"TNCC 9th Edition CHEAT SHEET | ABCDE
Survey, AMPLE, Shock, GCS, and Key Trauma
Mnemonics | Final Exam Fast Review"
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?
A. Elevating the leg above the level of the heart
B. Repositioning the leg and applying ice
C. Elevating the leg to the level of the heart
D. Preparing the patient for ultrasound of the leg
C. Elevating the leg to the level of the heart
Rationale: Musculoskeletal and Wounds\Musculoskeletal
This patient is exhibiting signs of possible compartment syndrome which is a dangerous
complication of fractured extremities. The pain is often out of proportion to the injury and
might not respond to pain medications. Elevate the limb to the level of the heart to decrease
dependent edema but not above the heart, which can cause increased venous congestion and
pressure within the compartment.
A teenaged patient presents to the emergency department with left arm pain after a ground
level fall. The patient identifies as transgender and shares they are homeless. The ED staff are
concerned the patient is experiencing human trafficking. What is most consistent with human
trafficking?
A. The individual appears well nourished.
B. Those who are being trafficked rarely seek medical care.
C. It is infrequently associated with substance abuse.
D. Those experiencing human trafficking rarely self-disclose.
D. Those experiencing human trafficking rarely self-disclose.
, An intubated trauma patient has just been transported back from CT scan. Upon arrival to
their room in the emergency department, resistance is noted with bag-mask ventilations and
auscultation reveals unequal breath sounds. What is the most appropriate initial intervention
for this patient?
A. Place the patient back on the ventilator.
B. Extubated the patient.
C. Reposition the endotracheal tube.
D. Suction the endotracheal tube.
C. Reposition the endotracheal tube.
Which of the following assessment findings differentiates a tension pneumothorax from a
simple pneumothorax?
A. Increased work of breathing
B. Unilaterally diminished breath sounds
C. Tachycardia
D. Hypotension
D. Hypotension
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, what is the priority intervention?
A. Initiate transfer to a trauma center
B. Attempt family notification
C. Obtain additional imaging studies
D. Place an indwelling urinary catheter
A. Initiate transfer to a trauma center
A 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. Apply direct pressure to the wound
A trauma patient involved in a fall from 25 feet has a traumatic brain injury, three anterior rib
fractures on the right side, a small pneumothorax on the right, and a Grade III liver injury. The
patient was intubated and placed on a ventilator with PEEP. Chest tube was deferred at this
time. Upon reassessment, which finding is most concerning?
A. Severely diminished breath sounds on the right
B. Guarding in the right upper quadrant
C. Ecchymosis in the right upper quadrant
D. Crepitus to the right chest
A. Severely diminished breath sounds on the right
A patient with a traumatic brain injury has a mean arterial pressure (MAP) of 65 mm Hg (8.66
kPa) and an intracranial pressure (ICP) of 22 mm Hg (2.93 kPa). Which finding is most likely an
indication of the body's response to these findings?
A. Increased respiratory effort
B. Widening pulse pressure
C. Reflex tachycardia
D. Reflex hypotension
B. Widening pulse pressure
Rationale: Head and Torso Trauma\Head Trauma
This patient has a CPP (MAP − ICP) of less than 60 mm Hg (8 kPa) which is associated with poor
outcomes. When the CPP falls below normal levels, the central nervous system initiates the
Cushing response in an attempt to increase mean arterial pressure and improve CPP. Cushing
response assessment findings include widening pulse pressure, reflex bradycardia, and irregular,
decreased respiratory effort.
A patient presents, after a 25-foot fall, with paradoxical chest wall movement to the right
lower chest and complaints of shortness of breath. What is the priority intervention?
A. Surgical intervention
, B. Chest tube insertion
C. Needle decompression
D. Airway and ventilation support
D. Airway and ventilation support
A 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. Rhabdomyolysis
B. Fat embolism
C. Disseminated intravascular coagulopathy
D. Multiple organ dysfunctions syndrome
C. Disseminated intravascular coagulopathy
1.An older adult presents to the emergency department with complaints of dizziness,
headache, and nausea. The patient was involved in a motor vehicle collision 10 days ago.
There was no loss of consciousness and a hematoma is noted to the forehead. The patient is
currently on anticoagulant therapy. What is most likely the cause of their symptoms?
A. Intracerebral hemorrhage
B. Epidural hematoma
C. Diffuse axonal injury
D. Post-concussive syndrome
D. Post-concussive syndrome
Rationale: Special Populations\Older Adult
Post-concussive syndrome can occur days to weeks after injury or trauma. The other three
conditions present as a more rapid decline, especially in patients who are on anticoagulants.
1. Your 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?
Survey, AMPLE, Shock, GCS, and Key Trauma
Mnemonics | Final Exam Fast Review"
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?
A. Elevating the leg above the level of the heart
B. Repositioning the leg and applying ice
C. Elevating the leg to the level of the heart
D. Preparing the patient for ultrasound of the leg
C. Elevating the leg to the level of the heart
Rationale: Musculoskeletal and Wounds\Musculoskeletal
This patient is exhibiting signs of possible compartment syndrome which is a dangerous
complication of fractured extremities. The pain is often out of proportion to the injury and
might not respond to pain medications. Elevate the limb to the level of the heart to decrease
dependent edema but not above the heart, which can cause increased venous congestion and
pressure within the compartment.
A teenaged patient presents to the emergency department with left arm pain after a ground
level fall. The patient identifies as transgender and shares they are homeless. The ED staff are
concerned the patient is experiencing human trafficking. What is most consistent with human
trafficking?
A. The individual appears well nourished.
B. Those who are being trafficked rarely seek medical care.
C. It is infrequently associated with substance abuse.
D. Those experiencing human trafficking rarely self-disclose.
D. Those experiencing human trafficking rarely self-disclose.
, An intubated trauma patient has just been transported back from CT scan. Upon arrival to
their room in the emergency department, resistance is noted with bag-mask ventilations and
auscultation reveals unequal breath sounds. What is the most appropriate initial intervention
for this patient?
A. Place the patient back on the ventilator.
B. Extubated the patient.
C. Reposition the endotracheal tube.
D. Suction the endotracheal tube.
C. Reposition the endotracheal tube.
Which of the following assessment findings differentiates a tension pneumothorax from a
simple pneumothorax?
A. Increased work of breathing
B. Unilaterally diminished breath sounds
C. Tachycardia
D. Hypotension
D. Hypotension
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, what is the priority intervention?
A. Initiate transfer to a trauma center
B. Attempt family notification
C. Obtain additional imaging studies
D. Place an indwelling urinary catheter
A. Initiate transfer to a trauma center
A 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. Apply direct pressure to the wound
A trauma patient involved in a fall from 25 feet has a traumatic brain injury, three anterior rib
fractures on the right side, a small pneumothorax on the right, and a Grade III liver injury. The
patient was intubated and placed on a ventilator with PEEP. Chest tube was deferred at this
time. Upon reassessment, which finding is most concerning?
A. Severely diminished breath sounds on the right
B. Guarding in the right upper quadrant
C. Ecchymosis in the right upper quadrant
D. Crepitus to the right chest
A. Severely diminished breath sounds on the right
A patient with a traumatic brain injury has a mean arterial pressure (MAP) of 65 mm Hg (8.66
kPa) and an intracranial pressure (ICP) of 22 mm Hg (2.93 kPa). Which finding is most likely an
indication of the body's response to these findings?
A. Increased respiratory effort
B. Widening pulse pressure
C. Reflex tachycardia
D. Reflex hypotension
B. Widening pulse pressure
Rationale: Head and Torso Trauma\Head Trauma
This patient has a CPP (MAP − ICP) of less than 60 mm Hg (8 kPa) which is associated with poor
outcomes. When the CPP falls below normal levels, the central nervous system initiates the
Cushing response in an attempt to increase mean arterial pressure and improve CPP. Cushing
response assessment findings include widening pulse pressure, reflex bradycardia, and irregular,
decreased respiratory effort.
A patient presents, after a 25-foot fall, with paradoxical chest wall movement to the right
lower chest and complaints of shortness of breath. What is the priority intervention?
A. Surgical intervention
, B. Chest tube insertion
C. Needle decompression
D. Airway and ventilation support
D. Airway and ventilation support
A 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. Rhabdomyolysis
B. Fat embolism
C. Disseminated intravascular coagulopathy
D. Multiple organ dysfunctions syndrome
C. Disseminated intravascular coagulopathy
1.An older adult presents to the emergency department with complaints of dizziness,
headache, and nausea. The patient was involved in a motor vehicle collision 10 days ago.
There was no loss of consciousness and a hematoma is noted to the forehead. The patient is
currently on anticoagulant therapy. What is most likely the cause of their symptoms?
A. Intracerebral hemorrhage
B. Epidural hematoma
C. Diffuse axonal injury
D. Post-concussive syndrome
D. Post-concussive syndrome
Rationale: Special Populations\Older Adult
Post-concussive syndrome can occur days to weeks after injury or trauma. The other three
conditions present as a more rapid decline, especially in patients who are on anticoagulants.
1. Your 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?
