TNCC final exam test 2024 open book with verified answers, Exams of Nursing

Download TNCC final exam test 2024 open book with verified answers and more Exams Nursing in PDF only on Docsity! TNCC final exam test 2024 open book with verified answers You are treating a 27-year old male in respiratory distress who was involved in a house fire. Calculating TBSA burned is deferred d/t the need for emergent intubation. At what rate should you begin fluid resuscitation? A) 1000 mL/hrB) 500 mL/hr C) 250 mL/hrD) 125 mL/hr - correct answer-B) 500 mL/hr A patient has been in the ED for several hours waiting to be admitted. He sustained multiple rib fractures and a femur fracture after a fall. He has been awake, alert, and c/o leg pain. His wife reported suddenly becoming anxious and confused. Upon reassessment, the patient is restless, with respiratory distress and petechiae to his neck. the patient is exhibiting signs of symptoms commonly associated with which of the following conditions? A) acute lung injuryB) fat embolismC) PTXD) pulmonary contusion - correct answer-B) fat embolism Which pulse pressure description is an indication of early hypovolemic shock? A) widenedB) narrowed C) boundingD) weak - correct answer-B) narrowed Which of the following considerations is most important when caring for a geriatrictrauma patient?A) head to to examB) medical historyC) incontinenceD) falls - correct answer-B) medical history Which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax? A) increased work of breathingB) unilaterally diminished breath soundsC) pleuritic chest painD) hypotension that worsens with inspiration - correct answer-D) hypotension that worsens with inspiration. 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. The nurse is caring for a 120 kg male is brought in after a warehouse fire and is calculating the patient's fluid resuscitation needs. He has painful red blistering to the entire surface of both upper extremities and superficial burns to the anterior chest. Using the modified Lund and Browder chart to calculate the total BSA burned, how much IV fluids would be administered in the first 8 hours? A) 2280 mL B) 3840 mLC) 4560 mL 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 deficitsB) Multiple abrasions to the extremities C) Multiple requests of waterD) Smell of alcohol on breath - correct answer-D) Smell of alcohol on breath Which of the following occurs during the third impact of a motor vehicle crash? A) The driver of the vehicle collides with the steering wheelB) the vehicle collides with a treeC) 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 A passenger is brought to the emergency department of a rural hospital following ahigh-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 nurseC) Obtained imaging studiesD) Place a gastric tube - correct answer-A) initiate transfer to a trauma center Which of the following injuries is LEAST likely to be promptly identified? A) spleenB) lungC) bowel D) brain - correct answer-C) bowel Patients with a crush injury should be monitored for which of the following conditions? A) Hypernatremia B) Hypercalcemia C) DysrhythmiasD) polyuria - correct answer-C) Dysrhythmias What finding raises suspicion of complete spinal cord injury? A) Weakness in the lower extremitiesB) Priapism C) voluntary anal sphincter toneD) intact reflexes distal to the injury - correct answer-B) Priapism 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 functionB) Tachycardia and respiratory depressionC) Tachycardia and absent motor function below the level of injuryD) 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 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 careC) engage in therapeutic communication to determine the MOID) provide the family with injury prevention recourses - correct answer-A) report your suspicion of the maltreatment in accordance with local regulations A 36-year old female has a deformity of the left wrist after a fall. She is reluctant tomove 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 heartD) 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 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 heartB) repositioning and apply iceC) Elevating the extremity to the level of the heartD) Preparing the patient for ultrasound - correct answer-C) Elevating the extremityto the level of the heart Which of the following is a late sign of increased intracranial pressure? A) Restlessness or drowsinessB) Nausea and vomitingC) Decreased respiratory effortD) Amnesia and anxiety - correct answer-C) Decreased respiratory effort D) it does not increases the risk of life threatening hemorrhage from unstable injuries - correct answer-C) it can worsen cord damage from an unstable spinal injury 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? 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 examC) after palpation of the spine if the patient has no point tenderness the the vertebral columnD) after physical examination if the patient has not neck pain with movement - correct answer-A) after a physical examination if the patient has no radiologic abnormalities on a computed tomography scan If a patient has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation? A) potassiumB) magnesiumC) sodiumD) calcium - correct answer-D) calcium Tearing of the bridging veins is most frequently associated with which brain injury? A) epidural hematoma B) subdural hematoma ***C) diffuse axonal injuryD) intracerebral hematoma - correct answer-B) subdural hematoma A trauma patient is en route to a rural ED. Radiology notifies the charge nurse thatthe 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) BriefB) loopC) debriefD) huddle - correct answer-D) huddle 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 statB) chest to make sure the ventilator is plugged inC) suction the ET tubeD) confirm ET tube placement - correct answer-D) confirm ET tube placement What factor contributes most the kinetic energy of a body in motion? A) accelerationB) massC) velocityD) inertia - correct answer-C) velocity During the primary survey of an unconscious patient with multi-system trauma, thenurse 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 statusC) assist respirations using a BVMD) insert an oropharyngeal airway if there is no gag reflex - correct answer-D) insert an oropharyngeal airway if there is no gag reflex 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) preparednessC) responseD) recovery - correct answer-A) mitigation 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? A. Diagnostic peritoneal lavageB. Serial FAST examsC. Abdominal and pelvic CT scansD. Serial abdominal assessments - correct answer-A) diagnostic peritoneal lavage 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. A) pulse oximetry and capnogaphy **B) respiratory rate and capnographyC) pulse oximetry and respiratory rateD) capnography and capnometry - correct answer-A) pulse oximetry and capnogaphy Which of the following values indicates the need for alcohol withdrawal interventions? A) CIWA-Ar of 36 ***B) GCS 13C) ETCo2 of 48 mm HgD) heart rate of 45 beats/min - correct answer-A) CIWA-Ar of 36 An unresponsive trauma patient has an oropharyngeal airway in place, shallow andlabored 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 medicationsD) contact anesthesia for assistance - correct answer-A) Ventilate with a BVM The trauma nurse knows that placing a bariatric patients in a "ramped position" provides better visualization during the insertion of which device? A) Intraosseous lineB) orogastric tubeC) ET tube ***D) urinary catheter - correct answer-C) ET tube 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 thecostal 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 abruptionB) preterm laborC) uterine ruptureD) fetal demise - correct answer-A) placental abruption