Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Item 1 — Triage prioritization (mass-casualty, START)
A chemical plant explosion sends multiple victims to your ED
triage area. Which patient should be assigned IMMEDIATE (red)
priority and taken first to a resuscitation bay?
A. A conscious adult with partial-thickness burns to both hands
who can obey commands.
B. An adult who is apneic after repositioning the airway but has
a carotid pulse.
C. A child crying who has a small laceration to the scalp with
active bleeding controlled.
D. An adult with a closed femur fracture and stable vital signs.
Correct answer: B
Rationale:
Step 1 — Apply START principles: immediate (red) includes
victims with airway compromise, respiratory failure, or
uncontrolled hemorrhage. An apneic patient who regains
,respirations with repositioning but still exhibits compromised
breathing or unstable airway is highest priority for immediate
intervention (airway control, advanced airway). CHEMM
Why others are incorrect:
A — Partial-thickness burns to hands who is conscious and
obeys commands is delayed (yellow) unless there are
airway/respiratory issues or > critical TBSA.
C — Child with small laceration and controlled bleeding is
minimal (green).
D — Closed femur fracture with stable vitals is delayed (yellow).
(Level: Application; Client Need: Safe, Effective Care
Environment — Management of Care)
Item 2 — ABCs and c-spine control (trauma)
A 28-year-old motorcyclist arrives after a high-speed crash. He is
awake but reports neck pain. Vitals: RR 22, SpO₂ 96% on room
air, HR 118, BP 110/68. Which is the nurse’s first action?
A. Remove helmet to assess for scalp lacerations.
B. Apply cervical spine immobilization with manual in-line
stabilization and a cervical collar.
C. Give IV morphine for pain control immediately.
D. Obtain a CT head and cervical spine order.
Correct answer: B
Rationale:
Step 1 — In blunt trauma with neck pain, the priority is airway
protection plus spinal motion restriction to prevent secondary
,spinal cord injury. Apply manual in-line stabilization and cervical
collar before helmet removal (unless helmet prevents airway
management). Removal may be necessary later by trained
personnel.
Why others are incorrect:
A — Removing the helmet may destabilize the cervical spine; do
not remove without proper technique and team.
C — Pain control is important but secondary to stabilizing
spine/airway.
D — Imaging is required but after initial stabilization.
(Level: Application; Client Need: Physiological Integrity —
Reduction of Risk Potential)
Item 3 — Maslow’s hierarchy & nursing priorities
Which nursing action best reflects application of Maslow’s
hierarchy when prioritizing care for multiple ED patients?
A. Administering pain medication to a postoperative patient
with high pain scores.
B. Ensuring a patient with active GI bleeding (hematemesis) has
airway and circulation stabilized first.
C. Offering spiritual support to a patient with terminal
diagnosis.
D. Addressing a patient’s complaint of loneliness to improve
cooperation with discharge teaching.
Correct answer: B
, Rationale:
Step 1 — Maslow’s places physiological needs (airway,
breathing, circulation) at the base; life-threatening
physiological problems supersede safety, love/belonging,
esteem, and self-actualization. Stabilizing airway/circulation for
hematemesis is top priority.
Why others are incorrect:
A — Pain control is important (physiological) but less urgent if
not life-threatening.
C & D — These are higher-level needs (psychosocial) and come
after life/safety needs are addressed.
(Level: Analysis; Client Need: Safe, Effective Care Environment)
Item 4 — Septic shock (recognition & immediate
interventions)
A 62-year-old with suspected urosepsis arrives febrile,
confused, HR 130, BP 82/42, RR 28. Skin is warm and flushed.
Which action should the nurse implement first?
A. Obtain blood cultures and start broad-spectrum IV antibiotics
promptly.
B. Place the patient in Trendelenburg position to raise BP.
C. Start an aggressive IV crystalloid bolus (e.g., 30 mL/kg) and
call for vasopressors if hypotension persists.
D. Administer IV hydrocortisone empirically.
Correct answer: C
Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
EMERGENCY NURSING AND TRIAGE TEST BANK
Item 1 — Triage prioritization (mass-casualty, START)
A chemical plant explosion sends multiple victims to your ED
triage area. Which patient should be assigned IMMEDIATE (red)
priority and taken first to a resuscitation bay?
A. A conscious adult with partial-thickness burns to both hands
who can obey commands.
B. An adult who is apneic after repositioning the airway but has
a carotid pulse.
C. A child crying who has a small laceration to the scalp with
active bleeding controlled.
D. An adult with a closed femur fracture and stable vital signs.
Correct answer: B
Rationale:
Step 1 — Apply START principles: immediate (red) includes
victims with airway compromise, respiratory failure, or
uncontrolled hemorrhage. An apneic patient who regains
,respirations with repositioning but still exhibits compromised
breathing or unstable airway is highest priority for immediate
intervention (airway control, advanced airway). CHEMM
Why others are incorrect:
A — Partial-thickness burns to hands who is conscious and
obeys commands is delayed (yellow) unless there are
airway/respiratory issues or > critical TBSA.
C — Child with small laceration and controlled bleeding is
minimal (green).
D — Closed femur fracture with stable vitals is delayed (yellow).
(Level: Application; Client Need: Safe, Effective Care
Environment — Management of Care)
Item 2 — ABCs and c-spine control (trauma)
A 28-year-old motorcyclist arrives after a high-speed crash. He is
awake but reports neck pain. Vitals: RR 22, SpO₂ 96% on room
air, HR 118, BP 110/68. Which is the nurse’s first action?
A. Remove helmet to assess for scalp lacerations.
B. Apply cervical spine immobilization with manual in-line
stabilization and a cervical collar.
C. Give IV morphine for pain control immediately.
D. Obtain a CT head and cervical spine order.
Correct answer: B
Rationale:
Step 1 — In blunt trauma with neck pain, the priority is airway
protection plus spinal motion restriction to prevent secondary
,spinal cord injury. Apply manual in-line stabilization and cervical
collar before helmet removal (unless helmet prevents airway
management). Removal may be necessary later by trained
personnel.
Why others are incorrect:
A — Removing the helmet may destabilize the cervical spine; do
not remove without proper technique and team.
C — Pain control is important but secondary to stabilizing
spine/airway.
D — Imaging is required but after initial stabilization.
(Level: Application; Client Need: Physiological Integrity —
Reduction of Risk Potential)
Item 3 — Maslow’s hierarchy & nursing priorities
Which nursing action best reflects application of Maslow’s
hierarchy when prioritizing care for multiple ED patients?
A. Administering pain medication to a postoperative patient
with high pain scores.
B. Ensuring a patient with active GI bleeding (hematemesis) has
airway and circulation stabilized first.
C. Offering spiritual support to a patient with terminal
diagnosis.
D. Addressing a patient’s complaint of loneliness to improve
cooperation with discharge teaching.
Correct answer: B
, Rationale:
Step 1 — Maslow’s places physiological needs (airway,
breathing, circulation) at the base; life-threatening
physiological problems supersede safety, love/belonging,
esteem, and self-actualization. Stabilizing airway/circulation for
hematemesis is top priority.
Why others are incorrect:
A — Pain control is important (physiological) but less urgent if
not life-threatening.
C & D — These are higher-level needs (psychosocial) and come
after life/safety needs are addressed.
(Level: Analysis; Client Need: Safe, Effective Care Environment)
Item 4 — Septic shock (recognition & immediate
interventions)
A 62-year-old with suspected urosepsis arrives febrile,
confused, HR 130, BP 82/42, RR 28. Skin is warm and flushed.
Which action should the nurse implement first?
A. Obtain blood cultures and start broad-spectrum IV antibiotics
promptly.
B. Place the patient in Trendelenburg position to raise BP.
C. Start an aggressive IV crystalloid bolus (e.g., 30 mL/kg) and
call for vasopressors if hypotension persists.
D. Administer IV hydrocortisone empirically.
Correct answer: C
