TNCC FINAL EXAM 2 LATEST VERSIONS 2024-2025 CONTAINS 100 QUESTIONS AND CORRECT ANSWERS (VE, Exams of Nursing

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CONTAINS 100 QUESTIONS AND CORRECT

ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED

A+

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/ 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 - answerA) 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

CONTAINS 100 QUESTIONS AND CORRECT

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A+

Why is a measure of serum lactate obtained in the initial assessment of the trauma patient? Answer: c - answera) to measure oxygenation and ventilation b) to quantify the base deficit for the adequacy of cellular perfusion c) *to gauge end-organ perfusion and tissue hypoxia ** d) to determine the underlying cause of shock 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?

CONTAINS 100 QUESTIONS AND CORRECT

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A+

Answer: A - answerA) 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 - answerA) epidural hematoma B) diffuse axonal injury C) post-concussive syndrome D) subdural hematoma ***

CONTAINS 100 QUESTIONS AND CORRECT

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A+

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? Answer: D - answerA) Alert with no neurologic deficits B) Multiple abrasions to the extremities C) Multiple requests of water D) Smell of alcohol on breath *** Which of the following occurs during the third impact of a motor vehicle crash? Answer: C - answerA) The driver of the vehicle collides with the steering wheel

CONTAINS 100 QUESTIONS AND CORRECT

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B) the vehicle collides with a tree A+

CONTAINS 100 QUESTIONS AND CORRECT

ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED

A+

C) the aorta is torn at its attachment with the ligamentum arteriosum D) the airbag deploys and strikes the front seat passenger *** 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 - answerA) initiate transfer to a trauma center ** B) provide report to the operating room nurse C) Obtained imaging studies D) Place a gastric tube Which of the following injuries is LEAST likely to be promptly identified?

CONTAINS 100 QUESTIONS AND CORRECT

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A+

Answer: C - answerA) spleen B) lung C) bowel *** D) brain Patients with a crush injury should be monitored for which of the following conditions? Answer: C - answerA) Hypernatremia B) Hypercalcemia C) Dysrhthmias ** D) polyuria What finding raises suspicion of complete spinal cord injury?

CONTAINS 100 QUESTIONS AND CORRECT

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A+

Answer: B - answerA) Weakness in the lower extremities B) Priapism *** C) voluntary anal sphincter tone D) intact reflexes distal to the injury A patient with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? Answer: D - answerA) 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 ***

CONTAINS 100 QUESTIONS AND CORRECT

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A+

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 thepriority nursing intervention? Answer: A - answerA) 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 resourse 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?

CONTAINS 100 QUESTIONS AND CORRECT

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A+

Answer: C - answerA) 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 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? Answer: B - answerA) 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.

CONTAINS 100 QUESTIONS AND CORRECT

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A+

Which of the following is a late sign of increased intracranial pressure? Answer: C Cushing Response Widening pulse pressure Reflex bradycardia Decreased RR - answerA) Restlessness or drowsiness B) Nausea and vomiting C) Decreased respiratory effort** D) amnesia and anxiety

CONTAINS 100 QUESTIONS AND CORRECT

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A+

Which of the following mnemonics can help the nurse prioritize care for a

CONTAINS 100 QUESTIONS AND CORRECT

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A+

trauma patient withmassive uncontrolled hemorrhage? Answer: B - answerA) ABC B) MARCH*** C) AVPU D) VIPP 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 - answerA) initiate two large caliber intravenous lines for Ringers lactate solution administration *** B) Administer Dilaudid for pain control and provide comfort care

CONTAINS 100 QUESTIONS AND CORRECT

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C) Place the patient in an observation A+ area for care within the next

few hours

CONTAINS 100 QUESTIONS AND CORRECT

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A+

D) Contact the command center for the personnel to notify next of kin. 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 - answerA) needle decompression B) tube thoracostomy C) dressing removal ** D) surgical repair A patient is found lying on the floor after falling 13 hours ago. Which of the following lab values isexpected with a

CONTAINS 100 QUESTIONS AND CORRECT

ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED

musculoskeletal complication associated A+ with this presentation?

CONTAINS 100 QUESTIONS AND CORRECT

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A+

Answer: A - answerA) elevated creatine kinase *** B) decreased potassium level C) decreased WBC D) elevated GFR 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 - answerA) 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

CONTAINS 100 QUESTIONS AND CORRECT

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A+

D) preparing for drug assisted intubation Which of the following is a component of the trauma triad of death? Answer: A hypothermia, metabolic acidosis, coagulopathy - answerA) Acidosis ** B) hyperthermia C) hemorrhage D) sepsis A 35-year old male presents with facial trauma after bring struck inthe face with a baseball. atear-drop shaped left pupil is noted on exam.

CONTAINS 100 QUESTIONS AND CORRECT

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What type of injury is suspected? A+

CONTAINS 100 QUESTIONS AND CORRECT

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A+

Answer: B - answerA) oculomotor nerve palsy B) globe rupture *** C) uncal herniation D) retinal detachment Which of the following is true about the log roll maneuver? Answer: C - answerA) 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

CONTAINS 100 QUESTIONS AND CORRECT

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EMS arrives with the intoxicated A+ driver of a car involved in a MVC.

EMS

CONTAINS 100 QUESTIONS AND CORRECT

ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED

A+

reports significant damage to the drivers side of the car. The patient is asking to have the cervical color removed. when is it appropriate to remove the cervical collar? Answer: A - answerA) after a physical examination if the patient has no radiologic abnormalities on a computed tomography scan

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B) after physician evaluation if the patient has not neurologic abnormalities on exam C) after palpation of the spine if the patient has no point tenderness the the vertebral column D) after physical examination if the patient has not neck pain with movement Tearing of the bridging veins is most frequently associated with which brain injury? Answer: B - answerA) epidural hematoma

CONTAINS 100 QUESTIONS AND CORRECT

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A+

B) subdural hematoma ***

CONTAINS 100 QUESTIONS AND CORRECT

ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED

A+

C) diffuse axonal injury

CONTAINS 100 QUESTIONS AND CORRECT

ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED

A+

D) intracerebral hematoma If a patient has received multiple transfusions of banked blood preserved with citrate, whichelectrolyte is most likely to drop and require supplementation? Answer: D - answerA) potassium B) magnesium C) sodium D) calcium *** 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?