Relias ED RN A Actual Exam 2026/2027 |
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Graded
Triage, Initial Assessment & Acuity
Q1: Using the Emergency Severity Index (ESI), which patient description meets the
criteria for ESI Level 1 (requires immediate life-saving intervention)?
A. A 65-year-old with chest pain and diaphoresis.
B. A 20-year-old with a simple forearm laceration.
C. A 40-year-old who is unresponsive, apneic, and pulseless.
D. An 8-year-old with a fever of 102°F and a sore throat.
Correct Answer: C
Rationale: The best answer is C because ESI Level 1 is reserved for patients who are
unresponsive, apneic, or in cardiac or respiratory arrest requiring immediate intervention
like CPR or intubation, whereas the other conditions, while serious, are not immediately
dying.
Q2: You are triaging a patient who presents with acute onset of severe right upper
quadrant pain, fever, and jaundice. The patient is diaphoretic and vomiting. To which
ESI level should this patient be assigned?
A. ESI Level 2 (High-risk situation)
B. ESI Level 3 (Needs 2 or more resources)
C. ESI Level 4 (Needs 1 resource)
D. ESI Level 5 (No resources needed)
Correct Answer: A
Rationale: This choice is correct because the patient is exhibiting signs of possible
cholangitis or severe gallbladder disease, which is considered a high-risk situation that
could rapidly deteriorate, requiring immediate physician evaluation regardless of the
number of resources.
Q3: A 32-year-old female presents to triage with a complaint of "the worst headache of
my life" that started suddenly 20 minutes ago. Her vital signs are stable. What is the
most appropriate triage action?
A. Assign ESI Level 4 and have her wait in the lobby.
B. Assign ESI Level 5 and advise her to see her PCP.
,C. Assign ESI Level 2 and send her immediately to the treatment area for a CT scan.
D. Assign ESI Level 3 and place her in a room to wait for the physician.
Correct Answer: C
Rationale: In the ED, our priority is recognizing life threats like a subarachnoid
hemorrhage; sudden severe "thunderclap" headache is a high-risk red flag that requires
immediate diagnostic workup (Level 2) even if vital signs are currently stable.
Q4: During the primary survey of a trauma patient, you note the patient is breathing but
has tracheal deviation to the left and absent breath sounds on the right. What
intervention should you prepare for immediately?
A. Chest tube insertion
B. Intubation
C. Pericardiocentesis
D. Fluid bolus
Correct Answer: A
Rationale: This choice is correct because these classic signs indicate a tension
pneumothorax, which is a life-threatening air trapping issue requiring immediate
decompression, typically via needle thoracostomy followed by chest tube insertion.
Q5: (ESI Triage Scenario) You are triaging three patients simultaneously. Patient A is a
78-year-old with sudden confusion and atrial fibrillation (HR 140). Patient B is a
25-year-old with a 2cm laceration on the chin requiring sutures. Patient C is a
50-year-old with flank pain and hematuria. Who is the highest priority for immediate
medical evaluation?
A. Patient A (ESI Level 2)
B. Patient B (ESI Level 4)
C. Patient C (ESI Level 3)
D. Patient B because he is bleeding.
Correct Answer: A
Rationale: The best answer is A because new-onset confusion in an elderly patient with
tachycardia suggests a potential stroke, sepsis, or cardiac crisis, which is a high-risk
situation (Level 2), whereas the others are stable urgent or non-urgent patients.
Q6: A patient presents with a chemical burn to the eye from an alkaline substance.
What is the priority nursing intervention in triage?
A. Patch the eye and prepare for transfer.
B. Apply antibiotic ointment.
C. Irrigate the eye copiously with water or saline for at least 15-30 minutes.
D. Assess visual acuity.
Correct Answer: C
, Rationale: This choice is correct because alkaline burns penetrate deeply and cause
rapid damage; the immediate priority is dilution and removal of the chemical through
copious irrigation, which should not be delayed for other assessments.
Q7: When assessing a pediatric patient in triage, you notice that the child is lethargic,
has weak pulses, and capillary refill >4 seconds. How should this child be triaged using
the ESI system?
A. ESI Level 2
B. ESI Level 3
C. ESI Level 1
D. ESI Level 4
Correct Answer: C
Rationale: This aligns with emergency nursing standards because signs of shock
(lethargy, weak pulses, delayed capillary refill) indicate an immediate life threat requiring
aggressive resuscitation, which defines an ESI Level 1 patient.
Q8: A patient arrives via EMS with a gunshot wound to the abdomen. He is responsive
but pale and diaphoretic. Blood pressure is 90/palpable. What is the most appropriate
initial nursing action?
A. Initiate a 18-gauge IV and begin a rapid fluid bolus.
B. Wait for the trauma surgeon to arrive.
C. Obtain a full set of vital signs and a urine sample.
D. Prepare the patient for a CT scan.
Correct Answer: A
Rationale: The best answer is A because this patient is likely in hypovolemic shock;
immediate access with large-bore IVs and fluid resuscitation is the priority intervention
to maintain perfusion while awaiting definitive care.
Q9: A patient presents with suicidal ideation but has a specific plan and means to carry
it out. They are currently calm but refuse to promise safety. Which disposition is most
appropriate?
A. Discharge with a list of counselors.
B. Observe in the lobby until seen.
C. Place in a safe room and assign a 1:1 observer (sitter).
D. Send for chest X-ray and discharge.
Correct Answer: C
Rationale: This choice is correct because a patient with high intent, a plan, and means
is an immediate safety risk; constant observation (1:1 sitter) is required to prevent
self-harm while psychiatric evaluation is arranged.
Complete Test Updated | 100% Correct and
Verified Answers | Pass Guaranteed - A+
Graded
Triage, Initial Assessment & Acuity
Q1: Using the Emergency Severity Index (ESI), which patient description meets the
criteria for ESI Level 1 (requires immediate life-saving intervention)?
A. A 65-year-old with chest pain and diaphoresis.
B. A 20-year-old with a simple forearm laceration.
C. A 40-year-old who is unresponsive, apneic, and pulseless.
D. An 8-year-old with a fever of 102°F and a sore throat.
Correct Answer: C
Rationale: The best answer is C because ESI Level 1 is reserved for patients who are
unresponsive, apneic, or in cardiac or respiratory arrest requiring immediate intervention
like CPR or intubation, whereas the other conditions, while serious, are not immediately
dying.
Q2: You are triaging a patient who presents with acute onset of severe right upper
quadrant pain, fever, and jaundice. The patient is diaphoretic and vomiting. To which
ESI level should this patient be assigned?
A. ESI Level 2 (High-risk situation)
B. ESI Level 3 (Needs 2 or more resources)
C. ESI Level 4 (Needs 1 resource)
D. ESI Level 5 (No resources needed)
Correct Answer: A
Rationale: This choice is correct because the patient is exhibiting signs of possible
cholangitis or severe gallbladder disease, which is considered a high-risk situation that
could rapidly deteriorate, requiring immediate physician evaluation regardless of the
number of resources.
Q3: A 32-year-old female presents to triage with a complaint of "the worst headache of
my life" that started suddenly 20 minutes ago. Her vital signs are stable. What is the
most appropriate triage action?
A. Assign ESI Level 4 and have her wait in the lobby.
B. Assign ESI Level 5 and advise her to see her PCP.
,C. Assign ESI Level 2 and send her immediately to the treatment area for a CT scan.
D. Assign ESI Level 3 and place her in a room to wait for the physician.
Correct Answer: C
Rationale: In the ED, our priority is recognizing life threats like a subarachnoid
hemorrhage; sudden severe "thunderclap" headache is a high-risk red flag that requires
immediate diagnostic workup (Level 2) even if vital signs are currently stable.
Q4: During the primary survey of a trauma patient, you note the patient is breathing but
has tracheal deviation to the left and absent breath sounds on the right. What
intervention should you prepare for immediately?
A. Chest tube insertion
B. Intubation
C. Pericardiocentesis
D. Fluid bolus
Correct Answer: A
Rationale: This choice is correct because these classic signs indicate a tension
pneumothorax, which is a life-threatening air trapping issue requiring immediate
decompression, typically via needle thoracostomy followed by chest tube insertion.
Q5: (ESI Triage Scenario) You are triaging three patients simultaneously. Patient A is a
78-year-old with sudden confusion and atrial fibrillation (HR 140). Patient B is a
25-year-old with a 2cm laceration on the chin requiring sutures. Patient C is a
50-year-old with flank pain and hematuria. Who is the highest priority for immediate
medical evaluation?
A. Patient A (ESI Level 2)
B. Patient B (ESI Level 4)
C. Patient C (ESI Level 3)
D. Patient B because he is bleeding.
Correct Answer: A
Rationale: The best answer is A because new-onset confusion in an elderly patient with
tachycardia suggests a potential stroke, sepsis, or cardiac crisis, which is a high-risk
situation (Level 2), whereas the others are stable urgent or non-urgent patients.
Q6: A patient presents with a chemical burn to the eye from an alkaline substance.
What is the priority nursing intervention in triage?
A. Patch the eye and prepare for transfer.
B. Apply antibiotic ointment.
C. Irrigate the eye copiously with water or saline for at least 15-30 minutes.
D. Assess visual acuity.
Correct Answer: C
, Rationale: This choice is correct because alkaline burns penetrate deeply and cause
rapid damage; the immediate priority is dilution and removal of the chemical through
copious irrigation, which should not be delayed for other assessments.
Q7: When assessing a pediatric patient in triage, you notice that the child is lethargic,
has weak pulses, and capillary refill >4 seconds. How should this child be triaged using
the ESI system?
A. ESI Level 2
B. ESI Level 3
C. ESI Level 1
D. ESI Level 4
Correct Answer: C
Rationale: This aligns with emergency nursing standards because signs of shock
(lethargy, weak pulses, delayed capillary refill) indicate an immediate life threat requiring
aggressive resuscitation, which defines an ESI Level 1 patient.
Q8: A patient arrives via EMS with a gunshot wound to the abdomen. He is responsive
but pale and diaphoretic. Blood pressure is 90/palpable. What is the most appropriate
initial nursing action?
A. Initiate a 18-gauge IV and begin a rapid fluid bolus.
B. Wait for the trauma surgeon to arrive.
C. Obtain a full set of vital signs and a urine sample.
D. Prepare the patient for a CT scan.
Correct Answer: A
Rationale: The best answer is A because this patient is likely in hypovolemic shock;
immediate access with large-bore IVs and fluid resuscitation is the priority intervention
to maintain perfusion while awaiting definitive care.
Q9: A patient presents with suicidal ideation but has a specific plan and means to carry
it out. They are currently calm but refuse to promise safety. Which disposition is most
appropriate?
A. Discharge with a list of counselors.
B. Observe in the lobby until seen.
C. Place in a safe room and assign a 1:1 observer (sitter).
D. Send for chest X-ray and discharge.
Correct Answer: C
Rationale: This choice is correct because a patient with high intent, a plan, and means
is an immediate safety risk; constant observation (1:1 sitter) is required to prevent
self-harm while psychiatric evaluation is arranged.
