Download TNCC 9TH REAL EXAM ACTUAL VERIFIED EXAM TEST BANK 250 QUESTIONS AND ANSWERS VERIFIED ANSWE and more Exams Nursing in PDF only on Docsity!
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A 5-year old child presents to the ED with bruises to the upper arms and buttocks in various stages of healing and multiple small, clean, round burns to the back. There are no abnormalities found based on the pediatric assessment triangle or primary survey. Which of the following is the priority nursing intervention? Answer: A - ANSA) report your suspicion of the maltreatment in accordance with local regulations *** B) apply ice to the bruises and consult wound care C) engage in therapeutic communication to determine the MOI D) provide the family with injury prevention resourse A 20-year old male presents to the ED c/o severe lower abd pain after landing hard on the bicycle cross bars which performing an aerial BMX maneuver. Secondary assessment reveals lower abd tenderness and scrotal ecchymosis. Which of the following orders would the nurse questions? Answer: C - ANSA) Fast exam B) CT scan C) straight cath for urine sample *** D) ice and elevation of the scrotum A 35-year old male presents with facial trauma after bring struck inthe face with a baseball. a tear-drop shaped left pupil is noted on exam. What type of injury is suspected? Answer: B - ANSA) oculomotor nerve palsy B) globe rupture *** C) uncal herniation D) retinal detachment A 36-year old female has a deformity of the left wrist after a fall. She is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention? Answer: B - ANSA) apply a sling and elevate the extremity to the level of the heart. B) apply a splint and ELEVATE ABOVE THE LEVEL OF THE HEART *** C) Apply a sling and elevate the extremity above the level of the heart D) apply a splint and elevate the extremity to the level of the heart. A 49-year old restrained driver involved in a MVC presents to the trauma center c/o abd, pelvic, and bil lower extremity pain Vitals signs are stable. The nurse can
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anticipate all of these negative fast exam except which of the following?
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A patient arrives with a large open chest wound after being assault ed with a machete, Prehospital providers placed a nonporous dressing over the chest wound and tapes it
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on 3 sides. He is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis, and decreasing blood pressure. Which of the following is the MOST appropriate interventions? Answer: C - ANSA) needle decompression B) tube thoracostomy C) dressing removal ** D) surgical repair A patient has been in the ED for several hours waiting to be admitted. He sustained multiple rib fractures and a femur fracture after a fall. He has been awake, alert, and c/o leg pain. His wife reported suddenly becoming anxious and confused. Upon reassessment, the patient is restless, with respiratory distress and petechiae to his neck. the patient is exhibiting signs of symptoms commonly associated with which of the following conditions? Answer: B - ANSA) acute lung injury B) fat embolism *** C) PTX D) pulmonary contusion A patient is found lying on the floor after falling 13 hours ago. Which of the following lab values is expected with a musculoskeletal complication associated with this presentation? Answer: A - ANSA) elevated creatine kinase *** B) decreased potassium level C) decreased WBC D) elevated GFR A patient is thrown against a car during a tornado and presents with obvious bilateral femoral fractures. The patient is pale, alert, disoriented, and has delayed cap refill. Which of the following interventions would be most appropriate for this patient based on the disaster triage principle? Answer: A - ANSA) initiate two large caliber intravenous lines for Ringers lactate solution administration *** B) Administer Dilaudid for pain control and provide comfort care C) Place the patient in an observation area for care within the next few hours D) Contact the command center for the personnel to notify next of kin.
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Answer: D - ANSA) Bradycardia and ipsilateral absences of motor function B) Tachycardia and respiratory depression C) Tachycardia and absent motor function below the level of injury D) Bradycardia and absent motor function below the level of the injury *** A patient with lower extremity fracture complains of severe pain and tightness in his calf, minimally relieved by pain medications. Which of the following is the priority nursing intervention? Answer: C - ANSA) elevating the extremity above the level of the heart B) repositioning and apply ice C) Elevating the extremity to the level of the heart *** D) Preparing the patient for ultrasound A trauma patient is en route to a rural ED. Radiology notifies the charge nurse that the CT scanner will be out of service for several of hours. The team gathers to plan accordingly. Which of the following terms best describes this trauma teams communication? Answer: D - ANSA) Brief B) loop C) debrief D) huddle *** A trauma patient is restless and repeatedly asking "where am I?" vital signs upon arrival were BP 100/60 mm Hg, HR 96 beats/min, and RR 24 breaths/min. Her skin is cool and dry. Current vital signs are BP 104/84mm Hg, HR 108, RR 28 breaths/min. The patient is demonstrating signs and symptoms of which stage of shock? Answer: A - ANSA) compensated ** B) Progressive C) irreversible D) decompensated An elderly patient with a history of anticoagulant use presents after a fall at home that day. she denies any loss of consciousness. She has a hematoma to her forehead and complains of headache, dizziness, and nausea. Which is a most likely cause of her symptoms? Answer: D - ANSA) epidural hematoma
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B) diffuse axonal injury C) post-concussive syndrome
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cervical color removed. when is it appropriate to remove the cervical collar?
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Answer: A - ANSA) after a physical examination if the patient has no radiologic abnormalities on a computed tomography scan *** B) after physician evaluation if the patient has not neurologic abnormalities on exam C) after palpation of the spine if the patient has no point tenderness the the vertebral column D) after physical examination if the patient has not neck pain with movement EMS brings a patient who fell riding his bicycle. Using the American College of Surgeons screening guidelines, which assessment finding would prompt the nurse to prepare the patient for radiologic spine clearance? Answer: D - ANSA) Alert with no neurologic deficits B) Multiple abrasions to the extremities C) Multiple requests of water D) Smell of alcohol on breath *** Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of future disaster. Which phase of the disaster life cycle does this describe? Answer: A - ANSA) mitigation *** B) preparedness C) response D) recovery If a patient has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation? Answer: D - ANSA) potassium B) magnesium C) sodium D) calcium *** Patients with a crush injury should be monitored for which of the following conditions? Answer: C - ANSA) Hypernatremia B) Hypercalcemia C) Dysrhthmias ** D) polyuria
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B) subdural hematoma *** C) diffuse axonal injury D) intracerebral hematoma The most reassuring finding for a male patient with hop pain after a fall is which of the following? Answer: D - ANSA) a normal prostate exam B) absence of abdominal distension C) a normal fast exam D) pelvic stability *** The nurse is caring for a 120 kg male is brought in after a warehouse fire and is calculating the patient's fluid resuscitation needs. He has painful red blistering to the entire surface of both upper extremities and superficial burns to the anterior chest. Using the modified Lund and Browder chart to calculate the total BSA burned, how much IV fluids would be administered in the first 8 hours? (upper arm 4+4 / lower arm 3+3 / hand 2.5+2.5) = 19% TBSA. 120 kg x (2 mL) x (19% TBSA) = 4560 mL 4560 / 2 (half of fluids given in first 8 hours) = 2280 mL Answer: A - ANSA) 2280 mL *** B) 3840 mL C) 4560 mL D) 7680 mL The trauma nurse knows that placing a bariatric patients in a "ramped position" provides better visualization during the insertion of which device? Answer: C - ANSA) Intraosseous line B) orogastric tube C) ET tube *** D) urinary catheter What bedside monitoring parameters are used to assess for adequacy of oxygenation and effectiveness of ventilation? Answer: A - ANSA) pulse oximetry and capnogaphy **
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B) respiratory rate and capnography C) pulse oximetry and respiratory rate
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consistent with obstructive shock. Hypotension worsens with inspiration due to increased intrathoracic pressure. Late signs include distended neck veins, tracheal deviation, and cyanosis. - ANSA) increased work of breathing
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B) unilaterally diminished breath sounds C) pleuritic chest pain D) hypotension that worsens with inspiration *** Which of the following considerations is most important when caring for a geriatric trauma patient? Answer: B - ANSA) head to to exam B) medical history ** C) incontinence D) falls Which of the following injuries is LEAST likely to be promptly identified? Answer: C - ANSA) spleen B) lung C) bowel *** D) brain Which of the following is a component of the trauma triad of death? Answer: A hypothermia, metabolic acidosis, coagulopathy - ANSA) Acidosis ** B) hyperthermia C) hemorrhage D) sepsis Which of the following is a late sign of increased intracranial pressure? Answer: C Cushing Response Widening pulse pressure Reflex bradycardia Decreased RR - ANSA) Restlessness or drowsiness B) Nausea and vomiting C) Decreased respiratory effort** D) amnesia and anxiety Which of the following is an expected finding in a patient with a thoracostomy connected to a chest drainage system?
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Which of the following patients warrants referral to a burn center?
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Answer: C - ANSA) a 21- year old female with a partial thickness burn to the right forearm B) a 40-year old hypertensive male with a superficial burn to the back C) a 52-year old diabetic male with partial thickness burn to the left lower leg *** D) a 35-year old hyperlipidemic female with superficial burns to the anterior thorax. Which pulse pressure description is an indication of early hypovolemic shock? Answer: B - ANSA) widened B) narrowed *** C) bounding D) weak Why is a measure of serum lactate obtained in the initial assessment of the trauma patient? Answer: c - ANSa) to measure oxygenation and ventilation b) to quantify the base deficit for the adequacy of cellular perfusion c) *to gauge end-organ perfusion and tissue hypoxia ** d) to determine the underlying cause of shock You are caring for a patient who was involved in a MVA and is 32 weeks pregnant. Findings of your secondary survey include abd pain on palpation, fundal high at the costal margin, and some dark bloody show. Varying, accelerations and decelerations are noted on the cardiotocography. These findings are most consistent with which of the following? Answer: A - ANSA) placental abruption *** B) preterm labor C) uterine rupture D) fetal demise You are treating a 27-year old male in respiratory distress who was involved in a house fire. Calculating TBSA burned is deferred d/t the need for emergent intubation. At what rate should you begin fluid resuscitation? Answer: B - ANSA) 1000 mL/hr B) 500 mL/hr *** C) 250 mL/hr D) 125 mL/hr A 5-year old child presents to the ED with bruises to the upper arms and buttocks in various stages of healing and multiple small, clean, round burns
