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" TNCC 10TH EDITION EXAM 3 LATEST VERSIONS
(VERSION A & B) COMPLETE 200 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
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Breathing and Ventilation" - ansDuring which part of the primary survey would you anticipate the need for a chest tube, intubation, decompression of pneumothorax, oxygen, or BVMs?
- attach CO2 detector and assess for evidence of exhaled CO2; 2. observe for rise and fall of the chest w/ assisted ventilations; 3. auscultate over epigastrium for gurgling AND lungs for bilateral breath sounds - ansWhat three assessments must be done if the patient is intubated?
- inspect AND palpate skin color, temp, moisture and 2. palpate a pulse - ansTo assess circulation, you must do these two main tasks: A.Alert with no neurologic deficits - ansUsing the American College of Surgeons screening guidelines, what assessment finding would prompt the nurse to prepare a patient for cervical spine imaging? A.Alert with no neurologic deficits B.Multiple abrasions to the extremities C.Ecchymosis to the flank D.Responds to verbal stimulation A.Cardiogenic - ansA patient is brought to the emergency department with chest pain and shortness of breath following a high-speed motor vehicle collision in which they were the unrestrained driver. There is crepitus to the left chest with clear and equal breath sounds. The vital signs are BP 80/40 mmHg, HR 140 beats/minute, and RR 40 breaths/minute. Cardiac monitor shows sinus tachycardia with premature ventricular contractions. These findings are most consistent with which type of shock? A.Cardiogenic B.Neurogenic C.Hypovolemic D.Obstructive
A.Decrease the rate of manual ventilation. - ansAn adult patient who sustained a severe head trauma has been intubated and is being manually ventilated via a bag-mask device at a rate of 18 breaths/minute. The patient has received one intravenous fluid bolus of 500 mL of warmed isotonic crystalloid solution. The PaCO2 is 30 mm Hg (4.0 kPa), and the pulse oximetry is 92%. BP is 142/70 mm Hg. What is the most important intervention to manage the cerebral blood flow? A.Decrease the rate of manual ventilation. B.Initiate another fluid bolus. C.Recheck endotracheal tube placement. D.Increase the amount of oxygen delivered. A.Initiate warming measures - ansA patient is brought to the emergency department following a snowmobile crash with prolonged exposure time prior to transport. The patient is confused. Vital signs are BP 96/54 mm Hg, HR 114 beats/minute, RR 24 breaths/minute, T 34.6oC (94.2oF) and an SpO2 of 90% on oxygen at 15L per non- rebreather mask. Other findings include ETCO2 24, serum lactate of 6 mmol/L, and a pH of 6.8. Based on these findings, what is the most appropriate intervention? A.Initiate warming measures B.Titrate oxygen to 6 L per nasal cannula C.Bolus with 500 mL isotonic crystalloids D.Vigorously massage the extremities A.Report your suspicion of maltreatment in accordance with local regulations - ansA 5- year-old child presents to the emergency department 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? A.Report your suspicion of maltreatment in accordance with local regulations B.Apply ice to the bruises and provide wound care C.Engage in therapeutic communication to determine the mechanism of injury D.Provide the family with injury prevention resources A.Reverse Trendelenburg - ansWhat position optimizes ventilation in the obese patient with a lumbar fracture? A.Reverse
assess ETT position by noting the number at teeth/gums AND secure ETT - ansIf the patient is intubated and you've already assessed ETT placement, what else needs to be done with the ETT? (step 10) Assessing patency and protection of the airway, Step 7 of "Alertness and Airway with Simultaneous Cervical Spinal Stabilization" - ansDuring which part of the primary survey would there be anticipation for intubation, insertion of OPA/NPA, removal of any loose teeth or foreign objects, or suctioning? B. Rising diastolic - ansWhich blood pressure finding is associated with early or compensated hypovolemic shock? A.Rising systolic B.Rising diastolic C.Decreasing diastolic D.Decreasing systolic B.A 2-year-old lands on grass from a second-story balcony - ansBased on fall mechanism, which patient warrants prehospital transfer to a trauma center? A.A 35-year-old lands on a wooden porch from an 8-foot ladder B.A 2-year-old lands on grass from a second-story balcony C.A 14-year-old forcefully pushed onto cement from standing D.A 50-year-old lands on a carpeted floor after tripping B.Amputation of a limb - ansWhich of the following situations could cause functional grief? A.Inability to live at home B.Amputation of a limb C.Loss of one's self-image D.Destruction of the patient's car B.Control the bleeding - ansAn unconscious patient arrives following a motor vehicle collision. The patient is on a backboard with a cervical collar in place and one intravenous line running. Respirations are shallow and there is active brisk bleeding from a large leg wound. What is the priority intervention for this patient? A.Check for a patent airway B.Control the bleeding C.Start a second intravenous line
D.Ventilate with a bag-mask device B.During the secondary surveyt - ansWhen should the definitive calculation for intravenous fluid resuscitation rate be performed for a patient with burns? A.As soon as the patient arrives
B.Medical history including current medications - ansWhat is the most important consideration during the initial assessment when caring for an older adult who has sustained serious injuries? A.They are likely to be fearful in the emergency department B.Medical history including current medications C.Availability of support systems after discharge
D.Accessibility to a primary care physician B.Notify the provider of the change - ansYour patient is a pedestrian struck by a car and thrown 35 feet. They were unconscious at the scene but became responsive with initial and subsequent Glasgow Coma Scale (GCS) scores of 13 (E- 3, V-4, M-6). The patient has bilateral subdural hematomas and is awaiting transfer to the ICU. Your next assessment reveals a GCS of 9 (E-2, V-2, M-5). What is the priority nursing intervention? A.Hold all pain medications B.Notify the provider of the change C.Repeat the GCS in 30 minutes D.Place the patient in Trendelenburg position blankets, room temp increase, warmed fluids, warming lights - ansIn Step 16 of "Exposure and Environment", you must name at least one of these interventions: bony deformity, loose teeth, edema, inhalation injury, sounds, tongue obstruction, burns, fluids, foreign objects, vocalization - ansFour of these must be identified to assess patency and protection of the airway: Bowel sounds heard in the left lower chest - ansA patient involved in a high- speed rollover is complaining of increased difficulty breathing. There is a small penetrating wound to the sixth intercostal space in the left lateral chest. Which finding is most consistent with an injury to the diaphragm? A.Severe left-sided abdominal pain B.Bowel sounds heard in the left lower chest C.Pain radiating to the left shoulder. D.Decreased breath sounds on the left side Breath sounds, depth/pattern/rate, spontaneous breathing, subcutaneous emphysema, increased work of breathing, symmetrical chest rise and fall, tracheal deviation/JVD, open wounds/deformities, skin color - ansFour of these must be identified to assess breathing effectiveness: C.3240 mL - ansA patient who weighs 120 kg is brought to the emergency department after sustaining partial thickness burns to both upper extremities and chest with a total body surface area burned of 27%. How much intravenous fluid should be administered in the first 8 hours? A. mL
C.Allowing family to participate in the care of the patient - ansWhile caring for a child who has been injured, what nursing intervention is consistent with a family- center approach? A.Identifying a single family member to speak with B.Having the family make all the care decisions C.Allowing family to participate in the care of the patient D.Limiting dissemination of complex information C.Apply direct pressure to the wound - ansA patient has uncontrolled bleeding from a wound to his right upper extremity. What is the priority intervention? A.Initiate two intravenous access sites B.Place the patient on supplemental oxygen C.Apply direct pressure to the wound D.Use a tourniquet to control the bleeding C.Decreased body temperature - ansA severely injured patient has been intubated and is being mechanically ventilated. The patient has received a balanced resuscitation including multiple blood products. Under which circumstance will it be harder for the hemoglobin to release oxygen to the tissues? A.Decreased pH B.Elevated carbon dioxide level C.Decreased body temperature D.Increased metabolic demand C.Decreased respiratory effort - ansWhich of the following is a late sign of increased intracranial pressure? A.Restlessness B.Vomiting C.Decreased respiratory effort D.Narrowing pulse pressure C.Disseminated intravascular coagulopathy - ansA trauma patient is being held in the emergency department because there are no available inpatient beds. The patient sustained a femur fracture and required multiple blood products. The patient now has blood oozing from abrasions, IV sites, the nose, and gums. What condition is most consistent with these findings?
A. Rhabdomyolysi s B.Fat embolism C.Disseminated intravascular coagulopathy D.Multiple organ dysfunctions syndrome
D.Determines the underlying cause of shock C.Increasing work of breathing - ansThe trauma nurse is caring for an unrestrained driver who struck their head on the windshield following a high- speed MVC. The patient has been diagnosed with an anterior spinal cord injury at the level of C6. Which assessment finding would be most concerning? A.Distension of the bladder
B. Incontinence of stool C.Increasing work of breathing D.Inability to move the legs C. Inotropic support - ansA driver involved in a high-speed motor vehicle collision arrives in the emergency department. The vehicle's air-bag failed to deploy. The patient is drowsy but arousable and complaining of chest pain with ecchymosis noted to the chest. The patient is tachycardic and hypotensive with no evidence of uncontrolled bleeding. Cardiac monitor shows premature ventricular contractions. Which of the following is the most appropriate intervention for this patient? A.Rapid fluid boluses B.Tranexamic acid administration C.Inotropic support D.Hemostatic resuscitation C.Liver - ansYour patient was the unrestrained driver involved in a moderate speed motor vehicle collision. Assessment reveals tenderness in the upper right quadrant, crepitus in the lower right ribs, and ecchymosis around the umbilicus. The nurse is concerned about injury to which organ? A.Transverse colon B.Pancreas C.Liver D.Spleen C.Ramped - ansAn obese trauma patient requires intubation. Assuming there are no contraindications, which position will provide the best visualization for insertion of the endotracheal tube? A.Reverse Trendelenburg B.Lying on side C.Ramped D.Supine C.Tertiary - ansAn adult was thrown against a concrete wall during a factory explosion and sustained a femur fracture, liver laceration, and a small subdural hematoma. These injuries most likely occurred during what level of blast trauma? A.Primary
arrival, the patient is only responsive to pain, has bleeding from the nose, and multiple abrasions and contusions to the face. What is the priority intervention? A.Use a bulb syringe to suction out secretions from the mouth. B.Insert a nasopharyngeal airway to maintain an open airway. C.Use a jaw thrust to open the airway and look for signs of obstruction. D.Ask the patient to open their mouth to inspect the airway. cardiac monitor - ansWhat can be applied in step 12 of "Circulation and Control of Hemorrhage" for which credit is given in the LMNOP section? D.Assist ventilation with a bag-mask device - ansFollowing a gun shot wound, pre- hospital providers report diminished breath sounds bilaterally. Upon emergency department arrival, the patient is unresponsive with shallow respirations and an O2 sat of 88%. What is the priority intervention for this patient? A.Administer 15 L oxygen via nonrebreather mask B.Attach patient to a CO2 detector C.Prepare for a definitive airway D.Assist ventilation with a bag-mask device D.Coagulopathy - ansA patient who sustained severe injuries was brought to the emergency department following a high-speed motor vehicle collision. Interventions for hypovolemic shock have been initiated. What component of the trauma triad of death is most likely to have begun at the time of injury? A.Acidosis B.Hypothermia C.Hypocalcemia D.Coagulopathy D.Gently rewarm over 15 to 30 minutes - ansA patient arrives following prolonged exposure of their left hand to the cold. The patient is awake and alert and complains of a tingling sensation to the fingers. Assessment reveals swelling and bright red skin to the left hand and a 1-inch round clear blister to the dorsum of that hand. Which of the following nursing interventions is most appropriate for this patient? A.Massage the injured areas to promote circulation B.Drain and debride the blister on the hand C.Immerse in water between 37.5oC and 39.5oC (99.5oF to 103.1oF).
D.Gently rewarm over 15 to 30 minutes D.Insert an oropharyngeal airway if there is no gag reflex - ansDuring the primary survey of an unconscious patient with multi-system trauma, the nurse notes snoring respirations. Which priority nursing intervention should be performed next?
fat embolism - ansA patient has been in the emergency department for several hours waiting to be admitted. They sustained multiple rib fractures and a femur fracture after a fall. The patient has been awake, alert, and complaining of leg pain. Their spouse
reported that the patient 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? A.Acute lung injury B.Fat embolism C.Pneumothorax D.Pulmonary contusion flank - ansDuring the head-to-toe, where would you find Grey-Turner's sign? Globe rupture - ansA 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? A.Oculomotor nerve palsy B.Globe rupture C.Retrobulbar hematoma D.Retinal detachment glucose - ansIn Step 13 of "Disability", what is assessed if pt is altered? Immediately initiate isolation precautions - ansThree adults present at different times during a one-hour period with a high fever, fatigue, and headache. All three patients have a rash which started on their mouth, face, and arms with progression to the chest and abdomen. They all visited the same grocery store within the last week. What is the most appropriate intervention from triage for these patients? A.Move them to a decontamination area B.Mask the patients and send them to the waiting room C.Immediately initiate isolation precautions D.Send them to the waiting room without a mask In Step 15 of "Exposure and Environment" - ansAt what point PRIOR TO the head- to- toe is the patient inspected for obvious injuries? Initiate two large-caliber intravenous lines for isotonic crystalloid administration. - ansA patient is thrown against a car during a tornado and presents with obvious bilateral femur fractures. The patient is pale, alert, disoriented, and has delayed
