Background: Emergency departments (EDs) face rising patient volumes and delays, which stimulate interest in expanding nurses’ roles through initiatives like nurse-initiated X-ray (NIXR) protocols. These models aim to reduce wait times and improve efficiency without compromising diagnostic accuracy or patient safety. We aimed to systematically evaluate the clinical effectiveness, diagnostic accuracy, workflow efficiency, safety, and satisfaction associated with nurse-initiated X-ray protocols in ED settings. Methods: This review followed PRISMA guidelines. A comprehensive search of PubMed, Scopus, Web of Science, and CINAHL was conducted using terms related to nurse-initiated radiography, the Ottawa Ankle Rules (OAR), and ED imaging. Studies were eligible if they evaluated nurse-led X-ray protocols in patients with isolated limb trauma. Five studies met the inclusion criteria, including randomized controlled trials and observational designs. Outcomes included diagnostic accuracy, emergency department length of stay (LOS), imaging rates, and satisfaction. Results: All five studies show that nurse-initiated use of OAR reduced unnecessary imaging without compromising fracture detection. LOS reduced in several studies, with improvements ranging from 20 to 26 minutes. Diagnostic accuracy was comparable or superior to physician-led imaging, and patient and staff satisfaction were high. Despite variations in implementation models and training standards, NIXR was shown to be safe and effective. Conclusion: Nurse-initiated X ray protocols enhance ED efficiency, reduce unnecessary imaging, and maintain diagnostic accuracy when supported by structured training and decision tools such as OAR. Wider adoption requires standardized policies and interdisciplinary collaboration to ensure safe, effective practice.