Emergency Nursing & Triage NCLEX Practice (40 Questions)

FT–Emergency Nursing and Triage NCLEX Practice Quiz and Questions

Welcome to your NCLEX reviewer and practice questions quiz about Emergency Nursing and Triage. Test your competence about emergency nursing in this nursing test bank.

Emergency Nursing & Triage NCLEX Practice Quiz

In this section are the practice problems and questions for emergency nursing and triage NCLEX practice quiz. In this nursing test bank, there are 40 practice questions divided into two parts. Please check out also our reviewer for emergency nursing below.

Quizzes included in this guide are:



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Emergency Nursing & Triage NCLEX Practice (Part 1: 20 Questions)

Welcome to the first part of your quiz about emergency nursing. If you are having trouble with the questions, why not read our reviewer first (see below) to refresh your memory.


Emergency Nursing Reviewer

“Emergency!” The very event that is linked to drama and hysteria. The word emerge in emergency, and an emergency suddenly emerges — it happens all of a sudden, at any time to anyone, and anywhere. The person specifically the nurse who responds at the scene in the emergency department or on the medical-surgical unit faces the ultimate challenge of his or her nursing skills. In this medical setting, you plan a solution for a short period of time and there is no room for error.


  • Any trauma or sudden illness that requires immediate intervention to prevent imminent severe damage or death.
  • Any condition that — in the opinion of the patient, his family, or whoever assumes the responsibility of bringing the patient to the hospital — requires immediate medical intervention. This condition continues until the determination has been made that the patient’s life or wellbeing is not threatened.

Emergency Nursing

  • Emergency nursing is a nursing specialty that focuses on the care of patients who require prompt medical attention to avoid long-term disability or death. It involves the assessment, diagnosis, and treatment of perceived, actual or potential, sudden or urgent, physical or psychosocial problems that are primarily episodic or acute.

Emergency Medical Services

  • Responsible for establishing, regulating, coordinating, and monitoring the components involved in the provision of emergency care.
  • Team of healthcare providers that provides emergency care.

1. Emergency Medical Technician (EMT). Also known as an ambulance technician, is a health professional that provides emergency medical services. EMTs are most commonly found working in ambulances. They are also the most common type of providers in all of EMS.

2. Emergency Medical Technician Intermediates (EMTI). EMTIs are next to EMTs. Intermediates maintain a critical skill set that can often be life-saving to those involved in accidents, emergencies and in more complicated procedures.

3. Emergency Medical Technician Paramedics (EMTP). EMTPs are the highest level of EMTs. Paramedics are advanced providers of emergency medical care and are highly educated in topics such as anatomy and physiology, cardiology, medications, and medical procedures.

Four Basic Steps for Emergencies

1. Know your facility. It is important to know what emergency resources are available in each location, the placement of the equipment such overhead sprinkler systems, fire extinguishers, and defibrillators. In the hospital setting, healthcare providers, especially nurses, should know where the E-carts and E-kits are placed. They need to be available to providers very easily.

2. Know the proper scope of your emergency care. The nurse should know his or her role, accountability, and responsibility when dealing with emergency situations. The nurse is responsible of the following:

  • Deciding when to call the doctor
  • Coordinating care
  • Assisting with other emergency procedures
  • Performing emergency assessment and interventions

Primary and Secondary Assessment

  • Primary Assessment. A primary assessment allows for the recognition of potentially life threatening conditions and the correct management to be implemented. The acronym ABCDE provides the basis of the primary assessment and it is an easy way to remember the correct order for assessing patients presenting to the emergency department.
    • Airway. The most important component to be established and maintained to prevent hypoxia and ultimately death.
    • Breathing. Assessed after the airway. During times of acute injury and stress, the respiratory system can be compromised.
    • Circulation. Adequate circulation is needed to maintain tissue perfusion and cellular oxygenation. This system involves the heart, vessels, and blood volume.
    • Disability. A neurological assessment to assess for motor or sensory deficits is vital as a decrease in level of consciousness can affect ABC.
    • Exposure. Once the patient is exposed for full body assessment, their privacy needs to be respected by providing a gown and blanket.
  • Secondary Assessment. When all life threatening conditions have been found and corrected, the secondary assessment is undertaken. The main focus of the secondary assessment is to explore specific medical conditions the patient may have. The components of the secondary are continuous with the primary assessment A,B,C,D,E,F,G,H,I.
    • Full set of vital signs. Vital signs such as temperature, respiration rate, heart rate, blood pressure, and pain should be assessed.
    • Give comfort. For many patients in the emergency department, levels of pain may be quite high.
    • History. Understanding the complexity and processes involved in history taking allows nurses to gain a better understanding of patients’ problems.
      • The mnemonic AMPLE is a useful tool to guide history taking.
        • Allergies
        • Medications
        • Past medical history
        • Last meal
        • Events surrounding injury
    • Inspect posterior surfaces.

3. Know your patients. Nurses are responsible for identifying if the patient is under an emergency situation and recognizing patients’ symptoms, taking measures within their scope of practice to administer medications, providing other measures for symptom alleviation, and collaborating with other professionals to optimize patients’ comfort and families’ understanding and adaptation.

4. Stay prepared. Preparing for unexpected occurrences is only part of the equation. Being fast, ready, and accurate for an emergency also involves practicing good mental health strategies that can develop one’s level of competency in the event of a crisis.

Emergency Equipment, Drugs, and Procedures.

  • Ambu Bag. An Ambu bag is a medical tool used to force air into the lungs of patients who are not breathing or who  are not breathing adequately so still need assistance. The term AMBU comes from the acronym for “artificial manual breathing unit.”
  • Epinephrine. Epinephrine injection is used along with emergency medical treatment to treat life-threatening allergic reactions caused by insect bites or stings, foods, medications, latex, and other causes. 
  • Atropine Sulfate. Atropine is a prescription medicine used to treat the symptoms of low heart rate or bradycardia, reduce salivation and bronchial secretions before surgery or as an antidote for overdose of cholinergic drugs or mushroom poisoning.
  • Heparin. Heparin is used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels.
  • Protamine Sulfate. When bleeding requires reversal of heparinization, protamine sulfate (1% solution) by slow infusion will neutralize heparin sodium. No more than 50 mg should be administered, very slowly in any 10 minute period. Each mg of protamine sulfate neutralizes approximately 100 USP heparin units.
  • Tracheostomy Tray. Emergency tracheostomy is needed when breathing is obstructed and emergency personnel can’t put a breathing tube through your mouth and into your trachea.
    • General instruments (tissue tweezers, mosquito forceps, Cooper scissors, muscle retractors, and Mayo needle holder).
    • Scalpel
    • 14-gauge sheath
    • Dilator
    • Guidewire dilating forceps
    • Tracheostomy tube
  • Endotracheal Tube. Endotracheal intubation is a medical procedure in which a tube is placed into the windpipe or trachea through the mouth or nose. In most emergency situations, it is placed through the mouth.
  • CVP Kits. There are many different indications for placing a central venous line, but in emergency medicine, the most common indications include fluid resuscitation, drug infusions that could otherwise cause phlebitis or sclerosis, central venous pressure monitoring, emergency venous access, and transvenous pacing wire placement.
  • IV Equipment. Intravenous access is used when therapies cannot be used or are less effective by alternative routes.
    • Gloves
    • Skin disinfectant (alcohol swab)
    • 16-18 gauge IV catheter (smaller catheters may be used for pediatric patients, but larger is better in critical cases)

Guidelines for giving emergency care

1. Getting Started

A. Planning of action.

B. Gathering of materials needed.


2. Emergency Action Principles

A. Survey the scene. First, survey the scene for any possible hazards. Stop. Look. Listen. Feel. Safety first!

B. Perform Primary Assessment. If the area appears safe, check the victim for life-threatening conditions such as:

  •  Level of Consciousness

I. Assess for ABC.

  • Airway. The most important component to be established and maintained to prevent hypoxia and ultimately death.
  • Breathing. Assessed after the airway. During times of acute injury and stress, the respiratory system can be compromised.
  • Circulation. Adequate circulation is needed to maintain tissue perfusion and cellular oxygenation. This system involves the heart, vessels, and blood volume.
  • The central pulse of choice for adults is the carotid pulse. In children, the carotid pulse is usually used, although the femoral pulse is also an option. Infants (<1 year) have short necks and so the carotid is not palpated. Instead, the brachial or femoral pulses are used.
  • Do not move to the next step if the client is unstable.

C. Call for help. After checking the victim, call for help. Remain calm, and be prepared to give a description of the situation as well as the exact location where responders are needed.

Also, contact local site security and emergency response

D. Perform Secondary Assessment. The main focus of the secondary assessment is to explore specific medical conditions the patient may have.

I. Neurologic Assessment

  • Level of Consciousness. The normal state of consciousness comprises either the state of wakefulness, awareness, or alertness in which most human beings function while not asleep or one of the recognized stages of normal sleep from which the person can be readily awakened.
    • Alert. Mentally quick, active, and aware.
    • Lethargic. Quality of dullness, prolonged sleepiness, sluggishness, and serious drowsiness.
    • Stuporous. State of unresponsiveness and unaware of surroundings.
    • Semi-Comatose. Stupored but can be aroused.
    • Comatose
  • Glasgow Coma Scale. The Glasgow Coma Scale (GCS) is a neurological scale which aims to give a reliable and objective way of recording the state of a person’s consciousness for initial as well as subsequent assessment. 

Glasgow Coma Scale

EyeDoes not open eyesOpens eyes in response to painOpens eyes in response to voiceOpens eyes spontaneouslyN/AN/A
VerbalMakes no soundsMakes soundsWordsConfused, disorientedOriented, converses normallyN/A
MotorMakes no movementsExtension to painful stimuli (decerebrate response)Abnormal flexion to painful stimuli (decorticate response)Flexion / Withdrawal to painful stimuliLocalizes to painful stimuliObeys commands
  • Interpretation:
    • Severe, GCS < 8–9
    • Moderate, GCS 8 or 9–12
    • Minor, GCS ≥ 13.
  • Eye response (E)

There are four grades starting with the most severe:

1. No opening of the eye
2. Eye opening in response to pain stimulus. A peripheral pain stimulus, such as squeezing the lunula area of the person’s fingernail is more effective than a central stimulus such as a trapezius squeeze, due to a grimacing effect.
3. Eye opening to speech. Not to be confused with the awakening of a sleeping person; such people receive a score of 4, not 3.
4. Eyes opening spontaneously

  • Verbal response (V)

There are five grades starting with the most severe:

1. No verbal response
2. Incomprehensible sounds. Moaning but no words.
3. Inappropriate words. Random or exclamatory articulated speech, but no conversational exchange. Speaks words but no sentences.
4. Confused. The person responds to questions coherently but there is some disorientation and confusion.
5. Oriented. Person responds coherently and appropriately to questions such as the person’s name and age, where they are and why, the year, month, etc.

  • Motor response (M)

There are six grades:

1. No motor response
2. Decerebrate posturing accentuated by pain (extensor response: adduction of arm, internal rotation of shoulder, pronation of forearm and extension at elbow, flexion of wrist and fingers, leg extension, plantarflexion of foot)
3. Decorticate posturing accentuated by pain (flexor response: internal rotation of shoulder, flexion of forearm and wrist with clenched fist, leg extension, plantarflexion of foot)
4. Withdrawal from pain (absence of abnormal posturing; unable to lift hand past chin with supraorbital pain but does pull away when nail bed is pinched)
5. Localizes to pain (purposeful movements towards painful stimuli; e.g., brings hand up beyond chin when supraorbital pressure applied)
6. Obeys commands (the person does simple things as asked)

  • PERRLA. The list includes Pupils, Equal, Round, Reactive to, Light, Accomodation.
    • Pupils. Pupils are the black hole in the middle of the colored part of your eye (the iris).
    • Equal. Normal pupils are about the same size. But, for about one in five people, one is bigger than the other. This condition is called anisocoria and may be harmless. 
    • Round. Pupils should be perfectly round circles. Abnormal pupils may look like a keyhole or a cat’s eye.
    • Reactive to. The muscles in the iris open and close the pupil in response to light. Normal pupils get smaller in brighter light and larger in the dark.
    • Light. Normal pupils shrink in reaction to bright light. Both pupils should get smaller together, even when only shining direct light into one eye at a time. Both pupils should get bigger once it’s dark again.
    • Accommodation. Pupils change size as they switch from looking at something far away to something very near.
  • Motor movement and strength of muscles.
  • AVPU. Alert, Verbal, Pain, Unresponsive

II. History

  • Chief complaint.
  • Duration of the problem.
  • Mechanism of injury.
  • Associated manifestations.
  • Past medical history.
  • Current treatment and compliance.
  • Use of OTC drugs.
  • Routine use of alcohol or drugs.
  • Medication allergy.
  • Immunization history.
  • Pregnancy.

III. Pain Assessment. OPQRST is a useful mnemonic used by EMTs, paramedics, as well as nurses, medical assistants and other allied health professionals, for learning about the patient’s pain complaint. 

  • Onset of the event. What the patient was doing when it started (active, inactive, stressed, etc.), whether the patient believes that activity prompted the pain and whether the onset was sudden, gradual or part of an ongoing chronic problem. “Did your pain start suddenly or gradually get worse and worse?”
  • Provocation or palliation. Whether any movement, pressure such as palpation or other external factor makes the problem better or worse. This can also include whether the symptoms relieve with rest. “What makes your pain better or worse?”
  • Quality of the pain. This is the patient’s description of the pain. Questions can be open ended (“Can you describe it for me?”) or leading. “What does your pain feel like?”
  • Region and Radiation. Where the pain is on the body and whether it radiates (extends) or moves to any other area. “Point to where it hurts the most. Where does your pain go from there?”
  • Severity. The pain score (usually on a scale of 0 to 10). Zero is no pain and ten is the worst possible pain. Remember, pain is subjective and relative to each individual patient.
  • Timing. How long the condition has been going on and how it has changed since onset.

IV. General Appearance. Gait, unusual skin markings, affect, posture, skin color.

V. Head to toe Assessment. Establishing a good assessment would later-on provide a more accurate diagnosis, planning, and better interventions and evaluation, that’s why it’s important to have a good and strong assessment.

VI. Diagnostic Tests. A diagnostic procedure is an examination to identify an individual’s specific areas of weakness and strength in order to determine a condition, disease or illness.

E. Diagnosis. Nursing diagnoses represent the nurse’s clinical judgment about actual or potential health problems/life processes occurring with the individual, family, group or community.


F. Management. The nurse implements the nursing care plan, performing the determined interventions that were selected to help meet the goals/outcomes that were established.

G. Evaluation. The nurse evaluates the progress toward the goals/outcomes identified in the previous phases. If progress towards the goal is slow, or if regression has occurred, the nurse must change the plan of care accordingly. 

H. Client Disposition. Understanding the patient’s readmission risk stratification, needs of the patient upon discharge and the ability of the receiving facility to meet those needs all have a role in the patient’s well-being and can help to prevent readmission.

I. Documentation. The entire process is recorded or documented in order to inform all members of the health care team.

3. Golden Rules of Emergency Care

  • Obtain consent whenever possible
  • Be as calm and as direct as possible
  • Care for the most serious injuries first
  • Keep onlookers away from the injured person
  • Handle victim to a minimum
  • Loosen tight clothing
  • Do not leave the victim alone
  • Do not assume that the obvious injuries are the only ones
  • Don’t give false reassurance
  • Do not require the victim to make decision



  • Trier in French, battlefield screening, to sort out, to categorize, to classify.
  • The prioritization of patient care based on the severity of injury/illness, prognosis, and availability of resources.


  • To sort or classify all patients
  • Set priorities of care

Descriptions of a few Emergency Nurse roles:

Triage Nurse

  • An emergency nurse is assigned to triage patients as they arrive in the emergency department, and as such, is the first professional patients will see. 
  • This emergency nurse must be skilled at rapid, accurate physical examination and early recognition of life-threatening conditions.

ED Charge Nurse

  • An experienced emergency nurse is put in the role of charge nurse or team leader.
  • This nurse is responsible for the overall flow of the department.
  • He or she assigns nurses to patients, assures patients are being transported to and from tests outside the ED, addresses patient complaints and concerns, communicates with the house supervisor, takes phone calls, and assures nurses get their breaks.

Trauma Nurse

  • Trauma Nurses work in Trauma Centers and run the show when trauma patients come in by ambulance, helicopter, or personal vehicle.
  • This role requires specialized training and usually two years of experience.

Code Nurse

  • Code Nurses run the Code Rooms where the sickest of the sick patients go in the ED. No pulse, not breathing? No problem! The Code Nurse will run the ACLS-based codes and provide emergency care for these critically ill patients.

Disaster Response or Emergency Preparedness Nurse

  • In theory, all ED nurses are first-responders during a disaster.
  • All ED nurses should have annual training in disaster response per the policy of their facility.

Critical-Care Transport (CCT) Nurse (Ambulance)

  • CCT Nurses that work on ambulances are responsible for transporting critical care patients from one facility to another.

Burn Center Nurse

  • Emergency Nurses that work in Burn Centers are specially trained in burn victim resuscitation and burn care. Most major metropolitan areas will have at least one designated burn center with an emergency department.

Emergency Department Triage System (Three-Tier System)


  • Priority 1
  • Injuries are life threatening
  • Needs immediate attention and continuous evaluation
    • Severe head injury or comatose state
    • Active seizures
    • Sustain chemical splashes to the eye
    • Severe respiratory distress or cardiac arrest
    • Chest pain with acute dyspnea or cyanosis
    • Trauma
    • Severe chest or abdominal wound
    • Limb amputation
    • Severe shock
    • Excessively high temperature (40.6 °C)


  • Priority 2
  • Injuries have complications that are not life threatening
  • Needs to be treated within 1 to 2 hours (evaluation 30-60 minutes thereafter)
    • Asthma without respiratory distress
    • Persistent nausea and vomiting and/or diarrhea
    • Hypertension
    • Other types of severe pain
    • Simple fracture
    • Abdominal pain
    • Client with renal stone
    • Fever above 38.9 °C


  • Priority 3
  • Injuries do not have immediate complications
  • Can wait for several hours for medical treatment (evaluation every 1-2 hours)
    • Mild headache
    • Cold symptoms
    • Minor laceration
    • Sprain
    • Strains


  • Includes dead or even catastrophically injured patients who have a minimal chance for survival despite optimal medical care.

Cardiopulmonary Resuscitation (CPR)

Cardiopulmonary Resuscitation (CPR) incorporates rescue breathing with chest compression to circulate oxygen around the body while anticipating for further emergency help. CPR does not normally restart a person’s heart but when it is combined with early emergency help, early defibrillation, and early advanced hospital care, it can save many lives. Ribs may be broken during CPR but this is preferable to dying.

Basic Life Support (BLS)

  • Basic Life Support (BLS) is a specific level of prehospital, noninvasive emergency lifesaving medical care that attempts to give a person in cardiopulmonary arrest an open airway, adequate ventilation, and mechanical circulation (via chest compression) to the vital organs.
  • BLS includes recognition of signs of sudden cardiac arrest (SCA), heart attack, stroke, and foreign-body airway obstruction (FBAO); cardiopulmonary resuscitation (CPR); and defibrillation with an automated external defibrillator (AED).

Elements of Basic Life Support (BLS)

  • Maintain an open airway
  • Support the breathing
  • Support the circulation

Four Age Categories in Basic Life Support (BLS)

  • Newborn. First hour after birth until discharge from the hospital
  • Infant. Less than one year of age
  • Child. One to eight years of age
  • Adult. Age beyond that of a child

Procedures in Doing Cardiopulmonary Resuscitation (CPR)


Before Giving CPR

1. Check the scene and the person. Make sure the scene is safe, then tap the person on the shoulder and shout “Are you OK?” to ensure that the person needs help.
2. Call 911 for assistance. If it’s evident that the person needs help, call (or ask a bystander to call) 911, then send someone to get an AED. (If an AED is unavailable, or there is no bystander to access it, stay with the victim, call 911 and begin administering assistance.)
3. Open the airway. With the person lying on his or her back, tilt the head back slightly to lift the chin.
4. Check for breathing. Listen carefully, for no more than 10 seconds, for sounds of breathing. (Occasional gasping sounds do not equate to breathing.) If there is no breathing begin CPR.


CPR Steps according to Red Cross 

1. Push hard, push fast. Place your hands, one on top of the other, in the middle of the chest. Use your body weight to help you administer compressions that are at least 2 inches deep and delivered at a rate of at least 100 compressions per minute.
2. Deliver rescue breaths. With the person’s head tilted back slightly and the chin lifted, pinch the nose shut and place your mouth over the person’s mouth to make a complete seal. Blow into the person’s mouth to make the chest rise. Deliver two rescue breaths, then continue compressions.
Note: If the chest does not rise with the initial rescue breath, re-tilt the head before delivering the second breath. If the chest doesn’t rise with the second breath, the person may be choking. After each subsequent set of 30 chest compressions, and before attempting breaths, look for an object and, if seen, remove it.
3. Continue CPR steps. Keep performing cycles of chest compressions and breathing until the person exhibits signs of life, such as breathing, an AED becomes available, or EMS or a trained medical responder arrives on scene.

Note: End the cycles if the scene becomes unsafe or you cannot continue performing CPR due to exhaustion.

Automated External Defibrillation (AED)

  • Automated External Defibrillation (AED) is an equipment used to shock the heart with specialized electrical current in an attempt to stop the chaotic, disorganized contraction of the myocardial cells and allow them to start again in a synchronized fashion to restore a normal rhythmic heartbeat.
  • Indicated for pulseless patients and mostly for patients with ventricular fibrillation

Two Types of Machine

1. Monophasic. Monophasic AEDs are devices that emit a type of shock. It sends an electrical current in a single direction from an electrode on one side of the chest to an electrode on the other side.

2. Biphasic. Biphasic waveform defibrillators are devices that utilize bidirectional current flow as opposed to monophasic AED, where the current flows are in one direction.


While it’s important to know when to use a defibrillator, it’s just as important to know when not to use a defibrillator.

  • Patients with traumatic cardiac arrest. They have a window of about 10 minutes to be resuscitated. With each minute that goes by, their odds of survival decline by about 10%.
  • Children younger than one year of age
  • Absence of hospital protocols in defibrillating patients between the ages 1 and 7 years old or those who weigh less than 55 lbs (25 kg).

Advanced Cardiac Life Support (ACLS)

  • Advanced Cardiac Life Support (ACLS) involves lifesaving procedures, such as cardiac monitoring, administration of intravenous fluids and medications, and use of advanced airway adjuncts.

Criteria for Not Starting Cardiac Life Support

  • The patient has a valid Do Not Attempt Resuscitation (DNAR) Order
  • The patient has signs of irreversible death
  • No physiologic benefit can be expected because viral functions have deteriorated despite maximal therapy
  • Attempts to perform CPR would place the rescuer at risk of physical injury
  • Newborn: If gestation, birth weight, or congenital anomalies are associated with almost certain early death.

Terminating BLS in Out-of-Hospital Setting

  • Restoration of effective, spontaneous circulation and ventilation.
  • Care is transferred to a more senior-level emergency medical professional who may determine that the patient is unresponsive to the resuscitation attempt.
  • Presence of reliable criteria indicating irreversible death.
  • The rescuer is unable to continue because of exhaustion, or the presence of dangerous environmental hazards, or because continuation or resuscitative efforts places other lives in jeopardy.
  • A valid DNAR order is presented to rescuers.
  • There is a high degree of certainty that the patient will not respond to further ACLS.
  • Newborn: After 10 minutes without signs of life despite continuous and adequate resuscitation efforts.

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Gil Wayne graduated in 2008 with a bachelor of science in nursing. He earned his license to practice as a registered nurse during the same year. His drive for educating people stemmed from working as a community health nurse. He conducted first aid training and health seminars and workshops for teachers, community members, and local groups. Wanting to reach a bigger audience in teaching, he is now a writer and contributor for Nurseslabs since 2012 while working part-time as a nurse instructor. His goal is to expand his horizon in nursing-related topics. He wants to guide the next generation of nurses to achieve their goals and empower the nursing profession.


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