TNCC 9TH EDITION EXAM LATEST 2024-2025 COMPLETE 80 QUESTIONS AND CORRECT DETAILED ANSWER, Exams of Nursing

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TNCC 9TH EDITION EXAM LATEST 2024- 2025

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

You are speaking with the family of a critically injured patient. The spouse is crying loudly and the daughter is angry and yelling at the staff. Which of the following nursing interventions is most appropriate? - CORRECT ANSWER >>Spiritual support A trauma patient is being held in the emergency department, because there are no available inpatient beds. The patient has seen a femur fracture and required multiple blood products. The patient now has blood oozing from abrasions, IV sides, the nose, and gums. What condition is most consistent with these findings? - CORRECT ANSWER >>DIC 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? - CORRECT ANSWER >>continue to ICU

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 -

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 When can an accurate determination of total body surface area burned be made in order to make a definitive calculation for intravenous fluid resuscitation? - CORRECT ANSWER >>after removal of clothing A patient is thrown against a car during a tornado in presents with obvious bilateral femur fractures. The patient is pale, alert, disoriented, and has delayed capillary refill. Which of the following interventions would be most appropriate for this patient based on the disaster triage principles? - CORRECT ANSWER >>Initiate two large caliber IVs for LR administration A restrained driver involved in a motor vehicle collision is brought to the emergency department with abdominal, pelvic, and bilateral lower extremity pain. Vital signs are BP 114/78 mm Hg, HR 98 beats/minute, RR 22 breaths/minute. A FAST exam is negative for fluid in the

unilaterally fixed and dilated pupil 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 headto-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

sustained serious injuries? - CORRECT ANSWER

medical history including current medications What position optimizes ventilation in the obese patient with a lumbar fracture? - CORRECT ANSWER >>Reverse trendelenburg A 36-year-old patient has a deformity of the left wrist after a fall. The patient is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention? - CORRECT ANSWER >>Apply splint and elevate above the level of the heart 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 sustained serious injuries? - CORRECT ANSWER >>medical history including current medications What position optimizes ventilation in the obese patient with a lumbar fracture? - CORRECT ANSWER >>Reverse trendelenburg A 36-year-old patient has a deformity of the left wrist after a fall. The patient is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention? - CORRECT ANSWER >>Apply splint and elevate above the level of the heart What is the rationale for obtaining a serum lactate level during the initial assessment of a trauma patient - CORRECT ANSWER >>Gauges end-organ perfusion and tissue hypoxia 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? - CORRECT ANSWER

postconcussive syndrome?? A patient with a lower extremity fracture, complains of severe pain and tightness in his calf, minimally by pain medication's. Which of the following is a priority, nursing intervention? - CORRECT ANSWER >>Elevating the extremity to the level of the heart Based on full mechanism, which patient warrants prehospital transfer to a trauma center? - CORRECT ANSWER >>2-year-old falling from second story onto grass

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