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 category (single best answer)
A 42-year-old male arrives by ambulance after a motor-vehicle
crash. He is conscious, breathing 28/min, has a weak radial
pulse, and a large open femur fracture with obvious deformity.
According to common mass-casualty triage categories
(START/SALT), which triage category best fits this patient?
A. Minor (green)
B. Delayed (yellow)
C. Immediate (red)
D. Expectant (black)
Correct answer: C. Immediate (red)
Rationale:
, • Correct (C): The patient has significant physiologic
compromise (tachypnea and weak pulse) and an obviously
serious injury (open femur fracture) — criteria that
commonly place a victim in the immediate category
requiring rapid life- or limb-saving intervention and
prioritized transport. START/SALT triage prioritize patients
with compromised airway/breathing/circulation for
immediate care. NCBI+1
• A (Minor): Incorrect — “minor” refers to ambulatory,
walking wounded or those with superficial injuries who
can wait.
• B (Delayed): Incorrect — delayed are stable but require
care; this patient shows physiologic compromise that
elevates priority above delayed.
• D (Expectant): Incorrect — expectant is reserved for those
unlikely to survive given available resources (e.g.,
unresponsive with no respirations after simple maneuvers,
catastrophic injuries).
2 — Rapid cue recognition / priority (single best answer)
An ED triage nurse receives report for four new arrivals. Which
client should the nurse assess first?
A. A 68-year-old with chest pain 6/10, nitroglycerin relieved
pain to 3/10.
B. A 25-year-old with a laceration to the forearm, bleeding
,controlled with pressure.
C. A 50-year-old with sudden slurred speech and right-sided
weakness started 10 minutes ago.
D. A 19-year-old with fever 38.3°C and sore throat.
Correct answer: C. 50-year-old with sudden slurred speech and
right-sided weakness
Rationale:
• Correct (C): Sudden focal neurologic deficits with known
onset within a time window represent a possible acute
ischemic stroke — time-sensitive for interventions (e.g.,
thrombolysis or thrombectomy). Per stroke standards,
rapid assessment and activation of stroke pathway is
highest priority. NCSBN
• A: Chest pain is high priority but the client’s pain
decreased with nitroglycerin; still urgent but stroke within
thrombolytic window takes precedence for immediate
neuro evaluation.
• B: Controlled bleeding — lower immediate risk after
hemostasis.
• D: Fever/sore throat — lowest acuity relative to possible
stroke.
3 — CPR algorithm (multiple choice single best answer)
, A previously healthy adult collapses in a shopping mall.
Bystander calls emergency services and begins CPR. According
to current AHA adult BLS guidance, what is the priority
sequence for a single rescuer on an unresponsive adult?
A. Check responsiveness → call for help/activate EMS → pulse
check → start rescue breaths → chest compressions
B. Check responsiveness → call for help/activate EMS → check
breathing and pulse simultaneously (no more than 10 sec) →
begin high-quality chest compressions (CAB)
C. Call for help → open airway → provide two rescue breaths →
check pulse → begin compressions
D. Check pulse for 30–45 seconds → call for help → begin
compressions
Correct answer: B. Check responsiveness → call for
help/activate EMS → check breathing and pulse simultaneously
(no more than 10 sec) → begin high-quality chest compressions
(CAB)
Rationale:
• Correct (B): Current AHA adult BLS emphasizes early
recognition, activation of EMS, and immediate high-quality
chest compressions (compressions first in the CAB
sequence) with pulse/breathing checks limited to ≤10
seconds. Early compressions and rapid defibrillation when
indicated are cornerstones of survival. cpr.heart.org+1
• A: Incorrect — places rescue breaths before compressions;
for adult sudden collapse, compressions are prioritized.
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1 — Triage category (single best answer)
A 42-year-old male arrives by ambulance after a motor-vehicle
crash. He is conscious, breathing 28/min, has a weak radial
pulse, and a large open femur fracture with obvious deformity.
According to common mass-casualty triage categories
(START/SALT), which triage category best fits this patient?
A. Minor (green)
B. Delayed (yellow)
C. Immediate (red)
D. Expectant (black)
Correct answer: C. Immediate (red)
Rationale:
, • Correct (C): The patient has significant physiologic
compromise (tachypnea and weak pulse) and an obviously
serious injury (open femur fracture) — criteria that
commonly place a victim in the immediate category
requiring rapid life- or limb-saving intervention and
prioritized transport. START/SALT triage prioritize patients
with compromised airway/breathing/circulation for
immediate care. NCBI+1
• A (Minor): Incorrect — “minor” refers to ambulatory,
walking wounded or those with superficial injuries who
can wait.
• B (Delayed): Incorrect — delayed are stable but require
care; this patient shows physiologic compromise that
elevates priority above delayed.
• D (Expectant): Incorrect — expectant is reserved for those
unlikely to survive given available resources (e.g.,
unresponsive with no respirations after simple maneuvers,
catastrophic injuries).
2 — Rapid cue recognition / priority (single best answer)
An ED triage nurse receives report for four new arrivals. Which
client should the nurse assess first?
A. A 68-year-old with chest pain 6/10, nitroglycerin relieved
pain to 3/10.
B. A 25-year-old with a laceration to the forearm, bleeding
,controlled with pressure.
C. A 50-year-old with sudden slurred speech and right-sided
weakness started 10 minutes ago.
D. A 19-year-old with fever 38.3°C and sore throat.
Correct answer: C. 50-year-old with sudden slurred speech and
right-sided weakness
Rationale:
• Correct (C): Sudden focal neurologic deficits with known
onset within a time window represent a possible acute
ischemic stroke — time-sensitive for interventions (e.g.,
thrombolysis or thrombectomy). Per stroke standards,
rapid assessment and activation of stroke pathway is
highest priority. NCSBN
• A: Chest pain is high priority but the client’s pain
decreased with nitroglycerin; still urgent but stroke within
thrombolytic window takes precedence for immediate
neuro evaluation.
• B: Controlled bleeding — lower immediate risk after
hemostasis.
• D: Fever/sore throat — lowest acuity relative to possible
stroke.
3 — CPR algorithm (multiple choice single best answer)
, A previously healthy adult collapses in a shopping mall.
Bystander calls emergency services and begins CPR. According
to current AHA adult BLS guidance, what is the priority
sequence for a single rescuer on an unresponsive adult?
A. Check responsiveness → call for help/activate EMS → pulse
check → start rescue breaths → chest compressions
B. Check responsiveness → call for help/activate EMS → check
breathing and pulse simultaneously (no more than 10 sec) →
begin high-quality chest compressions (CAB)
C. Call for help → open airway → provide two rescue breaths →
check pulse → begin compressions
D. Check pulse for 30–45 seconds → call for help → begin
compressions
Correct answer: B. Check responsiveness → call for
help/activate EMS → check breathing and pulse simultaneously
(no more than 10 sec) → begin high-quality chest compressions
(CAB)
Rationale:
• Correct (B): Current AHA adult BLS emphasizes early
recognition, activation of EMS, and immediate high-quality
chest compressions (compressions first in the CAB
sequence) with pulse/breathing checks limited to ≤10
seconds. Early compressions and rapid defibrillation when
indicated are cornerstones of survival. cpr.heart.org+1
• A: Incorrect — places rescue breaths before compressions;
for adult sudden collapse, compressions are prioritized.
