TNCC 14th Edition TNP Latest 2024/25 Exam with Complete Questions and Correct Answers - Pr, Exams of Nursing

Download TNCC 14th Edition TNP Latest 2024/25 Exam with Complete Questions and Correct Answers - Pr and more Exams Nursing in PDF only on Docsity! TNCC 14TH EDITION TNP LATEST 2024/25 EXAM WITH COMPLETE QUESTIONS AND CORRECT ANSWERS A 5-year-old child presents to the emergency department 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. Which of the following is the priority nursing intervention? A.Report your suspicion of maltreatment in accordance with local regulations B.Apply ice to the bruises and provide wound care C.Engage in therapeutic communicati - ansA.Report your suspicion of maltreatment in accordance with local regulations 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 - ansGlobe rupture 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 - ansC.Inotropic support A nurse verbalizes guilt and remorse after caring for multiple severely injured patients during a staffing crisis. The nurse expresses anger stating that the patients did not receive quality care and begins exhibiting aggression toward colleagues. This is most consistent with which condition? A.Compassion fatigue B.Vicarious trauma C.Secondary traumatic stress D.Moral injury - ansD.Moral injury A patient arrives following prolonged exposure of their left hand to the cold. The patient is awake and alert and complains of a tingling sensation to the fingers. Assessment reveals swelling and bright red skin to the left hand and a 1-inch round clear blister to the dorsum of that hand. Which of the following nursing interventions is most appropriate for this patient? A.Massage the injured areas to promote circulation B.Drain and debride the blister on the hand C.Immerse in water between 37.5 - ansD.Gently rewarm over 15 to 30 minutes A patient arrives with a large metal rod embedded in their left thigh and no active bleeding. Which intervention is most appropriate for this patient? A.Remove the rod immediately to facilitate cleansing. B.Apply a tourniquet to the leg above the metal rod. C.Hold antibiotics until after the rod is removed. D.Prepare the patient for surgery to remove the rod. - ansD.Prepare the patient for surgery to remove the rod. 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. The patient 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? A.Needle decompression B.Tube thoracostomy C.Dressing removal D.Surgical repair - ansC.Dressing removal A patient has been diagnosed with an incomplete spinal cord injury at L1. Which finding would indicate sacral sparing? A.Involuntary flexion of the great toe B.Priapism C.Voluntary anal sphincter tone D.Numbness to the perianal area - ansVoluntary anal sphincter tone 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.Reflex hypotension B.Increased respiratory effort C.Reflex tachycardia D.Widening pulse pressure - ansD.Widening pulse pressure 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 - ansC.Decreased body temperature 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 - ansC.Disseminated intravascular coagulopathy A trauma patient who is 30-weeks pregnant arrives at the emergency department following a motor vehicle collision. Which normal physiologic change should be considered when assessing ventilatory status? A.Increased functional reserve capacity B.Increased oxygen consumption C.Decreased minute ventilation D.Slower desaturation rates with apnea - ansB.Increased oxygen consumption An adult patient involved in a motor vehicle collision is brought to the emergency department of a rural critical access facility. They complain of neck pain, shortness of breath, and diffuse abdominal pain. The Glasgow Coma Score is 15. Vital signs are: BP 98/71 mm Hg, HR 125 beats/minute, RR 26 breaths/minute, and SpO2 94% on high- flow oxygen via non-rebreather mask. Which of the following is the priority intervention for this patient? A.Expedite transport to the CT scanner B.Prepare the pati - ansC.Expedite transfer to the closest trauma center An adult patient was brought to the emergency department following a motorcycle crash. On arrival, the patient is only responsive to pain, has bleeding from the nose, and multiple abrasions and contusions to the face. What is the priority intervention? A.Use a bulb syringe to suction out secretions from the mouth. B.Insert a nasopharyngeal airway to maintain an open airway. C.Use a jaw thrust to open the airway and look for signs of obstruction. D.Ask the patient to open their mouth to inspect - ansC.Use a jaw thrust to open the airway and look for signs of obstruction. 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.Re - ansA.Decrease the rate of manual ventilation. An adult pedestrian was struck on the right side by a sport utility vehicle traveling at 40 mph. The patient is awake and alert and the right leg is shortened. Following initial resuscitation with fluids, the patient remains hypotensive. What would be the priority intervention? A.Send blood for type and crossmatch B.Apply a pelvic binder C.Prepare the patient for surgery D.Insert a urinary catheter - ansApply a pelvic binder An adult was thrown against a concrete wall during a factory explosion and sustained a femur fracture, liver laceration, and a small subdural hematoma. These injuries most likely occurred during what level of blast trauma? A.Primary B.Secondary C.Tertiary D.Quaternary - ansC.Tertiary An obese trauma patient requires intubation. Assuming there are no contraindications, which position will provide the best visualization for insertion of the endotracheal tube? A.Reverse Trendelenburg B.Lying on side C.Ramped D.Supine - ansC.Ramped 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 - anspost-concussive syndrome An unconscious patient arrives following a motor vehicle collision. The patient is on a backboard with a cervical collar in place and one intravenous line running. Respirations are shallow and there is active brisk bleeding from a large leg wound. What is the priority intervention for this patient? A.Check for a patent airway B.Control the bleeding C.Start a second intravenous line D.Ventilate with a bag-mask device - ansB.Control the bleeding Antibiotics, consults, head CT, imaging, law enforcement, mandatory reporting, psychosocial support, social services, splinting, tetanus, and wound care are all interventions that you do AFTER and before WHAT? - ansAFTER head-to-toe, BEFORE J (VIPP) At what point PRIOR TO the head-to-toe is the patient inspected for obvious injuries? - ansIn Step 15 of "Exposure and Environment" Based on fall mechanism, which patient warrants prehospital transfer to a trauma center? A.A 35-year-old lands on a wooden porch from an 8-foot ladder B.A 2-year-old lands on grass from a second-story balcony C.A 14-year-old forcefully pushed onto cement from standing D.A 50-year-old lands on a carpeted floor after tripping - ansB.A 2-year-old lands on grass from a second-story balcony During the head-to-toe, where would you find Cullen's sign? - ansumbilicus During the head-to-toe, where would you find Grey-Turner's sign? - ansflank What are examples of nonpharmacologic measures? (must identify at least one during testing) - ansDistraction, family presence, padding bony prominences, repositioning, splinting, verbal reassurance What can be applied in step 12 of "Circulation and Control of Hemorrhage" for which credit is given in the LMNOP section? - anscardiac monitor What do you do when alterations are identified in any of the steps in the primary survery? - ansintervene as appropriate and reassess What does the J stand for at the end of the secondary survery? - ansjust keep evaluating - vipp What does VIPP stand for? - ansvital signs, injuries/interventions, primary survey, pain What is sometimes deferred at the end of the head-to-toe? - ansinspecting posterior 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 - ansB.Medical history including current medications What is the priority intervention for a child who has been diagnosed with an atlanto- occipital dislocation following a high-speed motor vehicle collision? A.Initiating a second large caliber intravenous line B.Maintaining spinal motion restriction C.Placing the patient on pulse oximetry D.Turning the patient to remove the backboard - ansB.Maintaining spinal motion restriction What is the rationale for obtaining a serum lactate level during the initial assessment of a trauma patient? A 5-year-old child presents to the emergency department 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. Which of the following is the priority nursing intervention? A.Report your suspicion of maltreatment in accordance with local regulations B.Apply ice to the bruises and provide wound care C.Engage in therapeutic communicati - ansA.Report your suspicion of maltreatment in accordance with local regulations 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 - ansGlobe rupture 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 - ansC.Inotropic support A nurse verbalizes guilt and remorse after caring for multiple severely injured patients during a staffing crisis. The nurse expresses anger stating that the patients did not receive quality care and begins exhibiting aggression toward colleagues. This is most consistent with which condition? A.Compassion fatigue B.Vicarious trauma C.Secondary traumatic stress D.Moral injury - ansD.Moral injury A patient arrives following prolonged exposure of their left hand to the cold. The patient is awake and alert and complains of a tingling sensation to the fingers. Assessment reveals swelling and bright red skin to the left hand and a 1-inch round clear blister to the dorsum of that hand. Which of the following nursing interventions is most appropriate for this patient? A.Massage the injured areas to promote circulation B.Drain and debride the blister on the hand C.Immerse in water between 37.5 - ansD.Gently rewarm over 15 to 30 minutes A patient arrives with a large metal rod embedded in their left thigh and no active bleeding. Which intervention is most appropriate for this patient? A.Remove the rod immediately to facilitate cleansing. B.Apply a tourniquet to the leg above the metal rod. C.Hold antibiotics until after the rod is removed. D.Prepare the patient for surgery to remove the rod. - ansD.Prepare the patient for surgery to remove the rod. 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. The patient 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? A.Needle decompression B.Tube thoracostomy C.Dressing removal D.Surgical repair - ansC.Dressing removal A patient has been diagnosed with an incomplete spinal cord injury at L1. Which finding would indicate sacral sparing? A.Involuntary flexion of the great toe B.Priapism C.Voluntary anal sphincter tone D.Numbness to the perianal area - ansVoluntary anal sphincter tone A patient has been in the emergency department for several hours waiting to be admitted. They sustained multiple rib fractures and a femur fracture after a fall. The patient has been awake, alert, and complaining of leg pain. Their spouse reported that the patient 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 co - ansfat embolism 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 - ansC.Apply direct pressure to the wound A patient involved in a high-speed rollover is complaining of increased difficulty breathing. There is a small penetrating wound to the sixth intercostal space in the left lateral chest. Which finding is most consistent with an injury to the diaphragm? A.Severe left-sided abdominal pain B.Bowel sounds heard in the left lower chest 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 - ansC.Disseminated intravascular coagulopathy A trauma patient who is 30-weeks pregnant arrives at the emergency department following a motor vehicle collision. Which normal physiologic change should be considered when assessing ventilatory status? A.Increased functional reserve capacity B.Increased oxygen consumption C.Decreased minute ventilation D.Slower desaturation rates with apnea - ansB.Increased oxygen consumption An adult patient involved in a motor vehicle collision is brought to the emergency department of a rural critical access facility. They complain of neck pain, shortness of breath, and diffuse abdominal pain. The Glasgow Coma Score is 15. Vital signs are: BP 98/71 mm Hg, HR 125 beats/minute, RR 26 breaths/minute, and SpO2 94% on high- flow oxygen via non-rebreather mask. Which of the following is the priority intervention for this patient? A.Expedite transport to the CT scanner B.Prepare the pati - ansC.Expedite transfer to the closest trauma center An adult patient was brought to the emergency department following a motorcycle crash. On arrival, the patient is only responsive to pain, has bleeding from the nose, and multiple abrasions and contusions to the face. What is the priority intervention? A.Use a bulb syringe to suction out secretions from the mouth. B.Insert a nasopharyngeal airway to maintain an open airway. C.Use a jaw thrust to open the airway and look for signs of obstruction. D.Ask the patient to open their mouth to inspect - ansC.Use a jaw thrust to open the airway and look for signs of obstruction. 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.Re - ansA.Decrease the rate of manual ventilation. An adult pedestrian was struck on the right side by a sport utility vehicle traveling at 40 mph. The patient is awake and alert and the right leg is shortened. Following initial resuscitation with fluids, the patient remains hypotensive. What would be the priority intervention? A.Send blood for type and crossmatch B.Apply a pelvic binder C.Prepare the patient for surgery D.Insert a urinary catheter - ansApply a pelvic binder An adult was thrown against a concrete wall during a factory explosion and sustained a femur fracture, liver laceration, and a small subdural hematoma. These injuries most likely occurred during what level of blast trauma? A.Primary B.Secondary C.Tertiary D.Quaternary - ansC.Tertiary An obese trauma patient requires intubation. Assuming there are no contraindications, which position will provide the best visualization for insertion of the endotracheal tube? A.Reverse Trendelenburg B.Lying on side C.Ramped D.Supine - ansC.Ramped 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 - anspost-concussive syndrome An unconscious patient arrives following a motor vehicle collision. The patient is on a backboard with a cervical collar in place and one intravenous line running. Respirations are shallow and there is active brisk bleeding from a large leg wound. What is the priority intervention for this patient? A.Check for a patent airway B.Control the bleeding C.Start a second intravenous line D.Ventilate with a bag-mask device - ansB.Control the bleeding Antibiotics, consults, head CT, imaging, law enforcement, mandatory reporting, psychosocial support, social services, splinting, tetanus, and wound care are all interventions that you do AFTER and before WHAT? - ansAFTER head-to-toe, BEFORE J (VIPP) At what point PRIOR TO the head-to-toe is the patient inspected for obvious injuries? - ansIn Step 15 of "Exposure and Environment" Based on fall mechanism, which patient warrants prehospital transfer to a trauma center? A.A 35-year-old lands on a wooden porch from an 8-foot ladder B.A 2-year-old lands on grass from a second-story balcony C.A 14-year-old forcefully pushed onto cement from standing D.A 50-year-old lands on a carpeted floor after tripping - ansB.A 2-year-old lands on grass from a second-story balcony During the head-to-toe, where would you find Cullen's sign? - ansumbilicus During the head-to-toe, where would you find Grey-Turner's sign? - ansflank During the primary survey of an unconscious patient with multi-system trauma, the nurse notes snoring respirations. Which priority nursing intervention should be performed next? A.Open the airway with the head-tilt/chin-lift maneuver B.Auscultate bilateral breath sounds C.Assist respirations using a bag-mask device D.Insert an oropharyngeal airway if there is no gag reflex - ansD.Insert an oropharyngeal airway if there is no gag reflex During which part of the primary survey would there be anticipation for intubation, insertion of OPA/NPA, removal of any loose teeth or foreign objects, or suctioning? - ansAssessing patency and protection of the airway, Step 7 of "Alertness and Airway with Simultaneous Cervical Spinal Stabilization" During which part of the primary survey would you anticipate the need for a chest tube, intubation, decompression of pneumothorax, oxygen, or BVMs? - ans"Breathing and Ventilation" D.Accessibility to a primary care physician - ansB.Medical history including current medications What is the priority intervention for a child who has been diagnosed with an atlanto- occipital dislocation following a high-speed motor vehicle collision? A.Initiating a second large caliber intravenous line B.Maintaining spinal motion restriction C.Placing the patient on pulse oximetry D.Turning the patient to remove the backboard - ansB.Maintaining spinal motion restriction What is the rationale for obtaining a serum lactate level during the initial assessment of a trauma patient? A.Measures oxygenation and ventilation B.Assesses the degree of alkalosis and base deficit C.Gauges end-organ perfusion and tissue hypoxia D.Determines the underlying cause of shock - ansC.Gauges end-organ perfusion and tissue hypoxia What position optimizes ventilation in the obese patient with a lumbar fracture? A.Reverse Trendelenburg B.Supine C.Prone D.Fowler's - ansA.Reverse Trendelenburg What should you verbalize after completing all ETT assessments? - ansmoving patient from assisted ventilation to mechanical What three assessments must be done if the patient is intubated? - ans1. attach CO2 detector and assess for evidence of exhaled CO2; 2. observe for rise and fall of the chest w/ assisted ventilations; 3. auscultate over epigastrium for gurgling AND lungs for bilateral breath sounds What three items are obtained during the pertinent history assessment? - ansMedical records, prehospital report, SAMPLE When should 2 IV sites be established? - ansDuring "Circulation" assessment 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.During the secondary survey C.Should only be done at a burn center D.During the primary survey - ansB.During the secondary surveyt Which blood pressure finding is associated with early or compensated hypovolemic shock? A.Rising systolic B.Rising diastolic C.Decreasing diastolic D.Decreasing systolic - ansB. Rising diastolic Which of the following is a late sign of increased intracranial pressure? A.Restlessness B.Vomiting C.Decreased respiratory effort D.Narrowing pulse pressure - ansC.Decreased respiratory effort Which of the following is true about the log-roll maneuver? A.It causes less spinal motion than the lift-and-slide maneuver B.It is recommended for patients with unstable pelvic fractures C.It should be avoided with a suspected spine injury prior to imaging D.It decreases the risk of hemorrhage from unstable pelvic injuries - ansIt should be avoided with a suspected spine injury prior to imaging Which of the following is true about use of the focused assessment sonography for trauma exam for a patient with abdominal trauma? A.It has a higher sensitivity than diagnostic peritoneal lavage for fluid detection B.It can be used in hypotensive patients too unstable for computed tomography scan C.It can detect as little as 30 mL of fluid in the abdominal cavity D.It has high sensitivity in pediatric patients for identifying fluid in the peritoneum - ansB.It can be used in hypotensive patients too unstable for computed tomography scan Which of the following situations could cause functional grief? A.Inability to live at home B.Amputation of a limb C.Loss of one's self-image D.Destruction of the patient's car - ansB.Amputation of a limb While caring for a child who has been injured, what nursing intervention is consistent with a family-center approach? A.Identifying a single family member to speak with B.Having the family make all the care decisions C.Allowing family to participate in the care of the patient D.Limiting dissemination of complex information - ansC.Allowing family to participate in the care of the patient While caring for a trauma patient in the emergency department, what finding raises suspicion of a complete spinal cord injury? A.Weakness in the lower extremities B.Urinary incontinence C.Sacral sparing D.Spastic paralysis of the legs - ansurinary incontinence Your patient is a pedestrian struck by a car and thrown 35 feet. They were unconscious at the scene but became responsive with initial and subsequent Glasgow Coma Scale (GCS) scores of 13 (E-3, V-4, M-6). The patient has bilateral subdural hematomas and is awaiting transfer to the ICU. Your next assessment reveals a GCS of 9 (E-2, V-2, M- 5). What is the priority nursing intervention? A.Hold all pain medications B.Notify the provider of the change C.Repeat the GCS in 30 minutes D.Place the patie - ansB.Notify the provider of the change 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 - ansC.Liver A.Measures oxygenation and ventilation B.Assesses the degree of alkalosis and base deficit C.Gauges end-organ perfusion and tissue hypoxia D.Determines the underlying cause of shock - ansC.Gauges end-organ perfusion and tissue hypoxia What position optimizes ventilation in the obese patient with a lumbar fracture? A.Reverse Trendelenburg B.Supine C.Prone D.Fowler's - ansA.Reverse Trendelenburg A.Transverse colon B.Pancreas C.Liver D.Spleen - ansC.Liver - ansPrehospital shock index pg. 85 .. activation: .... are found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure - ansBaroreceptors: 1. A- airway and Alertness with simultaneous cervical spinal stabilization 2. B- breathing and Ventilation 3. circulation and control of hemorrhage 4. D - disability (neurologic status) 5. F - full set of vitals and Family presence 6. G - Get resuscitation adjuncts L- Lab results (arterial gases, blood type and crossmatch) M- monitor for continuous cardiac rhythm and rate assessment N- naso or orogastric tube consideration O- oxygenation and ventilation analysis: Pulse oxygemetry and end-tidal caron dioxide (ETC02) monitoring and capnopgraphy H- History and head to toe assessment I- Inspect posterior surfaces - ansABCDEFGHI 1. Apnea 2. GCS 8 or less 3. Maxillary fractures 4. Evidence of inhalation injury (facial burns) 5. Laryngeal or tracheal injury or neck hematoma 6. High risk of aspiration and patients inability to protect the airway 7. Compromised or ineffective ventilation - ansFollowing conditions might require a definitive airway 1. bony fractures and possible rib fractures, which may impact ventilation 2. palpate for crepitus 3. subcutaneous emphysema which may be a sign for a pneumothorax 4. soft tissue injury - ansPalpate the chest for 1. Check the presence of adequate rise and fall of the chest with assisted ventilation 2. Absence of gurgling on auscultation over the epigastrium 3. Bilateral breath sounds present on auscultation 4. Presence of carbon dioxide (CO2) verified by a CO2 device or monitor - ansIf the pt has a definitive airway in what should you do? 1. Dyspnea 2. Tachycardia 3. Decreased or absent breath sounds on the injured side 4. CP - ansSimple Pneumo assessment: 1. equal breath sounds bilaterally at the second intercostal space midclavicular line and the bases for fifth intercostal space at the axillary line - ansAuscultate the chest for: 1. Get a CT 2. Consider ABG 's if decreased LOC 3. Consider glucose check - ansD Interventions 1. Hypotension 2. JVD 3. Muffled heart sounds - ansBecks Triad: 1. open the airway, use jaw thrust 2. insert an oral airway 3. assist ventilations with a bag mask 4. prepare for definitive airway - ansIf breathing is absent.. 1. pain - hallmark sign, early sign 2. pressure - early sign 3. pallor, pules, paresthesia, paralysis - late sign - ansSix P's of compartment syndrome: 1. Preparation 2. Preoxygenation 3. Pretreatment 4. Paralysis and Induction 5. Protecting and positioning - v 6. Placement of proof - secure the tube 7. Post intubation - secure ETT Tube, get X-ray for placement - ansSteps of Rapid Sequence Intubation 1. Preparation and Triage 2. Primary Survery (ABCDE) with resuscitation adjuncts (F,G) 3. Reevaluation (consideration of transfer) 4. Secondary Survey (HI) with reevaluation adjuncts 5. Reevaluation and post resuscitation care 6. Definitive care of transfer to an appropriate trauma nurse - ansInitial Assessment 1. Suction the airway 2, Use care to avoid stimulating the gag reflex 3. If the airway is obstructed by blood or vomitus secretions, use a rigid suction device If foreign body is noted, remove it carefully with forceps or another appropriate method - ansIf Airway is not patent 1. The tongue obstructing the airway 2. loose or missing teeth 3. foreign objects 4. blood, vomit, or secretions' 5. edema 6. burns or evidence of inhalation injury Auscultiate or listen for: 1. Obstructive airway sounds such as snoring or gurgling 2. Possible occlusive maxillofacial bony deformity 3. Subcutaneous emphysema - ansInspect the mouth for: 50 to 150 - ansMAP Range A 14 gauge needle that is inserted into the 2nd intercostal space in the midclavicular line on the affected side over the top of the rib to avoid neuromuscular bundle that runs under the rib. Prepare for chest tube placement. - ansTension pneumo intervention A breath every 5 to 6 seconds: 10-12 ventilations per minute - ansBag mask ventilation activation: consist of carotid and aortic bodies. ... detect changes in blood oxygen and Co2 and pH. When Co2 rises or oxygen level of pH falls these receptors are activated and information is relayed to the CNS and the cardiorespiratory centers in the medulla , which increases respiratory rage and depth and BP - ansChemoreceptors: Air cannot escape intrapleural space.. can begin to compress heart. pt will have sever resp distress, hypotension, JVD. - ansTension pneumo any deformities? bleeding? contusions, lacs? skin temp?? place splints on deformities, pulses - ansHead to toe assessment: Extremities any lacs? deformities? blood at the urtheral meatus palpate pelvis with high pressure over the iliac wings downward and medially - ansHead to toe assessment: pelvis and perineum Aortic Dissection - ansUnequal extremity pulse strength possibility of.. apply direct pressure to bleeding elevate extremity Remove all clothes and assess for any obvious injuries and uncontrolled bleeding - ansE Flail chest - ansParadoxical chest wall movement from hemorrhage is leading cause. Hypovolemia is caused by decrease in the amount of circulating volume. Goal is to replace volume. - ansHypovolemic Shock Full set of vitals and family presence - ansF Get Resuscitation Adjuncts L - Labs (maybe a lactic acid), a b g 's, blood type M - monitors N - naso or oro gastric tubes O Oxygen and ETC02 monitors P - pain assessment and management - ansG H,I - ansSecondary Survery History and Head to toe MIST - prehospital report MOI Injuries sustained S s/s in the field T treatment in the field if patients family present get a better hx on them - ansH IF clothing is needed for evidence preserve in paper bag. Maintain body temp - cover the pt, turn up heat in room, administer warm fluids - ansE Interventions: immobilize cervical spine, tenderness, tracheal deviation - ansHead to toe assessment: Neck and cervical spine in massive transfusion protocol... responsible for dissolving clots - ansTXA inspect for lacs, abrasions, asymmetry of facial expressions palate for depressions and tenderness look at ears for drainage - ansHead to toe assessment: Head and face inspect posterior surfaces blogroll with at least 3 people. maintain c spine take out backboard Rectal tone per MD - ansI inspect, auscultate, palpate any spontaneous breathing, rate, depth, and degree of effort, use of accessory muscles lacs, contusions, auscilate lung sounds and heart sounds - ansHead to toe assessment: Chest jaw thrust maneuver to open airway and assess for obstruction. If pt has a suspected csi, the jaw thrust procedure should be done by two providers. One provider can maintain c-spine and the other can perform the jaw thrust maneuver. - ansWhile assessing airway pt is unable to open mouth, responds only to pain, or is unresponsive you should.. labs, wound care, tetanus, administer meds, prepare for transfer - ansSecondary Reval Adjuncts Needle pericardiocentesis, but it is a temp solution. Requires surgical evaluation. (Ultrasound guided) - ansCardiac Tamponade Intervention: occurs as a result of maldistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. Ex: Anaphylactic - release of antihistamines Septic Shock - systemic release of bacterial endotoxins, resulting in increased vascular permeability and vasodilation. Neurogenic shock - spinal cord injury results of loss in sympathetic nervous system control of vascular tone. Goal: Volume replacement and vasoconstriction - ansDistributive Shock Pediatric Assessment Triangle 1. General appearance - muscle tone, interactiveness, consoloability, poor or gaze, speech or cry 2. Work of breathing - inadequate or excessive, accessory muscle use, retractions, tripod position, abnormal upper airway sounds 3. Circulation of the skin - color, mottling or central or peripheral cyanosis, diaphoresis - ansPAT Pt is at hospital in the right amount of time, right care, right trauma facility, right resources - ansSafe Care: Reevaluation and Consider the need to Transfer - ansFinal step in primary survey reorganize care to C-ABC - ansIf uncontrolled hemorrhage .. results from hypo perfusion to the tissue due to an obstruction in either vasculature or heart. Goal is to relieve obstruction and improve perfusion. Ex: tension pneumo or cardiac tamponade are two classic examples that may result from trauma. - ansObstructive Shock Results from pump failure in the presence of adequate intravascular volume. There is a lack of cardiac output and end organ perfusion secondary to a decrease in myocardial contractility and/or valvular insufficiency. Ex: MI's or dysrhythmia are common causes - ansCariogenic Shock Sample is part of history S symptoms associated with injury A allergies and tetanus status M meds currently on including anticoagulant therapy P past medical hx L last oral intake E Events and environment factors related to the injury - ansSAMPLE stabilized vital signs, improved mental status, improved urine output - ansWhat are indicators of increased perfusion? Stroke Volume X HR - ansCardiac Output = the decrease coagulopathy .. you will you bleed more - ansThe colder you are the more acidic you are.. tracheal deviation and jvd - ansLate signs of tension pneumo: trauma its need early supplemental oxygen, start with 15 mL O2 and titrate oxygen delivery. - ansOxygen on trauma patients Tx is based on size, presence of sx, and stability. For those are aysmpomatic and stable. Observation with or without oxygen. Larger pneumo who are unstable or likely to deteriorate a chest tube is placed. - ansSimple pneumo interventions: Uncontrolled Hemorrhage - ansMajor cause of preventable death: A passenger is brought to the emergency department of a rural hospital following a high-speed MVC. When significant abdominal and pelvic injuries are noted in the primary survey, which of the following is the priority interventions? Answer: A - ANSA) initiate transfer to a trauma center ** B) provide report to the operating room nurse C) Obtained imaging studies D) Place a gastric tube A patient arrives with a large open chest wound after being assault ed with a machete, Prehospital providers placed a nonporous dressing over the chest wound and tapes it on 3 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 interventions? Answer: C - ANSA) needle decompression B) tube thoracostomy C) dressing removal ** D) surgical repair A patient has been in the ED 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 c/o leg pain. His wife reported suddenly becoming anxious and confused. Upon reassessment, the patient is restless, with respiratory distress and petechiae to his neck. the patient is exhibiting signs of symptoms commonly associated with which of the following conditions? Answer: B - ANSA) acute lung injury B) fat embolism *** C) PTX D) pulmonary contusion A patient is found lying on the floor after falling 13 hours ago. Which of the following lab values is expected with a musculoskeletal complication associated with this presentation? Answer: A - ANSA) elevated creatine kinase *** B) decreased potassium level C) decreased WBC D) elevated GFR A patient is thrown against a car during a tornado and presents with obvious bilateral femoral fractures. The patient is pale, alert, disoriented, and has delayed cap refill. Which of the following interventions would be most appropriate for this patient based on the disaster triage principle? Answer: A - ANSA) initiate two large caliber intravenous lines for Ringers lactate solution administration *** B) Administer Dilaudid for pain control and provide comfort care C) Place the patient in an observation area for care within the next few hours D) Contact the command center for the personnel to notify next of kin. A patient with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? Answer: D - ANSA) Bradycardia and ipsilateral absences of motor function B) Tachycardia and respiratory depression C) Tachycardia and absent motor function below the level of injury D) Bradycardia and absent motor function below the level of the injury *** A patient with 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? Answer: C - ANSA) elevating the extremity above the level of the heart B) repositioning and apply ice C) Elevating the extremity to the level of the heart *** D) Preparing the patient for ultrasound A trauma patient is en route to a rural ED. Radiology notifies the charge nurse that the CT scanner will be out of service for several of hours. The team gathers to plan accordingly. Which of the following terms best describes this trauma teams communication? Answer: D - ANSA) Brief B) loop C) debrief D) huddle *** A trauma patient is restless and repeatedly asking "where am I?" vital signs upon arrival were BP 100/60 mm Hg, HR 96 beats/min, and RR 24 breaths/min. Her skin is cool and dry. Current vital signs are BP 104/84mm Hg, HR 108, RR 28 breaths/min. The patient is demonstrating signs and symptoms of which stage of shock? Answer: A - ANSA) compensated ** B) Progressive C) irreversible D) decompensated An elderly patient with a history of anticoagulant use presents after a fall at home that day. she denies any loss of consciousness. She has a hematoma to her forehead and complains of headache, dizziness, and nausea. Which is a most likely cause of her symptoms? Answer: D - ANSA) epidural hematoma B) diffuse axonal injury C) post-concussive syndrome D) subdural hematoma *** An intubated trauma patient is being transferred to a tertiary care center. After moving the patient to the stretcher for transport, a drop in pulse oximetry to 85% is noted. Which of the following is the priority interventions? Answer: D - ANSA) call for a portable CXR stat B) chest to make sure the ventilator is plugged in C) suction the ET tube D) confirm ET tube placement An unresponsive trauma patient has an oropharyngeal airway in place, shallow and labored respiratory, and dusky skin. the trauma team has administered medications for drug assisted intubation and attempted intubation but was unsuccessful. What is the most appropriate immediate next step? Answer: A - ANSA) Ventilate with a BVM *** B) Prepare for cricothyroidotomy C) administer reversal medications D) contact anesthesia for assistance Caregivers carry a 2-year old into the ED who fell out of 2nd story window. The patient is awake and crying with increased work of breathing and pale skin. which of the following interventions has the highest priority? Answer: A - ANSA) padding the upper back while stabilizing the cervical spine *** B) applying a tight-fitting NRB mask with an attached resevior C) establishing intravenous access and administering a 20mL/kg bolus D) preparing for drug assisted intubation During the primary survey of an unconscious patient with multi-system trauma, the nurse notes snoring respirations. Which priority nursing interventions should be performed next? Answer: D - ANSA) open the airway with the head-tilt/chin lift maneuver B) auscultate bilateral breath sounds to assess ventilatory status C) assist respirations using a BVM D) insert an oropharyngeal airway if there is no gag reflex *** What factor contributes most the kinetic energy of a body in motion? answer: C - ANSA) acceleration B) mass C) velocity *** D) inertia What finding raises suspicion of complete spinal cord injury? Answer: B - ANSA) Weakness in the lower extremities B) Priapism *** C) voluntary anal sphincter tone D) intact reflexes distal to the injury Which if the following values indicates the need for alcohol withdrawal interventions? Answer: A - ANSA) CIWA-Ar of 36 *** B) GCS 13 C) ETCo2 of 48 mm Hg D) heart rate of 45 beats/min Which is the effect of hypothermia on the oxyhemoglobin dissociation curve? Answer: A - ANSA) Hemoglobin does not readily release oxygen for use by the tissues *** B) The amount of oxygen available to the tissues increases C) Tissue oxygenation (PaO2) increases D) Hemoglobin molecule saturation (SaO2) decreases Which of the following assessment findings differentiates a tension PTX from a simple PTX? answer: D Assessment findings associated with tension pneumothorax include anxiety, severe restlessness, severe respiratory distress, and absent breath sounds on the injured side. Hypotension due to compression of the heart and great vessels is consistent with obstructive shock. Hypotension worsens with inspiration due to increased intrathoracic pressure. Late signs include distended neck veins, tracheal deviation, and cyanosis. - ANSA) increased work of breathing B) unilaterally diminished breath sounds C) pleuritic chest pain D) hypotension that worsens with inspiration *** Which of the following considerations is most important when caring for a geriatric trauma patient? Answer: B - ANSA) head to to exam B) medical history ** C) incontinence D) falls Which of the following injuries is LEAST likely to be promptly identified? Answer: C - ANSA) spleen B) lung C) bowel *** D) brain Which of the following is a component of the trauma triad of death? Answer: A hypothermia, metabolic acidosis, coagulopathy - ANSA) Acidosis ** B) hyperthermia C) hemorrhage D) sepsis Which of the following is a late sign of increased intracranial pressure? Answer: C Cushing Response Widening pulse pressure Reflex bradycardia Decreased RR - ANSA) Restlessness or drowsiness B) Nausea and vomiting C) Decreased respiratory effort** D) amnesia and anxiety Which of the following is an expected finding in a patient with a thoracostomy connected to a chest drainage system? Answer: D - ANSA) output of 200 mL/hr B) tubing clamp closed for transport C) dependent loops in the tubing to promote drainage D) fluctuations in the water serial chamber *** Which of the following is NOT considered goal-directed therapy of cardiogenic shock? Answer: C - ANSA) controlled fluid boluses B) antidysrhythmic administration C) pericardiocentesis *** D) cardiac cath Which of the following is possible complication of positive-pressure ventilation? Answer: A - ANSA) worsening pneumothorax B) worsening flail chest C) reabsorption of pleural air D) negative intrapleural pressure Which of the following is true about the log roll maneuver? Answer: C - ANSA) it causes less spinal motion than the lift and slide manuever B) it is recommended for patients with unstable pelvic fractures C) it can worsen cord damage from an unstable spinal injury *** D) it does not increases the risk of life threatening hemorrhage from unstable injuries Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? Answer: B - ANSA) ABC B) MARCH*** C) AVPU D) VIPP Which of the following occurs during the third impact of a motor vehicle crash? Answer: C - ANSA) The driver of the vehicle collides with the steering wheel B) the vehicle collides with a tree C) the aorta is torn at its attachment with the ligamentum arteriosum D) the airbag deploys and strikes the front seat passenger *** Which of the following patients warrants referral to a burn center? Answer: C - ANSA) a 21- year old female with a partial thickness burn to the right forearm B) a 40-year old hypertensive male with a superficial burn to the back C) a 52-year old diabetic male with partial thickness burn to the left lower leg *** D) a 35-year old hyperlipidemic female with superficial burns to the anterior thorax. Which pulse pressure description is an indication of early hypovolemic shock? Answer: B - ANSA) widened B) narrowed *** A 56-year- male patient involved in a MVC is brought to the ED of a rural critical access facility. He c/o neck pain, SOB, and diffuse abd pain. His GCS is 15. His vitals are as follows: BP 98/71 HR 125 beats/min RR 26 breaths/min SpO2 94% on high flow O2 via NRB mask which of the following is the priority intervention for this patient? Answer: C - ANSA) Expedite transport to the CT scanner B) prepare the patient for spinal radiographs C) expedite transfer to the closest trauma center *** D) notify the patients family A passenger is brought to the emergency department of a rural hospital following a high-speed MVC. When significant abdominal and pelvic injuries are noted in the primary survey, which of the following is the priority interventions? Answer: A - ANSA) initiate transfer to a trauma center ** B) provide report to the operating room nurse C) Obtained imaging studies D) Place a gastric tube A patient arrives with a large open chest wound after being assault ed with a machete, Prehospital providers placed a nonporous dressing over the chest wound and tapes it on 3 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 interventions? Answer: C - ANSA) needle decompression B) tube thoracostomy C) dressing removal ** D) surgical repair A patient has been in the ED 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 c/o leg pain. His wife reported suddenly becoming anxious and confused. Upon reassessment, the patient is restless, with respiratory distress and petechiae to his neck. the patient is exhibiting signs of symptoms commonly associated with which of the following conditions? Answer: B - ANSA) acute lung injury B) fat embolism *** C) PTX D) pulmonary contusion A patient is found lying on the floor after falling 13 hours ago. Which of the following lab values is expected with a musculoskeletal complication associated with this presentation? Answer: A - ANSA) elevated creatine kinase *** B) decreased potassium level C) decreased WBC D) elevated GFR A patient is thrown against a car during a tornado and presents with obvious bilateral femoral fractures. The patient is pale, alert, disoriented, and has delayed cap refill. Which of the following interventions would be most appropriate for this patient based on the disaster triage principle? Answer: A - ANSA) initiate two large caliber intravenous lines for Ringers lactate solution administration *** B) Administer Dilaudid for pain control and provide comfort care C) Place the patient in an observation area for care within the next few hours D) Contact the command center for the personnel to notify next of kin. A patient with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? Answer: D - ANSA) Bradycardia and ipsilateral absences of motor function B) Tachycardia and respiratory depression C) Tachycardia and absent motor function below the level of injury D) Bradycardia and absent motor function below the level of the injury *** A patient with 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? Answer: C - ANSA) elevating the extremity above the level of the heart B) repositioning and apply ice C) Elevating the extremity to the level of the heart *** D) Preparing the patient for ultrasound A trauma patient is en route to a rural ED. Radiology notifies the charge nurse that the CT scanner will be out of service for several of hours. The team gathers to plan accordingly. Which of the following terms best describes this trauma teams communication? Answer: D - ANSA) Brief B) loop C) debrief D) huddle *** A trauma patient is restless and repeatedly asking "where am I?" vital signs upon arrival were BP 100/60 mm Hg, HR 96 beats/min, and RR 24 breaths/min. Her skin is cool and dry. Current vital signs are BP 104/84mm Hg, HR 108, RR 28 breaths/min. The patient is demonstrating signs and symptoms of which stage of shock? Answer: A - ANSA) compensated ** B) Progressive C) irreversible D) decompensated An elderly patient with a history of anticoagulant use presents after a fall at home that day. she denies any loss of consciousness. She has a hematoma to her forehead and complains of headache, dizziness, and nausea. Which is a most likely cause of her symptoms? Answer: D - ANSA) epidural hematoma B) diffuse axonal injury C) post-concussive syndrome D) subdural hematoma *** An intubated trauma patient is being transferred to a tertiary care center. After moving the patient to the stretcher for transport, a drop in pulse oximetry to 85% is noted. Which of the following is the priority interventions? Answer: D - ANSA) call for a portable CXR stat B) chest to make sure the ventilator is plugged in C) suction the ET tube D) confirm ET tube placement An unresponsive trauma patient has an oropharyngeal airway in place, shallow and labored respiratory, and dusky skin. the trauma team has administered medications for drug assisted intubation and attempted intubation but was unsuccessful. What is the most appropriate immediate next step? Answer: A - ANSA) Ventilate with a BVM *** B) Prepare for cricothyroidotomy C) administer reversal medications D) contact anesthesia for assistance Caregivers carry a 2-year old into the ED who fell out of 2nd story window. The patient is awake and crying with increased work of breathing and pale skin. which of the following interventions has the highest priority? Answer: A - ANSA) padding the upper back while stabilizing the cervical spine *** Answer: C - ANSA) Intraosseous line B) orogastric tube C) ET tube *** D) urinary catheter What bedside monitoring parameters are used to assess for adequacy of oxygenation and effectiveness of ventilation? Answer: A - ANSA) pulse oximetry and capnogaphy ** B) respiratory rate and capnography C) pulse oximetry and respiratory rate D) capnography and capnometry What factor contributes most the kinetic energy of a body in motion? answer: C - ANSA) acceleration B) mass C) velocity *** D) inertia What finding raises suspicion of complete spinal cord injury? Answer: B - ANSA) Weakness in the lower extremities B) Priapism *** C) voluntary anal sphincter tone D) intact reflexes distal to the injury Which if the following values indicates the need for alcohol withdrawal interventions? Answer: A - ANSA) CIWA-Ar of 36 *** B) GCS 13 C) ETCo2 of 48 mm Hg D) heart rate of 45 beats/min Which is the effect of hypothermia on the oxyhemoglobin dissociation curve? Answer: A - ANSA) Hemoglobin does not readily release oxygen for use by the tissues *** B) The amount of oxygen available to the tissues increases C) Tissue oxygenation (PaO2) increases D) Hemoglobin molecule saturation (SaO2) decreases Which of the following assessment findings differentiates a tension PTX from a simple PTX? answer: D Assessment findings associated with tension pneumothorax include anxiety, severe restlessness, severe respiratory distress, and absent breath sounds on the injured side. Hypotension due to compression of the heart and great vessels is consistent with obstructive shock. Hypotension worsens with inspiration due to increased intrathoracic pressure. Late signs include distended neck veins, tracheal deviation, and cyanosis. - ANSA) increased work of breathing B) unilaterally diminished breath sounds C) pleuritic chest pain D) hypotension that worsens with inspiration *** Which of the following considerations is most important when caring for a geriatric trauma patient? Answer: B - ANSA) head to to exam B) medical history ** C) incontinence D) falls Which of the following injuries is LEAST likely to be promptly identified? Answer: C - ANSA) spleen B) lung C) bowel *** D) brain Which of the following is a component of the trauma triad of death? Answer: A hypothermia, metabolic acidosis, coagulopathy - ANSA) Acidosis ** B) hyperthermia C) hemorrhage D) sepsis Which of the following is a late sign of increased intracranial pressure? Answer: C Cushing Response Widening pulse pressure Reflex bradycardia Decreased RR - ANSA) Restlessness or drowsiness B) Nausea and vomiting C) Decreased respiratory effort** D) amnesia and anxiety Which of the following is an expected finding in a patient with a thoracostomy connected to a chest drainage system? Answer: D - ANSA) output of 200 mL/hr B) tubing clamp closed for transport C) dependent loops in the tubing to promote drainage D) fluctuations in the water serial chamber *** Which of the following is NOT considered goal-directed therapy of cardiogenic shock? Answer: C - ANSA) controlled fluid boluses B) antidysrhythmic administration C) pericardiocentesis *** D) cardiac cath Which of the following is possible complication of positive-pressure ventilation? Answer: A - ANSA) worsening pneumothorax B) worsening flail chest C) reabsorption of pleural air D) negative intrapleural pressure Which of the following is true about the log roll maneuver? Answer: C - ANSA) it causes less spinal motion than the lift and slide manuever B) it is recommended for patients with unstable pelvic fractures C) it can worsen cord damage from an unstable spinal injury *** D) it does not increases the risk of life threatening hemorrhage from unstable injuries Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? Answer: B - ANSA) ABC B) MARCH*** C) AVPU D) VIPP Which of the following occurs during the third impact of a motor vehicle crash? Answer: C - ANSA) The driver of the vehicle collides with the steering wheel B) the vehicle collides with a tree C) the aorta is torn at its attachment with the ligamentum arteriosum D) the airbag deploys and strikes the front seat passenger ***