TNCC Exam 8th edition study.pdf | Exams Nursing

TNCC Exam 8th edition study

.A 35-year-old male presents with facial trauma after being struck in the face with a

baseball. A teardrop-shaped left pupil is noted on exam. What type of injury is

suspected? - ansGlobe rupture A teardrop-shaped pupil suggests a globe rupture.

.A patient with a complete spinal cord injury in neurogenic shock will demonstrate

hypotension and which other clinical signs? - ansBradycardia and absent motor function

below the level of injury Patients with a complete spinal cord injury will have absent

motor function below the level of the lesion. They become hypotensive and bradycardic

due to loss of autonomic nervous system function.

.During the primary survey of an unconscious patient with multi-system trauma, the

nurse notes snoring respirations. What priority nursing intervention should be performed

next? - ansInsert an oropharyngeal airway if there is no gag reflex Snoring respirations

may indicate airway obstruction from the tongue. Insert an airway adjunct to alleviate

obstruction by the tongue. Oropharyngeal airways can be used in patients without a gag

reflex.

1.What is the effect of hypothermia on the oxyhemoglobin dissociation curve -

ansHemoglobin does not readily release oxygen for use by the tissues A shift to the left

occurs in an environment of low metabolic demand (hypothermia, hypocapnia,

alkalosis), increasing hemoglobin's affinity for oxygen.

A 20-year-old male presents to the ED complaining of severe lower abdominal pain

after landing hard on the bicycle cross bars while performing an aerial BMX maneuver.

Secondary assessment reveals lower abdominal tenderness and scrotal ecchymosis.

Which of the following orders would the nurse question? - ansStraight catheter for urine

sample Insertion of a urinary catheter is contraindicated if urethral transection is

suspected. Signs and symptoms of urethral injury include blood at the meatus, perineal

ecchymosis, scrotal ecchymosis, and a high-riding or non-palpable prostate.

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?

- ansApply a splint and elevate the extremity above the level of the heart Splinting the

injured extremity stabilizes the extremity and reduces further injury. Elevation above the

level of the heart promotes venous return and may reduce swelling.

A 49-year-old restrained driver involved in a motor vehicle collision presents to the

trauma center complaining of abdominal, pelvic, and bilateral lower extremity pain. Vital

signs are stable. The nurse can anticipate all of these after a negative FAST exam

EXCEPT which of the following? - ansDiagnostic peritoneal lavage Diagnostic

peritoneal lavage is indicated for hemodynamically unstable patients or if FAST and CT

are not available.

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.

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.A 35 - year-old male presents with facial trauma after being struck in the face with a baseball. A teardrop-shaped left pupil is noted on exam. What type of injury is suspected? - ansGlobe rupture A teardrop-shaped pupil suggests a globe rupture. .A patient with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? - ansBradycardia and absent motor function below the level of injury Patients with a complete spinal cord injury will have absent motor function below the level of the lesion. They become hypotensive and bradycardic due to loss of autonomic nervous system function. .During the primary survey of an unconscious patient with multi-system trauma, the nurse notes snoring respirations. What priority nursing intervention should be performed next? - ansInsert an oropharyngeal airway if there is no gag reflex Snoring respirations may indicate airway obstruction from the tongue. Insert an airway adjunct to alleviate obstruction by the tongue. Oropharyngeal airways can be used in patients without a gag reflex. 1.What is the effect of hypothermia on the oxyhemoglobin dissociation curve - ansHemoglobin does not readily release oxygen for use by the tissues A shift to the left occurs in an environment of low metabolic demand (hypothermia, hypocapnia, alkalosis), increasing hemoglobin's affinity for oxygen. A 20-year-old male presents to the ED complaining of severe lower abdominal pain after landing hard on the bicycle cross bars while performing an aerial BMX maneuver. Secondary assessment reveals lower abdominal tenderness and scrotal ecchymosis. Which of the following orders would the nurse question? - ansStraight catheter for urine sample Insertion of a urinary catheter is contraindicated if urethral transection is suspected. Signs and symptoms of urethral injury include blood at the meatus, perineal ecchymosis, scrotal ecchymosis, and a high-riding or non-palpable prostate. 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?

ansApply a splint and elevate the extremity above the level of the heart Splinting the injured extremity stabilizes the extremity and reduces further injury. Elevation above the level of the heart promotes venous return and may reduce swelling. A 49-year-old restrained driver involved in a motor vehicle collision presents to the trauma center complaining of abdominal, pelvic, and bilateral lower extremity pain. Vital signs are stable. The nurse can anticipate all of these after a negative FAST exam EXCEPT which of the following? - ansDiagnostic peritoneal lavage Diagnostic peritoneal lavage is indicated for hemodynamically unstable patients or if FAST and CT are not available. 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? - ansReport your suspicion of maltreatment in accordance with local regulations Nurses are mandated reporters in most jurisdictions. With no alterations in the primary survey, this is the priority intervention. A 56-year-old male patient involved in a motor vehicle crash is brought to the emergency department of a rural critical access facility. He complains of neck pain, shortness of breath, and diffuse abdominal pain. His Glasgow Coma Score is 15. His vital signs are as follows: BP 98/71 mm Hg, HR 125 beats/minute, RR 26 breaths/minute, SpO2 94% on high-flow oxygen via non-rebreather mask. Which of the following is the priority intervention for this patient? - ansExpedite transfer to the closest trauma center The American College of Surgeons recommends that patients with significant injuries be transported to a trauma center for definitive care. This patient's injuries might not be definitively diagnosed, but his symptoms and vital signs indicate the need for A patient arrives with a large open chest wound after being assaulted with a machete. Prehospital providers placed a nonporous dressing over the chest wound and taped it on three 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 immediate intervention? - ansDressing removal This is the fastest effective intervention for this decompensating patient. A nonporous dressing taped on three sides is temporary and has variable effectiveness. If signs and symptoms of tension pneumothorax develop after the application of the dressing A patient has been in the emergency department 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 complaining of leg pain. His wife reported that he suddenly became anxious and confused. Upon reassessment, the patient is restless with respiratory distress and petechiae to his neck. The patient is exhibiting signs and symptoms most commonly associated with which of the following conditions? - ansFat embolism Symptoms of fat embolism include decreased mental status, restlessness, agitation, respiratory distress, and a petechial rash to the head, neck, anterior thorax, conjunctivae, buccal mucous membranes, and axillae. A patient is brought to the emergency department of a rural hospital following a high- speed motor vehicle collision. When significant abdominal and pelvic injuries are noted in the primary survey, which of the following is the priority intervention? - ansInitiate transfer to a trauma center Early consideration for transfer to a trauma center is essential to ensure optimal outcomes. A patient with a 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? - ansElevating the extremity to the level of the heart Elevating the extremity higher than the heart can reduce circulation and tissue perfusion if compartment syndrome is suspected.

EMS brings a patient from a motor vehicle crash. Vital signs are BP 90/49 mm Hg, heart rate 48 beats/minute, respiratory rate 12 breaths/minute, temperature 97.2°F (36.2° C). The patient exhibits urinary incontinence and priapism. These assessment findings are most consistent with which of the following types of spinal cord injury? - ansComplete Incontinence, priapism, and hypotension with bradycardia are manifestations of a complete spinal cord injury. EMS brings a patient who fell while 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? - ansSmell of alcohol on breath Suspected intoxication warrants radiologic spine clearance. If a patient has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation? - ansCalcium Hypocalcemia is a concern with massive transfusion because citrate is added to banked blood to prevent coagulation. Citrate chelates (binds with) calcium, rendering it inactive. Tearing of the bridging veins is most frequently associated with which brain injury? - ansSubdural hematoma Subdural hematomas are usually caused by tearing of the bridging veins and associated with direct injury to the underlying brain tissue. The most reassuring finding for a male patient with hip pain after a fall is which of the following? - ansPelvic stability Uncontrolled hemorrhage is the major cause of preventable death after injury. Unstable pelvic fractures increase the volume of the pelvic cavity and can be life-threatening due to blood loss. The nurse is assessing a patient with a fractured forearm that was splinted three hours ago. Which symptom is of most concern as a late sign of an evolving complication? - ansWeak radial pulse A weak radial pulse is evidence of an actual compromise in circulation. The nurse is caring for a 120 kg male 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 body surface area burned, how much IV fluid would be administered in the first 8 hours? - ans2280 mL Both upper arms = 8%, both lower arms = 6%, and both hands = 5%, yielding 19 * 2 * 120 = 4560 mL. Half of the total is equal to 2280 mL. Superficial burns are not included in the TBSA calculation for fluid resuscitation. The trauma nurse knows that placing a bariatric patient in a "ramped position" provides better visualization during the insertion of which device? - ansEndotracheal tube The ramped position is described as elevation of the head with the external auditory canal parallel with the sternal notch to provide better visualization of pharyngeal landmarks. This position is useful during intubation.

There has been a mass casualty incident a block from the hospital. The hospital is receiving dozens of patients. A truck arrives with an unresponsive patient in the back with obvious chest and abdominal trauma. Agonal respirations do not improve with airway positioning. Using the START triage algorithm, you would triage tag this patient as which of the following? - ansBlack This patient is unlikely to survive given the severity of their injuries and is triaged as expectant. Resources should be reserved for individuals considered to be more salvageable. What bedside monitoring parameters are used to assess for adequacy of oxygenation and effectiveness of ventilation? - ansPulse oximetry and capnography Pulse oximetry measures the percentage of hemoglobin saturated with oxygen. Capnography measures the amount of carbon dioxide exhaled. Carbon dioxide is the end-product of ventilation and a reflection of metabolism and pulmonary function. What factor contributes most to the kinetic energy of a body in motion? - ansVelocity Kinetic energy is equal to one half the mass multiplied by the square of the velocity. Doubling the velocity quadruples its contribution to kinetic energy. Doubling the mass only doubles its contribution to kinetic energy. What physiologic change in the elderly population increases the risk of traumatic injury?

ansDecreased subcutaneous fat Decreased subcutaneous fat and thinning of the skin increases the risk of injuries from soft tissue trauma and increases the risk of hypothermia When is the tertiary survey completed for a trauma patient? - ansWithin 24 hours of the trauma The tertiary survey consists of a complete examination performed following the primary and secondary surveys and within 24 hours after trauma to identify any injuries missed during the initial assessment. Which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax? - ansHypotension that worsens with inspiration Hypotension that worsens with inspiration is associated with tension pneumothorax due to compression of the heart and great vessels (obstructive shock). The increased intrathoracic pressure with inspiration worsens the hypotension. Which of the following injuries is LEAST likely to be promptly identified? - ansBowel Hollow organ injury signs and symptoms may be subtle and delayed but are associated with a high mortality rate if not identified. Which of the following is a component of the trauma triad of death? - ansAcidosis The three components of the trauma triad of death are acidosis, hypothermia and coagulopathy. Which of the following is a late sign of increased intracranial pressure? - ansDecreased respiratory effort Other late signs of increased intracranial pressure include dilated,

Which of the following pulse pressures indicate early hypovolemic shock? - ansNarrowed A rising diastolic blood pressure, reflecting peripheral vasoconstriction, results in a narrowed pulse pressure. Why is a measure of serum lactate obtained in the initial assessment of a trauma patient? - ansTo gauge end-organ perfusion and tissue hypoxia The serum lactate is an indicator of end-organ tissue perfusion and tissue hypoxia. You are caring for a patient who was involved in a motor vehicle crash and is 32 weeks pregnant. Findings of your secondary survey include abdominal pain on palpation, fundal height at the costal margin, and some dark bloody show. Varying accelerations and decelerations are noted on cardiotocography. These findings are most consistent with which of the following? - ansPlacental abruption The findings of abdominal pain, elevated fundal height, dark bloody show, and fetal distress are most consistent with placental abruption. You are treating a 27-year-old male in respiratory distress who was involved in a house fire. Calculating total body surface area (TBSA) burned is deferred due to the need for emergent intubation. At what rate should you begin fluid resuscitation? - ans mL/hour Prior to calculating TBSA, this is the recommended starting point for fluid resuscitation for patients 14 years of age and OLDER

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