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)
1 — Triage acuity (ESI)
A 56-year-old man arrives to triage with sudden onset severe
shortness of breath. He is pale, diaphoretic, speaking only two-
word sentences, respiratory rate 34/min, SpO₂ 85% on room air.
Which triage level (Emergency Severity Index) should the triage
nurse assign?
A. ESI level 1
B. ESI level 2
C. ESI level 3
D. ESI level 4
,Correct answer: A. ESI level 1
Rationale:
ESI level 1 is reserved for patients who require immediate, life-
saving interventions (e.g., airway support, immediate
oxygenation/ventilation, cardiopulmonary resuscitation). This
patient has severe respiratory distress, hypoxemia (SpO₂ 85%),
and inability to speak normally — indicators that immediate
intervention is needed. ESI level 2 is for high-risk situations
where the patient is not immediately requiring a life-saving
intervention but is at high risk; however here the need for
immediate airway/oxygenation places him at level 1. Levels 3–5
are for progressively less acute presentations. (See ESI
handbook for acuity criteria.) EMSC Improvement Center+1
2 — START mass casualty triage
At a multiple-victim building collapse, first responders apply
START triage. A walking victim is assessed and found to be
breathing 36 breaths/min, radial pulse present, follows
commands. According to START, this patient should be tagged:
A. Delayed (yellow)
B. Immediate (red)
C. Minor (green)
D. Deceased/expectant (black)
Correct answer: B. Immediate (red)
,Rationale:
START uses RPM (Respiration, Perfusion, Mental status).
Respirations >30/min classify a patient as immediate (red)
because severe respiratory compromise predicts need for
urgent airway/ventilatory intervention or rapid transport.
Presence of perfusion and ability to follow commands are
positive signs but do not override a respiratory rate >30 in
START. “Minor/green” applies to ambulatory/minor injuries;
deceased/expectant applies when no respirations after an
attempt to open the airway. CHEMM+1
3 — SALT triage + lifesaving interventions
During SALT triage at a mass casualty, a victim who initially
could ambulate is found to be unresponsive with audible
gurgling and ineffective respirations. According to SALT
principles, which action should be performed first?
A. Tag the patient immediate (red) and move on without
intervention
B. Perform a rapid life-saving intervention — open airway and
clear secretions — then re-assess and categorize
C. Transport the patient to the nearest hospital immediately
without further assessment
D. Apply a triage tag of black (expectant) because airway
compromise indicates poor prognosis
, Correct answer: B. Perform a rapid life-saving intervention —
open airway and clear secretions — then re-assess and
categorize
Rationale:
SALT explicitly includes performing immediate life-saving
interventions (e.g., jaw thrust, clearing airway, controlling
severe hemorrhage) when feasible before assigning a final
triage category; after the lifesaving intervention, the patient is
re-assessed. Tagging and moving on without trying lifesaving
measures is contrary to SALT. Expectant category is used for
those with injuries incompatible with life or who remain apneic
despite airway opening. CHEMM+1
4 — Chemical exposure decontamination priority
An adult is brought to the ED after industrial exposure to an
unknown liquid chemical with soaked clothing. They are awake,
coughing, and complain of eye burning. Which initial nursing
action is highest priority?
A. Administer IV morphine and keep the patient clothed to
avoid hypothermia
B. Remove clothing and jewelry, irrigate skin and eyes, place
contaminated items in sealed bag, then begin assessment and
supportive care
C. Send the patient to radiology for chest and abdominal x-rays
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
Questions (1–25)
1 — Triage acuity (ESI)
A 56-year-old man arrives to triage with sudden onset severe
shortness of breath. He is pale, diaphoretic, speaking only two-
word sentences, respiratory rate 34/min, SpO₂ 85% on room air.
Which triage level (Emergency Severity Index) should the triage
nurse assign?
A. ESI level 1
B. ESI level 2
C. ESI level 3
D. ESI level 4
,Correct answer: A. ESI level 1
Rationale:
ESI level 1 is reserved for patients who require immediate, life-
saving interventions (e.g., airway support, immediate
oxygenation/ventilation, cardiopulmonary resuscitation). This
patient has severe respiratory distress, hypoxemia (SpO₂ 85%),
and inability to speak normally — indicators that immediate
intervention is needed. ESI level 2 is for high-risk situations
where the patient is not immediately requiring a life-saving
intervention but is at high risk; however here the need for
immediate airway/oxygenation places him at level 1. Levels 3–5
are for progressively less acute presentations. (See ESI
handbook for acuity criteria.) EMSC Improvement Center+1
2 — START mass casualty triage
At a multiple-victim building collapse, first responders apply
START triage. A walking victim is assessed and found to be
breathing 36 breaths/min, radial pulse present, follows
commands. According to START, this patient should be tagged:
A. Delayed (yellow)
B. Immediate (red)
C. Minor (green)
D. Deceased/expectant (black)
Correct answer: B. Immediate (red)
,Rationale:
START uses RPM (Respiration, Perfusion, Mental status).
Respirations >30/min classify a patient as immediate (red)
because severe respiratory compromise predicts need for
urgent airway/ventilatory intervention or rapid transport.
Presence of perfusion and ability to follow commands are
positive signs but do not override a respiratory rate >30 in
START. “Minor/green” applies to ambulatory/minor injuries;
deceased/expectant applies when no respirations after an
attempt to open the airway. CHEMM+1
3 — SALT triage + lifesaving interventions
During SALT triage at a mass casualty, a victim who initially
could ambulate is found to be unresponsive with audible
gurgling and ineffective respirations. According to SALT
principles, which action should be performed first?
A. Tag the patient immediate (red) and move on without
intervention
B. Perform a rapid life-saving intervention — open airway and
clear secretions — then re-assess and categorize
C. Transport the patient to the nearest hospital immediately
without further assessment
D. Apply a triage tag of black (expectant) because airway
compromise indicates poor prognosis
, Correct answer: B. Perform a rapid life-saving intervention —
open airway and clear secretions — then re-assess and
categorize
Rationale:
SALT explicitly includes performing immediate life-saving
interventions (e.g., jaw thrust, clearing airway, controlling
severe hemorrhage) when feasible before assigning a final
triage category; after the lifesaving intervention, the patient is
re-assessed. Tagging and moving on without trying lifesaving
measures is contrary to SALT. Expectant category is used for
those with injuries incompatible with life or who remain apneic
despite airway opening. CHEMM+1
4 — Chemical exposure decontamination priority
An adult is brought to the ED after industrial exposure to an
unknown liquid chemical with soaked clothing. They are awake,
coughing, and complain of eye burning. Which initial nursing
action is highest priority?
A. Administer IV morphine and keep the patient clothed to
avoid hypothermia
B. Remove clothing and jewelry, irrigate skin and eyes, place
contaminated items in sealed bag, then begin assessment and
supportive care
C. Send the patient to radiology for chest and abdominal x-rays
