TNCC 9th Edition FINAL TEST QUESTIONS AND ANSWERS & Rationale. GRADED A+, Exams of Nursing

TNCC 9th Edition FINAL TEST QUESTIONS AND ANSWERS & Rationale. GRADED A+, Exams of Nursing “An 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. - Correct answer A. Decrease the rate of manual ventilation" "A patient with a spinal cord injury at C5 is being cared for in the emergency department while awaiting transport to a trauma center. Which of the following represents the highest priority for ongoing assessment and management for this patient? A. Maintain adequate respiratory status B. Administer balanced resuscitation fluid C. Perform serial assessments of neurologic function D. Maintain core temperature - Correct answer A. Maintain adequate respiratory status Rationale: Spinal cord injuries at C3 to C5 can cause the loss of phrenic nerve function, resulting in a paralyzed diaphragm and inability to breathe. Maintenance of respiratory function is the highest priority." A 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 - - Correct answer C Inotropic support "Which of the following situations could cause functional grief? A. Inability to live at home B. Amputation of a limb - Correct answer B. Amputation of a limb C. Loss of one's self-image D. Destruction of the patient's car Rationale: Preparation and Ongoing CarePsychosocial Aspects Functional grief relates to the loss of body function or body parts such as amputation of a limb, paralysis, or loss of sight. " "What 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 - Correct answer B. Medical history including current medications" "You are caring for a patient who was thrown from a bike and was not wearing a helmet. While performing the head-to-toe assessment, you note clear drainage from the right ear. Which of the following is the most appropriate next step? A. Clean the ear with a cotton-tipped applicator. B. Pack the ear with gauze. C. Notify the physician D. Document and continue the exam. - Correct answer C. Notify the physician" "When should the definitive calculation for intravenous fluid resuscitation rate be performed for a patient with burns? A. As soon as the patient arrives B. After removal of clothing C. Only at a burn center D. During the circulation assessment - Correct answer B. After removal of clothing" Rationale: Musculoskeletal and WoundsBurns Some fluid will be given initially, but an accurate fluid total is based on percentage of total body surface area which requires a good skin assessment and is calculated after clothing is removed. - "In a motor vehicle collision, which injury pathway is most likely to increase the patient's morbidity and mortality? A. Rotational B. Ejection C. Lateral D. Rollover - Correct answer B. Ejection" "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 - Correct answer C. Elevating the leg to the level of the heart Rationale: Musculoskeletal and WoundsMusculoskeletal 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. - Correct answer 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. - Correct answer C. Reposition the endotracheal tube." "10. 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 - Correct answer 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 - Correct answer 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 - Correct answer 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 - Correct answer 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 - Correct answer B Widening pulse pressure Rationale: Head and Torso TraumaHead 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." "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 - Correct answer D Post-concussive syndrome Rationale: Special PopulationsOlder 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. " "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 - Correct answer D. Post-concussive syndrome Rationale: Special PopulationsOlder 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. " "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 - Correct answer 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 - Correct answer C. Disseminated intravascular coagulopathy" "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? A. Transverse colon B. Pancreas C. Liver D. Spleen - Correct answer C. Liver Rationale: Head and Torso TraumaAbdominal and Pelvic Trauma Liver injuries are associated with right, lower rib fractures. They also can present with tenderness, guarding, or rigidity in the right upper quadrant, along with ecchymosis of the right upper quadrant or around the umbilicus, known as Cullen's sign. " "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? A. Oculomotor nerve palsy B. Globe rupture C. Retrobulbar hematoma D. Retinal detachment - - Correct answer B. Globe rupture Rationale: Head and Torso TraumaHead Trauma The globe of the eye consists of multiple layers. The sclera is the white outer layer, while the cornea covers the iris and pupil. When a full thickness injury occurs to the cornea, sclera, or both, the globe will rupture, causing the shape of the pupil to become irregular or teardrop-shaped. " "An adult arrives at the emergency department with superficial burns to the extremities following a house fire. The patient is reporting a headache with nausea and is drowsy and confused. What is the most likely cause of these symptoms? A. Capillary leak syndrome B. Rhabdomyolysis C. Carbon monoxide poisoning D. Hypothermia - Correct answer C. Carbon monoxide poisoning" "An adult patient is being treated in the emergency department after falling 30 feet and landing on their head. The patient has been intubated and initial stabilization efforts are ongoing. The vital signs are BP 70/40 mm Hg, HR 44 beats/minute, and respirations are being assisted at 16 breath/minute. The patient's skin is warm, dry, and of a normal color. These findings are most consistent with what type of shock? A. Spinal B. Hypovolemic C. Obstructive D. Neurogenic - Correct answer D. Neurogenic" " A patient with a chest tube is being transported to the intensive care unit and fluctuation is noted in the water seal chamber during inspiration and expiration. What is the best action for the nurse to take? A. Clamp the chest tube B. Return to the emergency department C. Assist ventilations with bag-mask device D. Continue to the intensive care unit - Correct answer D. Continue to the intensive care unit" "Which one of the following characteristics is found in high performing teams? A. Interdisciplinary collaboration B. Provide on-the-job training C. Work individually D. Minimal feedback to decrease confusion - Correct answer A. Interdisciplinary collaboration" " A 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 - Correct answer C. Decreased body temperature Rationale: Primary AssessmentAirway and Ventilation If the blood is not sufficiently warmed when transfused, it can produce hypothermia. In the oxyhemoglobin dissociation curve, a shift to the left increases the affinity of hemoglobin for oxygen making it harder to release for use by the tissues. Factors that can cause this shift include an elevated pH, decreased carbon dioxide, decreased temperature, and low metabolic demand. " “You are caring for a patient who was thrown from a bike and was not wearing a helmet. While performing the head-to-toe assessment, you note clear drainage from the right ear. Which of the following is the most appropriate next step? A. Clean the ear with a cotton-tipped applicator. B. Pack the ear with gauze. C. Notify the physician D. Document and continue the exam. - Correct answer C. Notify the physician" "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 - Correct answer A. Initiate transfer to a trauma center" "An adult who fell from a second story roof is brought to the emergency department by private vehicle. The patient is confused with unlabored respirations and has strong, palpable radial pulses. There is an open wound in proximity to an obvious deformity of the left lower extremity. What is the priority intervention? A. Initiate cervical spine stabilization B. Apply a splint to the lower extremity C. Put the patient on portable oxygen. D. Log roll the patient onto a spine board - Correct answer A. Initiate cervical spine stabilization" "An adult patient is brought to the emergency department following a vehicle "roll-over" with prolonged extrication. Assessment reveals swelling and bruising to the right proximal thigh and a weak pedal pulse. Skin is pale, cool, and moist. What is the most appropriate initial intervention? A. Application of a tourniquet to the affected extremity B. Application of a pelvic binder C. Fluid resuscitation to maintain a urine output of 0.5 mL/kg/hour D. Oxygen to maintain the ETCO2 between 30-35 mm Hg (3.9-4.6 kPa) - Correct answer B. Application of a pelvic binder" A patient arrives at the emergency department by private vehicle after sustaining an injury to the right lower extremity while using a saw. There is a large gaping wound to the right thigh area with significant bleeding. What is the priority intervention? A. Elevate the extremity to the level of the heart B. Initiate direct pressure C. Apply a tourniquet D. Cover the open wound with sterile saline dressings - Correct answer B. Initiate direct pressure Rationale: The first step inn controlling any bleeding is application of direct pressure." "What technique is most appropriate when obtaining a history from a patient who has experienced a sexual assault? A. Sitting next to the patient B. Ensuring the patient answers all the questions C. Asking for information only related to the assault D. Applying active listening - Correct answer D. Applying active listening Rationale: Therapeutic communication techniques such as active listening decrease unintentional distress during the interaction." "What is the appropriate technique for palpating the pelvis for stability? A. Apply gentle pressure over the iliac crests, downward and laterally B. Apply gentle pressure over the iliac crests, downward and medially C. Apply firm pressure over the iliac crests, downward and laterally D. Apply firm pressure over the iliac crests, downward and medially - Correct answer B. Apply gentle pressure over the iliac crests, downward and medially Rationale: To assess for pelvic instability, gentle pressure is applied over the iliac crests, downward and medially." "A trauma nurse cared for a child with devastating burns two weeks ago. The nurse called in sick for a couple of days and is now back working on the team. Which of the following would indicate this nurse is coping well? A. They are talking about taking the emergency nursing certification exam B. They keep requesting to be assigned to the walk-in/ambulatory area C. They are impatient and snap at their coworkers D. They are thinking about transferring out of the emergency department - Correct answer A. They are talking about taking the emergency nursing certification exam Rationale: This is an indication the nurse is taking positive steps to advance their own practice, a sign of resilience. B indicates the nurse is still not ready to return to their previous level of engagement in their job. C shows signs of burnout, irritability and frustration. D shows decreased satisfaction with the job, a sign of burnout." "The vital signs of a pregnant trauma patient at 30 weeks include a blood pressure of 94/62 mmHg and a heart rate of 108 beats/minute. Fetal heart tones are 124 beats/minute. The emergency nurse interprets the patient's hemodynamic findings as an indication of which of the following? A. Decompensated shock B. Normal vital signs in pregnancy C. Compensated shock D. Supine hypotension syndrome - Correct answer B. Normal vital signs in pregnancy Rationale: In pregnancy, the resting heart rate increases by 10 to 20 beats/minute. This is also a small decrease in systolic blood pressure and a larger decrease in diastolic blood pressure due to a decrease in peripheral resistance. Normal fetal heart rate is between 120 and 160 beats/minute." "Which of the following is considered a cornerstone of a high-performance trauma team? A. Individual goals B. Use of TeamSTEPPS C. Identification of a single decision maker D. Effective communication - Correct answer D. Effective communication Rationale: Skilled communication, cooperation, and coordination are the cornerstones of high-performance and high-quality trauma care." "In a patient with severe traumatic brain injury, hypocapnia causes which condition? A. Respiratory acidosis B. Metabolic acidosis C. Neurogenic shock D. Cerebral vasoconstriction - Correct answer D. Cerebral vasoconstriction Rationale: Hypocapnia, or low levels or carbon dioxide, will cause vasoconstriction, especially in the cerebral vasculature. A - hypercapnia from inadequate ventilation causes respiratory acidosis. B - metabolic acidosis results from tissue hypoperfusion and oxygen deficit. C - neurogenic shock is associated with spinal cord injuries and results in generalized vasodilation." "Which of following accurately describes ventilation principles associated with use of bag-mask device for an adult? A. Compress the bag-mask device at a rate of one breath every 6 seconds B. Delivers 100% oxygen C. Squeeze the bag-mask device completely for each breath D. Maintain the oxygen saturation levels between 92% and 94% - Correct answer A. Compress the bag-mask device at a rate of one breath every 6 seconds Rationale: If breathing is ineffective for an adult, assist ventilations by compressing the bag-mask device at a rate of one breath every 6 seconds." "While performing an assessment on a 13-month-old involved in a motor vehicle collision, the nurse identifies which of the following findings from the patient as a sign of possible altered mental status? A. Sunken fontanel B. Crying, but consolable C. Spontaneous movement of arms and legs D. Cooperation with the assessment - Correct answer D. Cooperation with the assessment Rationale: An alert older infant or toddler will recognize their caregiver, be cautious of strangers, and may not respond to commands or cooperate, which are normal." "What is the best measure of the adequacy of the cellular perfusion and can help to predict the outcome of resuscitation? A. End-tidal carbon dioxide B. Hematocrit C. Base deficit D. Oxygen saturation - Correct answer C. Base deficit Rationale: Base deficit serves as an endpoint measurement of the adequacy of cellular perfusion and, when used in conjunction with serum lactate, helps predict the success of the resuscitation." "Following a bomb explosion, fragmentation injuries from the bomb or objects in the environment are examples of which phase of injury? A. Primary B. Secondary C. Tertiary D. Quaternary - Correct answer B. Secondary Rationale: The secondary phase of a blast results from flying debris, projectiles, and bomb fragments causing lacerations or penetrating injuries." "An adult patient with a knife injury to the neck has an intact airway and is hemodynamically stable. They complain of difficulty swallowing and speaking. In the primary survey, further assessment is indicated next for which of the following conditions? A. Damage to the cervical spine B. An expanding pneumothorax C. Laceration of the carotid artery D. Injury of the thyroid gland - Correct answer A. Damage to the cervical spine Rationale: Penetrating neck trauma may include concurrent injuries to the cervical spine and cord, airway, or vascular neck structures. With an intact airway and hemodynamic stability, the other common concurrent injury is to the cervical spine." "What is the best position for maintaining an open airway in the obese patient? A. Prone B. Supine C. Reverse Trendelenburg D. Right lateral recumbent - Correct answer C. Reverse Trendelenburg Rationale: The reverse Trendelenburg position will benefit both airway maintenance and work of breathing in the obese patient." "What is the leading cause of preventable death for the trauma patient in the prehospital environment? A. Airway compromise B. Ineffective ventilation C. Secondary head injury D. Uncontrolled external hemorrhage - Correct answer D. Uncontrolled external hemorrhage Rationale: Uncontrolled external hemorrhage is the leading cause of preventable death after injury in the prehospital environment; assessment to identify uncontrolled external hemorrhage is key to the initial assessment process, beginning with the general impression." "The general impression step in the initial assessment provides the opportunity to do which of the following? A. Assess for uncontrolled internal hemorrhage B. Accurately triage the patient C. Reprioritize circulation before airway or breathing D. Activate the trauma team - Correct answer C. Reprioritize circulation before airway or breathing Rationale: The general impression is formed at the beginning of the primary survey to rapidly assess the need to reprioritize circulation before airway or breathing. This is done if uncontrolled external hemorrhage is identified." "Treatment for frostbite can include which of the following interventions? A. Warm the affected part over 30 to 60 minutes B. Use gentle friction to improve circulation C. Administer tissue plasminogen activator D. Drainage of all large and small blisters - Correct answer C. Administer tissue plasminogen activator Rationale: With frostbite, thrombus formation is a risk. Tissue plasminogen activator, a thrombolytic medication, has been effective in maintaining perfusion and decreasing the need for amputation when administered within 24 hours of rewarming." "A patient involved in a MVC has sustained a fracture to the second rib of the anterior left chest. Which concurrent injury is most commonly associated with this fracture? A. Blunt cardiac injury B. Brachial plexus injury C. Pneumothorax D. Hemothorax - Correct answer B. Brachial plexus injury Rationale: First and second rib fractures are most commonly associated with great vessel, head and spinal cord, and brachial plexus injuries." "Understanding the kinematic concepts associated with the mechanism of injury and energy transfer can initially assist the trauma care provider in which of the following? A. Anticipating the types of injuries that may be present B. Deciding whether law enforcement should be notified C. Determining needed laboratory tests D. Predicting the need for a surgical procedure - Correct answer A. Anticipating the types of injuries that may be present Rationale: Mechanism of injury and energy transfer can assist the provider in anticipating and evaluating the types of injuries that may be present and their severity." "A patient fell two weeks ago, striking their head. Today, the patient presented with a persistent headache and nausea and was diagnosed with a small subdural hematoma. The patient has been in the ED for 24 hours awaiting an inpatient bed. The night shift nurse reports the patient has been anxious, restless, shaky, and vomited twice during the night. The patient states they couldn't sleep because a young child kept coming into the room. What is the most likely cause for these signs and symptoms? A. Increased intracranial pressure B. Alcohol withdrawal C. Rhabdomyolysis D. Pulmonary embolus - Correct answer B. Alcohol withdrawal Rationale: Alcohol withdrawal is a common delayed condition because symptoms are difficult to identify early. Signs include autonomic hyperactivity, hand tremors, nausea or vomiting, psychomotor agitation, anxiety, insomnia, transient hallucinations, or seizures."