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.
, TNCC Exam 8th edition study
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.
.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.
, TNCC Exam 8th edition study
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.
