients.
NCSBN+1
Item 2 — ESI Level Identification (single best answer)
,In the Emergency Severity Index (ESI) 5-level triage, which level
would a patient who requires immediate life-saving
intervention be assigned?
A. ESI 1
B. ESI 2
C. ESI 3
D. ESI 4
Correct answer: A. ESI 1
Rationale (correct):
ESI Level 1 identifies patients who need immediate life-saving
interventions (e.g., intubation, immediate cardioversion, active
hemorrhage control). ESI is a validated 5-level system that
prioritizes life-threatening needs first. EMSC Improvement
Center+1
Rationale (incorrect options):
B. ESI 2 — High risk but not necessarily immediate life-saving
interventions (e.g., severe pain, potential for deterioration).
C. ESI 3 — Requires multiple resources but can wait for a short
time.
D. ESI 4 — Requires one resource (e.g., single X-ray).
Reference: ESI Handbook; ENA triage resources. EMSC
Improvement Center+1
Item 3 — START Mass Casualty Triage (single best answer)
, During an outdoor explosion with many casualties, first
responders use START triage. A victim is breathing after airway
repositioning, respiratory rate 36/min, has a radial pulse, and
follows commands. According to START rules, how should this
patient be triaged?
A. Immediate (red)
B. Delayed (yellow)
C. Minimal (green)
D. Expectant (black)
Correct answer: A. Immediate (red)
Rationale (correct):
In START, breathing rate >30/min after airway repositioning is an
immediate (red) criterion because tachypnea >30 indicates
significant physiologic compromise. Even if pulse and mental
status are present, the respiratory criterion drives the
classification as immediate. CHEMM+1
Rationale (incorrect options):
B. Delayed — Incorrect: Delayed if breathing rate ≤30, adequate
perfusion, and follow commands.
C. Minimal — Incorrect: Ambulatory/minor injuries only.
D. Expectant — Incorrect: For unsurvivable injuries or no signs
of life.
References: START algorithm summary; StatPearls review of
mass casualty triage. CHEMM+1
