TNCC 9th Edition final exam test - questions with correct and verified answers. Graded A+, Exams of Nursing

Download TNCC 9th Edition final exam test - questions with correct and verified answers. Graded A+ and more Exams Nursing in PDF only on Docsity! TNCC 9th Edition final exam test - questions with correct and verified answers. Graded A+ 1. You are caring for a patient who was thrown from a bike and was not wearing a helmet. While performing the head-to-toe assessment, you note clear drainage from the right ear. Which of the following is the most appropriate next step? A. Clean the ear with a cotton-tipped applicator. B. Pack the ear with gauze. C. Notify the physician D. Document and continue the exam. - Correct answer C. Notify the physician" 2. "A patient is brought to the emergency department of a rural hospital following a high-speed motor vehicle collision. When significant abdominal and pelvic injuries are noted in the primary survey, what is the priority intervention? A. Initiate transfer to a trauma center B. Attempt family notification C. Obtain additional imaging studies D. Place an indwelling urinary catheter - Correct answer A. Initiate transfer to a trauma center" 3. "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? A) Brief B) loop C) debrief D) huddle - Correct answer D) huddle" 4. "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? A) 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 - Correct answer D) confirm ET tube placement" 5. "What factor contributes most the kinetic energy of a body in motion? A) acceleration B) mass C) velocity D) inertia - Correct answer C) velocity" 6. "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? A) 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 - Correct answer D) insert an oropharyngeal airway if there is no gag reflex" 7. "Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of future disaster. Which phase of the disaster life cycle does this describe? A) mitigation B) preparedness C) response D) recovery - Correct answer A) mitigation" 8. "An adult who fell from a second story roof is brought to the emergency department by private vehicle. The patient is confused with unlabored respirations and has strong, palpable radial pulses. There is an open wound in proximity to an obvious deformity of the left lower extremity. What is the priority intervention? A. Initiate cervical spine stabilization B. Apply a splint to the lower extremity C. Put the patient on portable oxygen. D. Log roll the patient onto a spine board - Correct answer A. Initiate cervical spine stabilization" 9. "An adult patient who sustained a severe head trauma has been intubated and is being manually ventilated via a bag-mask device at a rate of 18 breaths/minute. The patient has received one intravenous fluid bolus of 500 mL of warmed isotonic crystalloid solution. The PaCO2 is 30 mm Hg (4.0 kPa), and the pulse oximetry is 92%. BP is 142/70 mm Hg. What is the most important intervention to manage the cerebral blood flow? A. Decrease the rate of manual ventilation. B. Initiate another fluid bolus. C. Recheck endotracheal tube placement. D. Increase the amount of oxygen delivered. - Correct answer A. Decrease the rate of manual ventilation." 10. "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? d) to determine the underlying cause of shock - Correct answer c) to gauge end-organ perfusion and tissue hypoxia" 22. "EMS brings a patient who fell riding his bicycle. Using the American College of Surgeons screening guidelines, which assessment finding would prompt the nurse to prepare the patient for radiologic spine clearance? A) Alert with no neurologic deficits B) Multiple abrasions to the extremities C) Multiple requests of water D) Smell of alcohol on breath - Correct answer D) Smell of alcohol on breath" 23. "Which of the following occurs during the third impact of a motor vehicle crash? A) 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 - Correct answer C) the aorta is torn at its attachment with the ligamentum arteriosum" 24. "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? A) initiate transfer to a trauma center B) provide report to the operating room nurse C) Obtained imaging studies D) Place a gastric tube - Correct answer A) initiate transfer to a trauma center" 25. "Which of the following injuries is LEAST likely to be promptly identified? A) spleen B) lung C) bowel D) brain - Correct answer C) bowel" 26. "Patients with a crush injury should be monitored for which of the following conditions? A) Hypernatremia B) Hypercalcemia C) Dysrhythmias D) polyuria - Correct answer C) Dysrhythmias" 27. "What finding raises suspicion of complete spinal cord injury? A) Weakness in the lower extremities B) Priapism C) voluntary anal sphincter tone D) intact reflexes distal to the injury - Correct answer B) Priapism" 28. "A patient with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? A) 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 - Correct answer D) Bradycardia and absent motor function below the level of the injury" 29. "A 5-year old child presents to the ED 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 the maltreatment in accordance with local regulations B) apply ice to the bruises and consult wound care C) engage in therapeutic communication to determine the MOI D) provide the family with injury prevention recourses - Correct answer A) report your suspicion of the maltreatment in accordance with local regulations" 30. "A 36-year old female has a deformity of the left wrist after a fall. She is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention? A) apply a sling and elevate the extremity to the level of the heart. B) apply a splint and elevate above the level of the heart C) Apply a sling and elevate the extremity above the level of the heart D) apply a splint and elevate the extremity to the level of the heart. - Correct answer B) apply a splint and ELEVATE ABOVE THE LEVEL OF THE HEART" 31. "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? A) 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 - Correct answer C) Elevating the extremity to the level of the heart" 32. "Which of the following is a late sign of increased intracranial pressure? A) Restlessness or drowsiness B) Nausea and vomiting C) Decreased respiratory effort D) Amnesia and anxiety - Correct answer C) Decreased respiratory effort" 33. "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? A) initiate two large bore 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. - Correct answer A) initiate two large bore intravenous lines for Ringers lactate solution administration" 34. "Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? A) ABC B) MARCH C) AVPU D) VIPP - Correct answer B) MARCH" 35. "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 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? A) needle decompression B) tube thoracostomy C) dressing removal D) surgical repair - Correct answer C) dressing removal" 36. "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? A) elevated creatine kinase B) decreased potassium level C) decreased WBC D) elevated GFR - Correct answer A) elevated creatine kinase" 37. "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? A) 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 - Correct answer A) padding the upper back while stabilizing the cervical spine" 38. "A 35-year old male presents with facial trauma after bring struck in the face with a baseball. a tear- drop shaped left pupil is noted on exam. What type of injury is suspected? D) negative intrapleural pressure - Correct answer A) worsening pneumothorax" 50. "Which of the following is NOT considered goal-directed therapy of cardiogenic shock? A) controlled fluid boluses B) antidysrhythmic administration C) pericardiocentesis D) cardiac cath - Correct answer C) pericardiocentesis" 51. "What bedside monitoring parameters are used to assess for adequacy of oxygenation and effectiveness of ventilation? A) pulse oximetry and capnogaphy B) respiratory rate and capnography C) pulse oximetry and respiratory rate D) capnography and capnometry - Correct answer A) pulse oximetry and capnogaphy" 52. "Which of the following values indicates the need for alcohol withdrawal interventions? A) CIWA-Ar of 36 B) GCS 13 C) ETCo2 of 48 mm Hg D) heart rate of 45 beats/min - Correct answer A) CIWA-Ar of 36" 53. "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? A) Ventilate with a BVM B) Prepare for cricothyroidotomy C) administer reversal medications D) contact anesthesia for assistance - Correct answer A) Ventilate with a BVM" 54. "The trauma nurse knows that placing a bariatric patients in a "ramped position" provides better visualization during the insertion of which device? A) Intraosseous line B) orogastric tube C) ET tube D) urinary catheter - Correct answer C) ET tube" 55. "You are caring for a patient who was involved in a MVA and is 32 weeks pregnant. Findings of your secondary survey include abd pain on palpation, fundal high at the costal margin, and some dark bloody show. Varying, accelerations and decelerations are noted on the cardiotocography. These findings are most consistent with which of the following? A) placental abruption B) preterm labor C) uterine rupture D) fetal demise - Correct answer A) placental abruption" 56. A patient fell two weeks ago, striking their head. Today, the patient presented with a persistent headache and nausea and was diagnosed with a small subdural hematoma. The patient has been in the ED for 24 hours awaiting an inpatient bed. The night shift nurse reports the patient has been anxious, restless, shaky, and vomited twice during the night. The patient states they couldn't sleep because a young child kept coming into the room. What is the most likely cause for these signs and symptoms? a. increase intracranial pressure b. alcohol withdrawal c. rhabdomyolysis d. pulmonary embolus - Correct answer b. alcohol withdrawal" 57. "Treatment for frostbite can include which of the following interventions? a. warm the affected part over 30-60 minutes b. use gentle friction to improve circulation c. administer tissue plasminogen activator d. leave all of the blisters intact - Correct answer c. administer tissue plasminogen activator" 58. "A patient with a spinal cord injury at C5 is being cared for in the emergency department while awaiting transport to a trauma center. Which of the following represents the highest priority for ongoing assessment and management for this patient? a. maintain adequate respiratory status. b. administer balanced resuscitation fluid c. perform serial assessments of neurologic function d. maintain core temperature - Correct answer a. maintain adequate respiratory status" 59. "Following a bomb explosion, fragmentation injuries from the bomb or objects in the environment are examples of which phase of injury? a. primary b. secondary c. tertiary d. quaternary - Correct answer b. secondary" 60. "A trauma nurse cared for a child with devastating burns two weeks ago. The nurse called in sick for a couple of days and is now back working on the team. Which of the following behaviors would indicate this nurse is coping well? a. They are talking about taking the emergency nursing certification examination. b. They keep requesting to be assigned to the walk-in/ambulatory area c. They are impatient and snap at their coworkers. d. They are thinking about transferring out of the emergency department. - Correct answer a. They are talking about taking the emergency nursing certification examination." 61. "Which of the following accurately describes ventilation principles associated with use of a bag-mask device for an adult? a. Compress the bag-mask device at a rate of one breath every 6 seconds. b. Delivers 100% oxygen. c. Squeeze the bag-mask device completely for each breath. d. Maintain the oxygen saturation levels between 92% and 94%. - Correct answer a. Compress the bag-mask device at a rate of one breath every 6 seconds." 62. "The general impression step in the initial assessment provides the opportunity to do which of the following? a. Assess for uncontrolled internal hemorrhage b. Accurately triage the patient c. Reprioritize circulation before airway or breathing. d. Activate the trauma team - Correct answer c. Reprioritize circulation before airway or breathing." 63. "The vital signs of a pregnant trauma patient at 30 weeks include a blood pressure of 94/62 mm Hg and a heart rate of 108 beats/minute. Fetal heart tones are 124 beats/minute. The emergency nurse interprets the patient's hemodynamic findings as an indication of which of the following? a. Decompensated shock b. Normal vital signs in pregnancy c. Compensated shock d. Supine hypotension syndrome - Correct answer b. Normal vital signs in pregnancy" 64. "While performing an assessment on a 13-month-old involved in a motor vehicle collision, the nurse identifies which of the following findings from the patient as a sign of possible altered mental status? a. Sunken fontanel b. Crying, but consolable c. Spontaneous movement of arms and legs d. Cooperation with the assessment - Correct answer d. Cooperation with the assessment" 65. "A patient involved in a MVC has sustained a fracture to the second rib of the anterior left chest. Which concurrent injury is most commonly associated with this fracture? a. Blunt cardiac injury b. Brachial plexus injury c. Pneumothorax d. Hemothorax - Correct answer b. Brachial plexus injury" 66. "A patient arrives at the emergency department by private vehicle after sustaining an injury to the right lower extremity while using a saw. There is a large gaping wound to the right thigh area with significant bleeding. What is the priority intervention? a. Elevate the extremity to the level of the heart b. Initiate direct pressure c. Apply a tourniquet d. Cover the open wound with sterile saline dressings - Correct answer b. Initiate direct pressure" 67. "What is the best position for maintaining an open airway in the obese patient? a. Prone b. Supine c. Reverse Trendelenburg d. Right lateral recumbent - Correct answer c. Reverse Trendelenburg" 84. "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" 85. "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" 86. "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" 87. "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" 88. "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" 89. "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" 90. "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" 91. "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" 92. "What position optimizes ventilation in the obese patient with a lumbar fracture? - Correct answer Reverse trendelenburg" 93. "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" 94. "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" 95. "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" 96. "A patient has been diagnosed with an incomplete spinal cord injury at L1. Which finding would indicate sacral sparing? - Correct answer voluntary anal sphincter tone" 97. "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" 98. "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" 99. "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" 100. "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"