TNCC FINAL EXAM TEST 2022 OPEN BOOK, Exams of Nursing

Download TNCC FINAL EXAM TEST 2022 OPEN BOOK and more Exams Nursing in PDF only on Docsity! TNCC FINAL EXAM TEST 2022 OPEN BOOK 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? Answer: A - ANS 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 resourse A 20-year old male presents to the ED c/o severe lower abd pain after landing hard on the bicycle cross bars which performing an aerial BMX maneuver. Secondary assessment reveals lower abd tenderness and scrotal ecchymosis. Which of the following orders would the nurse questions? Answer: C - ANS A) Fast exam B) CT scan C) straight cath for urine sample *** D) ice and elevation of the scrotum A 35-year old male presents with facial trauma after bring struck inthe face with a baseball. a tear-drop shaped left pupil is noted on exam. What type of injury is suspected? Answer: B - ANS A) oculomotor nerve palsy B) globe rupture *** C) uncal herniation D) retinal detachment 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 - ANS A) apply a sling and elevate the extremity to the level of the heart. TNCC FINAL EXAM TEST 2022 OPEN BOOK 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. A 49-year old restrained driver involved in a MVC presents to the trauma center c/o abd, pelvic, and bil lower extremity pain Vitals signs are stable. The nurse can anticipate all of these negative fast exam except which of the following? Answer: A The FAST exam is done at the bedside to identify pathological fluid in the abdominal and pelvic cavities. FAST exams reduce the use of more invasive diagnostic peritoneal lavage and can be repeated if clinical changes or hemodynamic changes occur. A negative FAST study does not rule out injury and may warrant a follow-up computed tomography scan. Serial FAST exams can identify increasing abdominal fluid collections from hemorrhage. Diagnostic peritoneal lavage/diagnostic peritoneal aspiration is performed by the surgical team to rapidly identify the presence of hemorrhage in patients who are hemodynamically unstable after trauma. - ANS A) diagnostic peritoneal lavage *** B) serial fast exams C) abdominal and pelvic CT scans D) serial abdominal assessments 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 TNCC FINAL EXAM TEST 2022 OPEN BOOK 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 - ANS 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 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 - ANS A) 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 - ANS A) 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? TNCC FINAL EXAM TEST 2022 OPEN BOOK Answer: D - ANS A) 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 - ANS 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 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 - ANS A) 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 - ANS A) padding the upper back while stabilizing the cervical spine *** B) applying a tight-fitting NRB mask with an attached resevior TNCC FINAL EXAM TEST 2022 OPEN BOOK 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 - ANS 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 *** EMS arrives with the intoxicated driver of a car involved in a MVC. EMS 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 - ANS A) after a physical examination if the patient has no radiologic abnormalities on a computed tomography scan *** 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 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 - ANS A) Alert with no neurologic deficits B) Multiple abrasions to the extremities C) Multiple requests of water D) Smell of alcohol on breath *** TNCC FINAL EXAM TEST 2022 OPEN BOOK 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 - ANS A) 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 - ANS A) acceleration B) mass C) velocity *** D) inertia What finding raises suspicion of complete spinal cord injury? Answer: B - ANS A) 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 - ANS A) CIWA-Ar of 36 *** TNCC FINAL EXAM TEST 2022 OPEN BOOK 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 - ANS A) 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. - ANS A) 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 - ANS A) head to to exam B) medical history ** TNCC FINAL EXAM TEST 2022 OPEN BOOK C) incontinence D) falls Which of the following injuries is LEAST likely to be promptly identified? Answer: C - ANS A) 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 - ANS A) 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 - ANS A) Restlessness or drowsiness B) Nausea and vomiting