Trauma Nursing Core Course Certification Exam (Version
1)– Emergency Trauma Nursing Assessment (TNCC EXAM)
Updated and Latest Questions and Correct Answers with
Rationale
1. What is the first step in the primary survey of a trauma patient?
A. Assessing the patient’s breathing
B. Checking for neurological deficits
C. Airway and cervical spine stabilization
D. Evaluating circulation and bleeding
Ans: C
Rationale: The primary survey follows a strict sequence to identify life-threatening injuries. Airway
assessment with cervical spine protection is always the first priority because a blocked airway can cause
death within minutes. Nurses must ensure the airway is clear of obstructions like blood or vomit.
Simultaneously, the cervical spine must be manually stabilized to prevent further injury. If the airway is
compromised, the team must intervene immediately before moving to breathing. This systematic
approach ensures that the most immediate threats to life are managed first. Following this order is a core
principle of trauma nursing and emergency care.
,2. During the ‘B’ phase of the primary survey, what is the nurse primarily assessing?
A. Blood pressure and heart rate
B. Body temperature and skin color
C. Breathing and ventilation
D. Bowel sounds and abdominal rigidity
Ans: C
Rationale: Breathing is the second component of the primary survey in the ABCDE mnemonic. During
this phase, the nurse assesses the quality of ventilation and oxygenation. It involves looking for chest rise
and fall, listening for breath sounds, and feeling for air movement. Conditions like tension pneumothorax
or flail chest must be identified here. If breathing is absent or ineffective, supplemental oxygen or
mechanical ventilation is initiated. Proper assessment ensures that the lungs are adequately oxygenating
the blood supply. Ignoring breathing issues can lead to rapid hypoxia and cardiac arrest in trauma
victims.
3. Which triage category is assigned to a patient with a life-threatening injury requiring
immediate intervention?
A. Green (Minor)
B. Yellow (Delayed)
C. Red (Immediate)
D. Black (Deceased)
Ans: C
,Rationale: Triage tags are used to prioritize patients based on the severity of their injuries. The Red tag
is reserved for patients who have life-threatening injuries but a high chance of survival with immediate
care. These patients often have issues with their airway, breathing, or massive hemorrhage. Emergency
nurses must recognize these patients quickly to ensure they receive resources first. Delaying care for a
‘Red’ patient can result in preventable death or permanent disability. In contrast, ‘Green’ patients can
wait, and ‘Yellow’ patients are serious but stable. The triage process is vital for maximizing the number of
lives saved during mass casualty events.
4. What does the ‘C’ in the ABCDE mnemonic stand for in trauma nursing?
A. Circulation and hemorrhage control
B. Consciousness level
C. Cervical spine evaluation
D. Chest tube insertion
Ans: A
Rationale: Circulation is the third step in the primary survey and focuses on cardiac output and blood
volume. Nurses assess for signs of shock by checking pulses, skin color, and capillary refill time. A major
focus of this stage is the identification and control of external hemorrhage. Uncontrolled bleeding is a
leading cause of preventable death in trauma patients. Pressure should be applied to wounds, and
tourniquets may be used for extremity bleeding. Intravenous access is usually established during this
phase to allow for fluid resuscitation. Maintaining effective circulation is essential for transporting
oxygen to the brain and other vital organs.
, 5. When assessing a trauma patient’s neurological status (Disability), which scale is most
commonly used?
A. Norton Scale
B. Glasgow Coma Scale (GCS)
C. Morse Fall Scale
D. Braden Scale
Ans: B
Rationale: The Glasgow Coma Scale (GCS) is the gold standard for assessing a patient’s level of
consciousness. It evaluates three parameters: eye opening, verbal response, and motor response. The
score ranges from a minimum of 3 to a maximum of 15. In trauma, a low GCS score indicates a higher
severity of brain injury. It helps nurses communicate the patient’s neurological status clearly to the
surgical team. A drop in the GCS score of two or more points is a significant clinical finding. Regular
reassessment is necessary to monitor for signs of intracranial pressure increases. This tool provides a
consistent and objective way to measure neurological function.
6. What is the primary purpose of ‘Exposure’ in the primary trauma survey?
A. To identify hidden injuries while preventing hypothermia
B. To check the patient’s identification
C. To allow for family members to see the patient
D. To prepare the patient for a surgical incision
Ans: A
1)– Emergency Trauma Nursing Assessment (TNCC EXAM)
Updated and Latest Questions and Correct Answers with
Rationale
1. What is the first step in the primary survey of a trauma patient?
A. Assessing the patient’s breathing
B. Checking for neurological deficits
C. Airway and cervical spine stabilization
D. Evaluating circulation and bleeding
Ans: C
Rationale: The primary survey follows a strict sequence to identify life-threatening injuries. Airway
assessment with cervical spine protection is always the first priority because a blocked airway can cause
death within minutes. Nurses must ensure the airway is clear of obstructions like blood or vomit.
Simultaneously, the cervical spine must be manually stabilized to prevent further injury. If the airway is
compromised, the team must intervene immediately before moving to breathing. This systematic
approach ensures that the most immediate threats to life are managed first. Following this order is a core
principle of trauma nursing and emergency care.
,2. During the ‘B’ phase of the primary survey, what is the nurse primarily assessing?
A. Blood pressure and heart rate
B. Body temperature and skin color
C. Breathing and ventilation
D. Bowel sounds and abdominal rigidity
Ans: C
Rationale: Breathing is the second component of the primary survey in the ABCDE mnemonic. During
this phase, the nurse assesses the quality of ventilation and oxygenation. It involves looking for chest rise
and fall, listening for breath sounds, and feeling for air movement. Conditions like tension pneumothorax
or flail chest must be identified here. If breathing is absent or ineffective, supplemental oxygen or
mechanical ventilation is initiated. Proper assessment ensures that the lungs are adequately oxygenating
the blood supply. Ignoring breathing issues can lead to rapid hypoxia and cardiac arrest in trauma
victims.
3. Which triage category is assigned to a patient with a life-threatening injury requiring
immediate intervention?
A. Green (Minor)
B. Yellow (Delayed)
C. Red (Immediate)
D. Black (Deceased)
Ans: C
,Rationale: Triage tags are used to prioritize patients based on the severity of their injuries. The Red tag
is reserved for patients who have life-threatening injuries but a high chance of survival with immediate
care. These patients often have issues with their airway, breathing, or massive hemorrhage. Emergency
nurses must recognize these patients quickly to ensure they receive resources first. Delaying care for a
‘Red’ patient can result in preventable death or permanent disability. In contrast, ‘Green’ patients can
wait, and ‘Yellow’ patients are serious but stable. The triage process is vital for maximizing the number of
lives saved during mass casualty events.
4. What does the ‘C’ in the ABCDE mnemonic stand for in trauma nursing?
A. Circulation and hemorrhage control
B. Consciousness level
C. Cervical spine evaluation
D. Chest tube insertion
Ans: A
Rationale: Circulation is the third step in the primary survey and focuses on cardiac output and blood
volume. Nurses assess for signs of shock by checking pulses, skin color, and capillary refill time. A major
focus of this stage is the identification and control of external hemorrhage. Uncontrolled bleeding is a
leading cause of preventable death in trauma patients. Pressure should be applied to wounds, and
tourniquets may be used for extremity bleeding. Intravenous access is usually established during this
phase to allow for fluid resuscitation. Maintaining effective circulation is essential for transporting
oxygen to the brain and other vital organs.
, 5. When assessing a trauma patient’s neurological status (Disability), which scale is most
commonly used?
A. Norton Scale
B. Glasgow Coma Scale (GCS)
C. Morse Fall Scale
D. Braden Scale
Ans: B
Rationale: The Glasgow Coma Scale (GCS) is the gold standard for assessing a patient’s level of
consciousness. It evaluates three parameters: eye opening, verbal response, and motor response. The
score ranges from a minimum of 3 to a maximum of 15. In trauma, a low GCS score indicates a higher
severity of brain injury. It helps nurses communicate the patient’s neurological status clearly to the
surgical team. A drop in the GCS score of two or more points is a significant clinical finding. Regular
reassessment is necessary to monitor for signs of intracranial pressure increases. This tool provides a
consistent and objective way to measure neurological function.
6. What is the primary purpose of ‘Exposure’ in the primary trauma survey?
A. To identify hidden injuries while preventing hypothermia
B. To check the patient’s identification
C. To allow for family members to see the patient
D. To prepare the patient for a surgical incision
Ans: A
