TCRN EXAM Questions and Correct Answers, Exams of Nursing

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TCRN EXAM

Shock - Answer -Lack of oxygen to the cells Hypovolemic Shock - Answer -Lack of volume ex: hemorrhage, burns Distributive Shock - Answer -Maldistribution of blood (pooled in extremities) Decreased preload ex: neurogenic shock Cardiogenic Shock - Answer -Inadequate cardiac output ex: blunt cardiac trauma Obstructive Shock - Answer -Inability of blood to enter or exit heart properly ex: tamponade, tension pneumothorax Systemic Inflammatory Response Syndrome (SIRS) - Answer -Severe tissue trauma activates an inflammatory response leading to vasodilation, capillary permeability, and coagulation

Early (Compensated) Shock - Answer -Normal BP Weak, thready pulse Deep and rapid RR Normal lactic levels Anxious Late (Decompensated) Shock - Answer -Decreased BP Tachycardia Shallow and rapid RR Increased Lactic Decreased LOC Decreased urinary output BUN to Creatinine Ratio - Answer -Normal - 10: Indicated effective renal function Trauma Triad of Death - Answer -Hypothermia Acidosis Coagulopathies Effects of Acidosis - Answer -Increased ICP Exacerbates coagulopathies Depressed myocardial contractility DIC - Answer -Excessive clotting > all clotting factors used > no more clotting > excessive bleeding Effects of coagulopathies - Answer -Decreased platelet count Decreased fibrinogen Decreased HnH

Increased PT, PTT Increased Ddimer Multi-Organ Dysfunction Syndrome (MODS) - Answer -Irreversible Shock resulting from Triad of Death Symptoms start within the first week after trauma Steps to control hemorrhage - Answer -Tourniquet TXA REBOA Permissive Hypotension Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) - Answer -Occlusion of the Aorta below the diaphragm to reduce bleeding Type A - Answer -RBC: Type A, O Plasma: Type A, AB Type B - Answer -RBC: Type B, O Plasma: Type B, AB Type AB - Answer -RBC: Type A, B, AB, O Plasma: AB Type O - Answer -RBC: Type O Plasma: Type A, B, AB, O Universal Donor of RBC and Plasma - Answer -Universal donor of RBC: O negative Universal donor of Plasma: AB negative

Cryoprecipitate - Answer -Concentrate of coagulation factors obtained from fresh frozen plasma Increases fibrinogen in the bloodstream Blood Transfusion in Peds - Answer -One unit of blood is 10ml/kg Complications of MTP - Answer -Hypothermia - warm all fluids and blood Hypocalcemia - replace calcium Acidosis - sodium bicarb TRALI - stop transfusion, supplemental oxygen Transfusion-Related Acute Lung Injury (TRALI) - Answer -Pulmonary edema due to rapid blood administration MTP Protocol - Answer -1 : 1 : 1 RBC : Plasma : Platelet Blood Loss Grades - Answer -I - Loss of 15% with normal BP II - Loss of 15-30% with normal BP III - Loss: of 31-40% with lowered BP IV - Loss > 40% with hemodynamic instability Permissive Hypotension - Answer -Maintaining BP as low as 70/40 so allow for clotting. Contra-indicated in head injuries, peds, and elderly SCIWORA - Answer -Spinal Cord Injury WithOut Radiological Abnormality Common in Age < 2 yrs Significance of Bariatric Patients - Answer -Increased HR and RR at baseline Increased abdominal pressures

Increased risk of coagulopathies SBIRT - Answer -Comprehensive intervention to deliver treatment for substance use disorders Screening Brief Intervention Referral to Treatment Triad of Abusive Brain Injury - Answer -Subdural Hemorrhage Retinal Hemorrhage Decreased LOC Types of Stress Disorders - Answer -State of Crisis - Immediately after event Acute Stress Disorder - Lasting at least three days Post Traumatic Stress Disorder - Lasting one month or longer Three things to identify state of crisis - Answer -1. Perception of the event

2. Support System
3. Coping mechanisms Steps of Research - Answer -1. Research question
4. Literature Review
5. Research Methodologies
6. Institutional Review Board (IRB) Quantitative Research Methods - Answer -Descriptive - Describe current status of variable Correlational Retrospective - Chart review association of variables Quasi-experimental - Comparison of independent and dependent variable, but no control group Experimental - Comparison of variable and control group

Qualitative Research Methods - Answer -Phenomenology - Describe experiences of the subjects in the study Grounded Theory - Collecting a hypothesis by discussing the viewpoints from the subjects Ethnography - Observations of behavioral patterns Tool Reliability vs Validity - Answer -Reliability - Consistency of the tool to measure what it is supposed to Validity - Extent to which tool measures what it is supposed to measure Role of the IRB - Answer -Ensure informed consent is obtained Subjects can make independent decisions Sentinel Event - Answer -An unexpected occurrence involving death or serious physical or psychological injury, not related to the natural course of the patient's illness Best Studied using Root Cause Analysis Trauma Center Designation vs Verification - Answer -Designated by the state Verified by American College of Surgeons Qualifications to be Trauma Center - Answer --Treatment protocols for resuscitation -Data Reporting -Active outreach program in community -Disaster planning National Trauma Data Bank - Answer -A collection of trauma data research and benchmarking COBRA / EMTALA - Answer -Patient must be offered medical screening exam > discharge, admitted, or transfer to another facility > Must have a receiving facility, accepting physician, and signed certification EMTALA also covers that consent can be waived in case of emergency

Types of Review - Answer -Primary - review of patient's chart in real time Secondary - Review after patient is discharged Tertiary - Peer Review (via committee or M&Ms) Quaternary - Hospital's quality committee, or external review Steps of Disaster Management - Answer -Mitigation Preparedness Response Recovery Compassion Fatigue - Answer -Loss of nurse's ability to empathize and provide compassionate care to patients Secondary Traumatic Stress leading to Burnout Autonomy - Answer -Ability of individual to determine his/her own course of action ex: not receiving blood due to religious reasons Beneficence - Answer -Duty of health care providers to be a benefit to the patients ex: prevent or remove harm from the patient Non-maleficence - Answer -Do no harm ex: honor DNR status of patient Veracity - Answer -Honesty, providing all information needed to make balanced decision ex: review all risks and benefits of surgery prior to consent Justice - Answer -Fair distribution of goods in society ex: medicare/medicaid

Protected Health Information may be shared to: - Answer -Past, present or future providers Law enforcement Medical reviews Intracranial Pressure Measurements - Answer -0-15 Normal 20-40 Elevated Above 40 Severely Elevated Deficits in Elevated ICP (20-40) - Answer -Ipsilateral - deficits above the neck on same side of bleed Contralateral - deficits below the neck on opposite side of blood Vomiting Disorientation Restlessness Deficits in Severely Elevated ICP (Above 40) - Answer -LOC Posturing Cushing's Triad Decorticate vs Decerebrate - Answer -DeCORticate - Hands are pulled towards the CORE (Early) DEcErEbratE - Extension of the arms and legs (Late) Extraventricular Device (EVD) - Answer -Allows drainage of CSF fluid Keep HOB 30 degrees Keep transducer level with the Foramen of Monro (Ear canal) Excessive drainage could lead to subdural hematoma Basilar Skull Fractures - Answer -Anterior Fossa fracture - Around eyes and forehead (Could affect eyes and nose) Middle Fossa - Around ears (Could affect hearing)

Posterior Fossa - Posterior portion of the head (Could lose gag reflex, or movement of the neck or tongue) Cerebral Contusion - Answer -Bruising on the surface of the brain Three Meninges - Answer -Pia Arachnoid Dura Meninges PAD the brain Epidural Bleed - Answer -Between the skull and dura mater Arterial Symptoms: Unconscious then brief lucid period, then rapid decline of LOC Treatment: Burr hole Subdural Bleed - Answer -Between the dura and arachnoid mater Venous Symptoms: Similar to epidural, but slower onset Treatment: Craniectomy Sub arachnoid Bleed - Answer -Between the arachnoid and pia mater Symptoms: Worst headache of my life Treatment: Surgery Diffuse Axonal Injury - Answer -Disruption of the axons in the cerebrum Symptoms: Posturing, Coma, Hyperthermia Levels of Consciousness - Answer -Alert Lethargic - sleepy

Obtunded - responses to loud voice or shaking Stuporous - Responds to painful stimuli Comatose - Not responding to painful stimuli Full Outline of UnResponsiveness (FOUR) - Answer -Eye response Motor response Brainstem reflexes Respirations Cushing's Triad - Answer -Signs of increased intracranial pressure: Hypertension with a widened pulse pressure Bradycardia Irregular respirations Tests for CSF leakage - Answer -"Halo" test Reagent strip - test for glucose Cerebral Perfusion Pressure (CPP) - Answer -CPP = MAP - ICP Indirect measurement of cerebral oxygen delivery CPP Measurements - Answer -80 - 100: Healthy Above is 60: Required for consciousness Less than 50: Critical reduction in brain tissue oxygenation Less than 30: Irreversible brain ischemia MAP - Answer -Mean Arterial Pressure MAP = (2D + S) / 3 Treatment of Elevated ICP - Answer -Reducing volume of the brain (mannitol, hypertonic saline)

Reducing the volume of the blood (elevated HOB, reduce cerebral activity, Anti-seizure medication) Reducing the volume of CSF (EVD) Maximize oxygenation (Reduction in CO2 in critical situations) Normalize blood glucose level Normalize temperature Spinal Cord Inuries - Answer -C1-C4 - breathe no more C5-T1 - upper extremities T4 - Nipple line T7 and above - lose the ability to cough T10 - Hip line L2-L5 - lower extremities S3 - That's the end Anterior Cord Injury - Answer -Descending (Brain to Body) Loss of motor function Posterior Cord Injury - Answer -Ascending (Body to Brain) Loss of proprioception, vibration, fine touch Lateral Cord - Answer -Ascending (Body to Brain) Controls pain, temperature, crude touch Central Cord Injury - Answer -Greater loss of motor function in upper vs lower extremities More likely to affect lateral cord Brown-Sequard Injury - Answer -Loss of motor function on same side of injury Loss of pain and temp on opposite side of injury

Cauda-Equina Syndrome - Answer -Damage to lower spinal cord, resulting in problems with bowel and bladder control Spinal Shock - Answer -Temporary neurological deficits immediately after spinal injury Islands of Sparing - Answer -Areas without deficits due to a partial cord injury Sensory Assessment in SCI - Answer -Start from areas of decreased sensation and move towards areas of increased sensation Neurogenic Shock - Answer -Activation of parasympathetic nervous system causing vasodilation, hypotension and bradycardia Treat with fluids, and vasopressors Autonomic Dysreflexia symptoms - Answer -Hypertension Bradycardia Headache Goose bumps (piloerection) Sweating above the level of the spinal injury Cool clammy skin below the level of the spinal injury Mandibular Fracture - Answer -Malocclusion of the jaw Dental involvement Le Fort Fractures - Answer - Orbital Fracture - Answer -Concerned for ocular entrapment Treatment for Maxillofacial Trauma - Answer -Allow patient to assume position that they can tolerate Suction as needed

Assess for surgical airway Intraocular Pressure - Answer -Above 20 is elevated Normal Ocular pH - Answer -7.0 - 7. Hyphema - Answer -Bleeding in the anterior chamber of the eye due to ruptured vessel in the iris High risk of secondary bleeding occurring on the 3-4 day Vitreous Hemorrhage - Answer -Bleeding in the eye Result in "cobwebs" or "floaters" Ruptured Globe - Answer -Can lead to tear-shaped pupils Use metal shield on affected eye Ocular Foreign Object - Answer -Secure protruding object and cover unaffected eye Retrobulbar Hemorrhage - Answer -Blood clot behind globe pushing it forward Use paper cup on affected eye Globe Luxation - Answer -Extrusion of eye ball from the socket Ocular entrapment - Answer -Orbital of the eye is stuck due to fracture Eye is angled downward toward the feet Rib Fractures - Answer -1st and 2nd - Tracheal trauma, great vessel injury 3rd through 9th - Lung trauma 9th through 12th on the left - Splenic injury, left kidney 9th through 12th on the right - Liver injury, right kidney

Sternum Fractures - Answer -Blunt cardiac injury, esophageal trauma Laryngeal trauma Symptoms - Answer -Hoarse voice Subcutaneous emphysema Flail Chest Segment - Answer -Three or more rib fractures in two or more locations causing a free- floating segment of the rib cage Paradoxical chest wall movement - Answer -Sinking of the flail segment during inspiration, and bulging of the flail chest segment during exhalation (opposite of normal) Treatment for Rib Fractures - Answer -Pain management Oxygenation Euvolemia Chest Physiotherapy Suctioning Aortic Trauma Symptoms - Answer -Higher systolic in the right upper extremity compared to the left upper. Difference of 20. Precordial Systolic Murmur Treatment for Aortic Injuries - Answer -Permissive Hypotension Beta-blockers Surgery Ankle Brachial Index - Answer -Ratio to determine severity of peripheral vascular disease ABI = Ankle SBP / Brachial SBP ABI Measurements - Answer -Greater than 0.9 : Normal

0.6 - 0.9 : Mild 0.3 - 0.6 : Moderate Less than 0.3 : Critical Ischemia Pericardial Tamponade - Answer -Collection of fluid in the pericardial sac Symptoms: Beck's Triad, Pulsus Alternans, Paradoxical pulse, Narrowed pulse pressure, PEA Treatment: Pericardiocentesis, Open thoracotomy Beck's Triad - Answer -Muffled heart tones Systemic Hypotension Distended neck veins Paradoxical Pulse - Answer -Decrease of more than 10 in arterial pressure during inspiration Pulsus Alternans - Answer -Alternating morphology of the QRS complex Blunt Cardiac Injury - Answer -Symptoms: CP, ST elevation, Right sided heart failure Treatment: Positive Inotropes (Ex: Dobutamine) Pneumothorax - Answer -Air in the pleural cavity May cause a "sucking sound" on inhalation Treatment: Three-sided occlusive dressing Tension Pneumothroax - Answer -Pneumo with excessive pressure, pushing the heart over to opposite side of injury. Obstructive shock Treatment: Needle thoracostomy, then chest tube Hemothorax - Answer -Collection of blood in the pleural cavity

Hypovolemic shock and obstructive shock Treatment: Chest tube, blood loss replacement Chest Drainage Set - Answer -Maintain set below the level of the chest Bubbling should occur in the water seal chamber, and suction chamber Pulmonary Contusion - Answer -Ruptured blood vessels in the lungs causing inflammatory response leading to respiratory acidosis Acute Respiratory Distress Syndrome (ARDS) - Answer -Inflammatory response causing Progressive alveolitis and fibrosis leading to Respiratory infections resulting in Stiff, non-compliant lungs with high pressures on the ventilator P:F ratio - Answer -Indirect measurement of the degree of oxygenation across the alveolar membrane P:F ratio = Oxygen in the blood (PaO2) / Oxygen delivered (FiO2) Healthy Adult = 400 Mild ARDS = 200- Moderate ARDS = 100- Severe ARDS = Less then 100 Treatment of ARDS - Answer -Euvolemia Lower Tidal Volume Elevated PEEP Prone Positioning ECMO

Extracorporeal Membrane Oxygenation (ECMO) - Answer -System that circulates the blood through an oxygenation system, to allow for the heart and lungs to recover Ruptured Diaphragm - Answer -Symptoms: Heart sounds shift to the right side Pain to LEFT shoulder Signs of obstructive shock Dysphagia Dyspnea Confirmed by laparotomy Treatment: Surgery Seatbelt Sign - Answer -Bruising along the lower abdomen Concern for small bowl injury and fractures of the lumbar spine Steps for Abdominal Assessment - Answer -Visualization Auscultation Percussion Palpation Tympany vs Dullness - Answer -Tympany - Hyperresonance, Air, Hollow organs Dullness - Hyporesonance, Fluid, Solid organs Narrowed vs Widened Pulse Pressure - Answer -Narrowed - Concerned for bleeding Widened - Concerned for head injuries Rebound Tenderness - Answer -Pain that increases when pressure is removed due to irritation caused by presence of blood, enzymes, and bacterial contaminants

Hollow Organs - Answer -Esophagus, Stomach, Small intestine, Large intestine Complications of Hollow Organ Injuries - Answer -Hematomas can cause obstructions hours or days after trauma Expected elevated WBC count, amylase, and lactic acid levels Escaping air can cause tympany and abdominal distention Rebound Tenderness Solid Organs - Answer -Spleen, Liver, Pancreas, Kidneys Injury to the Spleen - Answer -LUQ pain, Left shoulder pain Concerned for major blood loss Vulnerable to infections Treatment: Splenorrhaphy (surgical repair) or Splenectomy Long-term complications from a Splenectomy - Answer -Vulnerable to infections caused by encapsulated bacteria: Flu, PNA, Meningococcus, E.coli, Staph, and Strep Injury to the Liver - Answer -RUQ pain Concerned for blood loss Cullen's Sign (Bruising around the umbilicus) Injury to the Pancreas - Answer -Epigastric pain radiating to the back Abdominal Compartment Syndrome (ACS) - Answer -Increased abdominal pressure Symptoms: Decreased Urinary Output Decreased BP

Increased Central Venous Pressures Increased Systemic Vascular Resistance Respiratory acidosis Measuring Intra-abdominal pressure - Answer -Measure bladder pressure via foley Normal: Under 10 Grade I: 12- Grade II: 16- Grade III: 21- Grade IV: Greater than 25 Treatment of Abdominal Compartment Syndrome - Answer -Keep HOB flat Maintain MAP OR for decompression Stable vs unstable pelvic fracture - Answer -Stable - Ligaments intact Unstable - Ligaments affected, Disruption of blood vessels Pelvic Binder - Answer -Splint applied at the level of the greater trochanter and pubic symphysis Complications: Pressure ulcer Retroperitoneal Bleeding - Answer -Cullen's Sign Bruising to the flanks Anterior vs Posterior Urethral Trauma - Answer -Anterior - At end of urethra. More common in males. Usually due to straddle injuries or external forces. Posterior - Close to bladder. Almost always associated with pelvic fractures

Types of Bladder Rupture - Answer -Intraperitoneal - Top of bladder is ruptured into abdomen, can cause rebound tenderness and abdominal distention Extraperitoneal - Bottom of bladder is ruptured, can cause suprapubic swelling and tenderness Coopernail's Sign - Answer -Bruising to the scrotum or labia Urinoma - Answer -Collection of urine located outside the kidney or bladder Treatment: Percutaneous drain Complications of Renal Injury - Answer -Hemorrhage Infection AKI Long term complication - Hypertension Acute Kidney Injury (AKI) - Answer -Rapid loss of renal function due to damage to the kidneys Pre-Renal Failure - Answer -Poor blood flow to the kidneys Treatment: Fluids, vasopressors, inotropes Intra-Renal Failure - Answer -Damage to the kidneys due to nephrotoxins or ischemic sources Treatment: Withdraw nephrotoxins, diuretics Post-Renal Failure - Answer -Injury to the urinary collection system Treatment: Relieve obstruction, urinary catheterization Expected Lab Values in Renal Failure - Answer -Elevated Creatinine Elevated BUN Elevated Potassium Decreased HnH

Hemodialysis vs CRRT - Answer -Hemodialysis - Shorter treatments, but rapid shifts in electrolytes CRRT - Slower corrections, but requires more anticoagulation Respiratory Changes in Pregnant Patients - Answer -Elevated diaphragm Increased respiratory rate Decreased CO2 and Bicarb Circulation Changes in Pregnant Patients - Answer -Increased blood volume Increased heart rate Increased clotting factors Displace uterus to either side to prevent vena cava from becoming compressed GI / GU Changes in Pregnant Patients - Answer -More susceptible to splenic, liver, and bladder trauma Urinary Frequency Orthopedic Changes in Pregnant Patients - Answer -Relaxation of ligaments Apply pelvic binder in normal position, below the level of the uterus Preterm Labor Treatment - Answer -Tocolytic Agent - Mag Sulfate, Terbutaline Betamethasone (fetal lung maturity) Fetal monitoring Magnesium Toxicity - Answer -Decreased BP Decreased RR Decreased DTR Decreased urinary output Treatment: Calcium Gluconate

Uterine Rupture - Answer -Aggressive Fluid Resuscitation Immediate Laparotomy for maternal survival Kleihauer-Betke test - Answer -Test that detects the presence of fetal blood in the maternal circulation Indicating fetal injury pH of Amniotic Fluid - Answer -7.5 (Urine is more acidic) Emergency Delivery - Answer -To deliver shoulders, direct head downward to deliver anterior shoulder first Then, upward to deliver posterior shoulder Fundal Height - Answer -12 weeks - Pubic Symphysis 20 weeks - Umbilicus 40 weeks - Xyphoid Process Fetal Heart Rate - Answer -Normal: 120-160 Fetal Tachycardia: Early distress Fetal Bradycardia: Late distress If pregnant mother becomes pulseless... - Answer -CPR above the center of the sternum Displace Uterus laterally C-section if beyond 24 weeks Incidence - Answer -Number of people affected by an injury during a specific time period Morbidity - Answer -Number of people injured after traumatic incident

Mortality - Answer -Number of deaths in a specified time frame Direct, Additional, and Indirect Costs - Answer -Direct - Measurable costs of healthcare (Ex: Medical care, rehab) Additional - Additional outside of healthcare (Ex: police, fire, property damage) Indirect - Value of foregone productivity (Ex: Cost of training someone new due to someone being injured) Prevalence - Answer -Number of affected persons with particular injury in the population at a specified time divided by the whole population. High prevalence - high survivability Low prevalence - low survivability Injury Prevention Programs - Answer -Primary - Prevent occurrence of injury. Ex: Require fence around pool Secondary - Reduce the severity of injury. Ex: CPR class required for pool owners Tertiary - Improvement in outcomes related to traumatic injury. Ex: Easy access to helicopter 4 E's in Prevention Programs - Answer -Engineering Enforcement Educational Economic Prehospital Care priority - Answer -Airway Breathing Bleeding Controlled Spinal Precaution Primary Survey - Answer -A - Across the room inspection for uncontrolled bleeding A - Airway

B - Breathing C - Circulation D - Disability E - Exposure and environmental control F - Full set of vitals G - Get Monitoring (LMNOP) L - Labs M - Monitor cardiac rhythm N - NG or OG tube O - Oxygenation and ventilation P - Pain assessment Secondary Survey - Answer -H - History H - Head to toe exam I - Inspect the posterior surfaces J - Just keep reevaluating Prehospital Report - Answer -MIST M - Mechanism of injury I - Injuries sustained S - Signs and symptoms T - Treatment in the field Patient History - Answer -SAMPLE S - Symptoms A - Allergies M - Medication currently used P - Past medical history L - Last oral intake

E - Events related to injury Tertiary Survey - Answer -24 - 72 hours post admission Repeat of primary and secondary survey including review of all diagnostic tests Ventilator Associated Pneumonia (VAP) Prevention Tactics - Answer -Minimize sedation Elevate HOB Perform oral care Suctioning Inpatient Nutrition - Answer -Enterally (Stomach) is preferred over parenteral (IV) to reduce risk of sepsis Initiate nutrition 24-48 hours after trauma and 6 hours for burn patients Rehabilitation Results - Answer -Restoration - Ability to recover normal function Compensation - Replace normal function with other strategies Adaptation - Change lifestyle to adapt to disability Skilled Nursing Facility vs Long Term Care Hospital - Answer -Determined by the anticipated length of stay and complexity of patient's needs Living Will - Answer -A document that indicates what medical intervention an individual wants if he or she becomes incapable of expressing those wishes Durable Power of Attorney - Answer -Designates a surrogate decision maker when an individual is unable to make decisions Determining Brain Death - Answer -First, Remove all conditions that could impair neurologic function (Normalize electrolytes, Euthermia, Sedation) Then, Hyperoxygenative for at least 10 minutes