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 (Triage acuity)
A 54-year-old man arrives in triage after a motor vehicle crash.
He is awake but confused, RR 8 breaths/min with shallow
respirations, absent radial pulse, and pale, cool skin. According
to START triage principles during a mass casualty incident, what
tag/category should the triage nurse assign initially?
A. Minor (green) — ambulatory or delayed
B. Immediate (red) — highest priority for life-saving care
C. Expectant (black) — not expected to survive with available
resources
D. Observation (yellow) — urgent but not immediate
Correct answer: B
,Rationale:
• B (Correct): In START, a patient with inadequate
respirations (RR 8, shallow) and absent distal perfusion
signs with altered mental status meets criteria for
Immediate (red) because they require immediate lifesaving
interventions (airway/ventilation, circulation). START
emphasizes RPM (Respiration, Perfusion, Mental status) for
rapid categorization. CHEMM
• A (Incorrect): Minor/green is reserved for
ambulatory/walking wounded or those with minimal
injuries — this patient is physiologically unstable.
• C (Incorrect): Expectant/black is used for patients who
cannot be resuscitated with available resources (e.g., no
respirations even after airway repositioning). Because this
patient is breathing (albeit shallow) and has treatable
problems, immediate treatment is indicated first.
• D (Incorrect): Observation/yellow is for those who are
stable enough to wait briefly; this patient is unstable.
2 (ESI triage — ED setting)
A triage nurse using the Emergency Severity Index (ESI)
evaluates a patient with acute shortness of breath, SpO₂ 88%
on room air, accessory muscle use, and inability to speak more
than short phrases. What ESI level is most appropriate?
A. ESI level 1 — immediate life-threatening condition
,B. ESI level 2 — high risk or severe distress
C. ESI level 3 — multiple resources anticipated
D. ESI level 4 — one resource anticipated
Correct answer: B
Rationale:
• B (Correct): ESI level 2 is for patients who are high risk, in
severe pain/distress, or have abnormal vital signs and need
rapid evaluation — patients who should be seen quickly
but may not require immediate life-saving intervention at
triage. Respiratory distress with SpO₂ 88% and accessory
muscle use is high risk and fits level 2. EMSC Improvement
Center
• A (Incorrect): Level 1 requires immediate life-saving
interventions (e.g., cardiac arrest, intubation required at
once). If this patient required immediate intubation or was
pulseless, level 1 would apply.
• C/D (Incorrect): Levels 3–5 rely on predicted resource
needs and lower acuity; this patient’s compromised
respiratory status places them above those categories.
3 (Rapid recognition / cue prioritization)
An ED nurse receives report on four arriving patients. Which
client should the nurse see first?
, 1. 28-year-old with simple laceration to forearm, bleeding
controlled, stable vitals.
2. 72-year-old with sudden left facial droop and slurred
speech — symptoms began 1 hour ago.
3. 35-year-old with ankle pain after inversion injury, able to
bear weight.
4. 49-year-old with fever 101.5°F and ear pain.
A. 1 → 2 → 3 → 4
B. 2 → 4 → 3 → 1
C. 3 → 1 → 4 → 2
D. 4 → 2 → 1 → 3
Correct answer: B
Rationale:
• B (Correct): The stroke-symptom patient (72) is time-
sensitive (possible thrombolytic window) and must be
prioritized. Fever/ear pain is lower acuity than suspected
stroke but higher than simple laceration and ankle sprain
— so 4 after 2, then 3 and 1. This reflects prioritization of
time-dependent interventions and unstable/ potentially
deteriorating conditions (NGN emphasis on risk of harm).
NCSBN
• A/C/D (Incorrect): These orders delay evaluation of the
potentially time-sensitive stroke and therefore are not the
highest priority.
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1 (Triage acuity)
A 54-year-old man arrives in triage after a motor vehicle crash.
He is awake but confused, RR 8 breaths/min with shallow
respirations, absent radial pulse, and pale, cool skin. According
to START triage principles during a mass casualty incident, what
tag/category should the triage nurse assign initially?
A. Minor (green) — ambulatory or delayed
B. Immediate (red) — highest priority for life-saving care
C. Expectant (black) — not expected to survive with available
resources
D. Observation (yellow) — urgent but not immediate
Correct answer: B
,Rationale:
• B (Correct): In START, a patient with inadequate
respirations (RR 8, shallow) and absent distal perfusion
signs with altered mental status meets criteria for
Immediate (red) because they require immediate lifesaving
interventions (airway/ventilation, circulation). START
emphasizes RPM (Respiration, Perfusion, Mental status) for
rapid categorization. CHEMM
• A (Incorrect): Minor/green is reserved for
ambulatory/walking wounded or those with minimal
injuries — this patient is physiologically unstable.
• C (Incorrect): Expectant/black is used for patients who
cannot be resuscitated with available resources (e.g., no
respirations even after airway repositioning). Because this
patient is breathing (albeit shallow) and has treatable
problems, immediate treatment is indicated first.
• D (Incorrect): Observation/yellow is for those who are
stable enough to wait briefly; this patient is unstable.
2 (ESI triage — ED setting)
A triage nurse using the Emergency Severity Index (ESI)
evaluates a patient with acute shortness of breath, SpO₂ 88%
on room air, accessory muscle use, and inability to speak more
than short phrases. What ESI level is most appropriate?
A. ESI level 1 — immediate life-threatening condition
,B. ESI level 2 — high risk or severe distress
C. ESI level 3 — multiple resources anticipated
D. ESI level 4 — one resource anticipated
Correct answer: B
Rationale:
• B (Correct): ESI level 2 is for patients who are high risk, in
severe pain/distress, or have abnormal vital signs and need
rapid evaluation — patients who should be seen quickly
but may not require immediate life-saving intervention at
triage. Respiratory distress with SpO₂ 88% and accessory
muscle use is high risk and fits level 2. EMSC Improvement
Center
• A (Incorrect): Level 1 requires immediate life-saving
interventions (e.g., cardiac arrest, intubation required at
once). If this patient required immediate intubation or was
pulseless, level 1 would apply.
• C/D (Incorrect): Levels 3–5 rely on predicted resource
needs and lower acuity; this patient’s compromised
respiratory status places them above those categories.
3 (Rapid recognition / cue prioritization)
An ED nurse receives report on four arriving patients. Which
client should the nurse see first?
, 1. 28-year-old with simple laceration to forearm, bleeding
controlled, stable vitals.
2. 72-year-old with sudden left facial droop and slurred
speech — symptoms began 1 hour ago.
3. 35-year-old with ankle pain after inversion injury, able to
bear weight.
4. 49-year-old with fever 101.5°F and ear pain.
A. 1 → 2 → 3 → 4
B. 2 → 4 → 3 → 1
C. 3 → 1 → 4 → 2
D. 4 → 2 → 1 → 3
Correct answer: B
Rationale:
• B (Correct): The stroke-symptom patient (72) is time-
sensitive (possible thrombolytic window) and must be
prioritized. Fever/ear pain is lower acuity than suspected
stroke but higher than simple laceration and ankle sprain
— so 4 after 2, then 3 and 1. This reflects prioritization of
time-dependent interventions and unstable/ potentially
deteriorating conditions (NGN emphasis on risk of harm).
NCSBN
• A/C/D (Incorrect): These orders delay evaluation of the
potentially time-sensitive stroke and therefore are not the
highest priority.
