TNCC 9TH EDITION EXAM LATEST 2023-2024 COMPLETE 80 QUESTIONS AND CORRECT DETAILED ANSWERS, Exams of Nursing

Download TNCC 9TH EDITION EXAM LATEST 2023-2024 COMPLETE 80 QUESTIONS AND CORRECT DETAILED ANSWERS and more Exams Nursing in PDF only on Docsity! TNCC 9TH EDITION EXAM LATEST 2023-2024 COMPLETE 80 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+ An adult patient who sustained a severe head trauma has been intubated and has been manually ventilated via a bag mask device at a rate of 18 breaths per minute. The patient has received one intravenous fluid bolus of 500 ML of warmed isotonic crystalloid solution. The PaCO2 is 30 and a pulse ox symmetry is 92%. BP is 142/70. What is the most important intervention to manage the cerebral blood flow? - CORRECT ANSWER >>decrease the rate of manual ventilation An older patient with a history of anticoagulant use presents after a fall at home the previous day. She denies LLC. She has a hematoma to her for head and complains of headache, dizziness, and nausea. What is the most likely cause of her symptoms? - CORRECT ANSWER >>Subdural hematoma An adult who fell from a second story roof is brought to the emergency department by private vehicle. The patient is confused with an labored, respirations. It has strong, palpable, radial pulses. There is an open wound in proximity to Novios, deformity of the left lower extremity. What is the priority intervention? - CORRECT ANSWER >>Stabilize the C-spine A trauma patient is restless and repeatedly asking "where am I?" Vitals upon arrival were BP 110/60, HR 96, RR 24. Her skin is cool and dry. Current vital signs are BP 104/84, heart rate 108, respirations 28. The patient is demonstrating signs and symptoms of which stage of shock. - CORRECT ANSWER >>compensated A 35-year-old male presents with facial trauma after being struck in the face with a baseball. A teardrop shaped left people is noted on exam. What type of injury is suspected? - CORRECT ANSWER >>Globe rupture A patient has uncontrolled bleeding from a wound to his right upper extremity. What is a priority intervention? - CORRECT ANSWER >>Apply direct pressure to the wound A patient has received multiple transfusions of banks blood in the past two hours. the patient has - CORRECT ANSWER >>Calcium gluconate Three adults present at different times during a one-hour period with a high fever, fatigue, and headache. All three patients have a rash which started on their mouth, face, and arms with progression to the chest and abdomen. They all visited the same grocery store within the last week. What is the most appropriate intervention from triage for these patients? - CORRECT ANSWER >>immediately initiate isolation precautions A trauma patient who is 30 weeks pregnant arrives at the emergency department following a motor vehicle crash - CORRECT ANSWER >>increased oxygen consumption Following a gun shot wound, pre-hospital providers report diminished breath sounds bilaterally. Upon emergency department arrival, the patient is unresponsive with shallow respirations and an O2 sat of 88%. What is the priority intervention for this patient? - CORRECT ANSWER >>Pneumothorax, hemothoax, contusion, or flail chest 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? - CORRECT ANSWER >>reflex tachycardia An adult patient involved in an assault presents with shortness of breath, BP 88/50 mmHg, heart rate of 130 beats/minute, and RR 32 breaths/minute. The patient has muffled heart sounds and is cyanotic. What is the priority intervention? - CORRECT ANSWER >>pericardiocentesis Which blood pressure finding is associated with early or compensated hypovolemic shock? - CORRECT ANSWER >>rising diastolic A patient who jumped out of a second-floor window, landing on their feet is diagnosed with a lumbar spinal fracture. What is the most likely concurrent injury to have occurred? - CORRECT ANSWER >>calcaneus fracture During the primary survey of an unconscious, patient with multisystem trauma, the nurse notes snoring, respirations. What priority nursing intervention should be performed next? - CORRECT ANSWER >>Insert in oropharyngeal airway, if there is no gag reflex A patient with a complete spinal cord injury, who is a neurogenic shock will demonstrate hypotension and which other clinical signs? - CORRECT ANSWER >>Bradycardia and absent motor function below the level of injury A nurse, verbalizes, guilt and remorse after caring for multiple severely injured patience during a staffing crisis. The nurse expresses anger stating that the patient did not receive quality care and begins exhibiting aggression towards colleagues. This is most consistent with which condition? - CORRECT ANSWER >>emotional 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? - CORRECT ANSWER >>notify the provider A patient who weighs 120 kg is brought to the emergency department after sustaining partial thickness burns to both upper extremities and chest with a total body surface area burned of 27%. How much intravenous fluid should be administered in the first 8 hours? - CORRECT ANSWER >>3240 mL - unsure 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? - CORRECT ANSWER >>Those experiencing human trafficking rarely self-disclose. Which of the following is a late sign of increased intracranial pressure? - CORRECT ANSWER >>widening pulse pressure, reflex bradycardia, decreased respiratory effort A patient is brought to the emergency department of a rural hospital following a high-speed motor vehicle collision. When significant abdominal and pelvic injuries are noted in the primary survey, which of the following is a priority intervention? - CORRECT ANSWER >>Initiate transfer to trauma center 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? - CORRECT ANSWER >>control the bleeding 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? - CORRECT ANSWER >>Notify the provider of the change What is the most important consideration during the initial assessment when caring for an older adult who has sustained serious injuries? - CORRECT ANSWER >>medical history including current medications sparing? - CORRECT ANSWER >>voluntary anal sphincter tone Following a motor vehicle collision, a patient presents with decreased level of consciousness and respirations that are intermittently accompanied by snoring. It has been determined that it is safe to insert a nasopharyngeal airway. What is most important to consider when preparing to insert the nasopharyngeal airway? - CORRECT ANSWER >>gastric distention A patient arrives at the emergency department following a motor vehicle collision. Prehospital personnel report significant damage to the vehicle. The patient is alert and agitated with a strong odor of alcohol and appears intoxicated. After physician evaluation, under what circumstance can an order to remove the rigid cervical collar be anticipated? - CORRECT ANSWER >>no imaging abnormalities of the neck You are caring for a patient who was involved in a motor vehicle crash and is 32 weeks pregnant. Findings of your secondary survey include abdominal pain with rigidity on palpation, fundal height at the costal margin, and dark bloody vaginal discharge. Varying accelerations and decelerations are noted on cardiotocography. These findings are most consistent with which of the following? - CORRECT ANSWER >>Placental abruption 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? - CORRECT ANSWER >>paradoxical chest movement Patients with a crush injury should be monitored for which of the following conditions? - CORRECT ANSWER >>dysrhythmias A Patient with a Penetrating Abdominal Injury Presents with Hypotension and Tachycardia. What is the Priority Intervention? - CORRECT ANSWER >>Exploratory Laparotomy A Patient Involved in a Motorcycle Crash Presents with Bilateral Femur Fractures and Decreased Urine Output. What Condition Should Be Considered? - CORRECT ANSWER >>Compartment Syndrome A Patient with a Traumatic Brain Injury Develops Fever, Neck Stiffness, and Altered Mental Status. What is the Most Likely Diagnosis? - CORRECT ANSWER >>Meningitis A Patient with a Spinal Cord Injury at C5 Presents with Weakness in the Biceps and Deltoid Muscles. What is the Expected Neurological Level? - CORRECT ANSWER >>C6