TNCC TEST 2024 ACTUAL FINAL EXAM TEST BANK 300 QUESTIONS AND CORRET DETAILED ANSWERS, Exams of Nursing

Download TNCC TEST 2024 ACTUAL FINAL EXAM TEST BANK 300 QUESTIONS AND CORRET DETAILED ANSWERS and more Exams Nursing in PDF only on Docsity! TNCC TEST 2024 ACTUAL FINAL EXAM TEST BANK 300 QUESTIONS AND CORRET DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) | ALREADY GRADED A+ What are signs of Compensated shock? - ANSWER-Anxiety as blood is shunted from areas responsible for higher brain function, normal systolic BP, elevated diastolic BP, increased RR, bounding pulse, decreased urinary output. What are signs of Decompensated or Progressive shock? - ANSWER-Decreased LOC, decreased systolic BP, narrowing pulse pressure, tachycardia, weak pulses, rapid shallow respirations, cool and cyanotic skin, increased lactic acid levels What are signs of Irreversible shock? - ANSWER-Obtunded, marked hypotension and heart failure, bradycardia, bradypnea, organ failure, acidosis. A - ANSWER-Airway and Alertness with simultaneous cervical spinal stabilization B - ANSWER-Breathing and Ventilation C - ANSWER-Circulation and Control of Hemorrhage D - ANSWER-Disability (neurologic status) E - ANSWER-Exposure and Environmental control F - ANSWER-Full set of Vital Signs, Family Presence, Focused adjuncts When is the KB test appropriate and what does it determine? - ANSWER-Pregnant patient. Detects fetal RBC in maternal circulation. What do you inspect for in the airway? - ANSWER-Tongue obstruction, loose or missing teeth, foreign objects, blood, vomit, secretions, edema or evidence of burn. What is listened for with airway assessment? - ANSWER-Obstructive airway sounds such as snoring, gurgling or stridor, What is palpated with airway assessment? - ANSWER-Occlusive maxillofacial bony deformity. How can you ascertain if the advanced airway is properly placed? - ANSWER-1) Rise and fall of chest 2) Absence of gurgling on auscultation over epigastrium 3) Bilateral breath sounds 4) CO2 detection What are 2 examples of airway adjuncts? - ANSWER-Nasopharyngeal airway and Oropharyngeal airway What are the 3 indications for a definitive airway? - ANSWER-1) Failure to maintain or protect the airway 2) Failure to maintain oxygenation or ventilation 3) A specific anticipated clinical course What is a definitive airway? - ANSWER-A tracheal tube securely placed in the trachea with the cuff inflated. How do you determine when to use a naso or oropharangyeal airway? - ANSWER-Naso if they are conscious, oro if they have no gag reflex. What GCS score necessitates a definitive airway? - ANSWER-8 or less What is inspected during breathing assessment? - ANSWER-Spontaneous breaths, symmetrical chest rise and fall, depth pattern and rate, signs of difficulty, skin color, open pneumothoraces, JVD, singed nasal hairs. JVD and tracheal deviation can be an indication of what? - ANSWER-Tension pneumothorax What and where do you auscultate during breathing assessment? - ANSWER-Presence, quality, and equality at the 2nd intercostal space midclavicular line and the bases at the 5th intercostal space anterior axillary line. What do you palpate for during the breathing assessment? - ANSWER-Bony structures and possible rib fractures. How quickly should you ventilate with a bag mask device? - ANSWER-10-12 breaths per minute Give 4 examples of life threatening pulmonary injuries. - ANSWER-1) Open pneumothorax 2) Tension pneumothorax 3) Flail chest 4) Hemothorax What is inspected for during the Circulation and Control of Hemorrhage assessment? - ANSWER- Uncontrolled external bleeding and skin color What is Auscultated for during the Circulation and Control of Hemorrhage assessment? - ANSWER- Muffled heart sounds which may indicate pericardial tamponade. What is palpated for during the Circulation and Control of Hemorrhage assessment? - ANSWER-Presence of central pulses and skin temperature and moisture. If no central pulses are present what 4 conditions should be assessed for? - ANSWER-1) Penetrating heart wound 2) Pericardial tamponade 3) Rupture of great vessels 4) Abdominal Hemorrhage What does MIST stand for? - ANSWER-MOI Injuries sustained Signs and symptoms Treatment What does SAMPLE stand for? - ANSWER-Symptoms- Allergies- Medications- Past med hx- Last oral intake- Events and Environmental factors Which letters denote the resuscitation adjuncts? - ANSWER-FG Secondary survey includes which letters? - ANSWER-HI List the 6 steps of the initial assessment. - ANSWER-1) Preparation and triage 2) Primary survey with resuscitation adjuncts 3) Reevaluation 4) Secondary survey with reevaluation adjuncts 5) Reevaluation and post resuscitation care 6) Definitive care or transfer List the 7 P's of RSI. - ANSWER-1) Preparation 2) Preoxygenation 3) Pretreatment 4) Paralysis with induction 5) Protection and positioning 6) Placement with proof 7) Post intubation management Name the 3 types of Disruptive shock. - ANSWER-1) Anaphylactic shock 2) Septic Shock 3) Neurogenic Shock Name the 3 stages of shock. - ANSWER-1) Compensated shock 2) Decompensated or Progressive shock 3) Irreversible shock A - ANSWER-Airway and Alertness with simultaneous cervical spinal stabilization B - ANSWER-Breathing and Ventilation Cerebral autoregulation maintains a constant cerebral vascular blood flow as long as the MAP is in what range? - ANSWER-50-150 mmHg Normal cerebral perfusion pressure is what? - ANSWER-60-100 mmHg *** - *** = ICP - ANSWER-MAP - ICP Autoregulation maintains a steady state when the CPP is between what? - ANSWER-50 - 160 mmHg When cerebral autoregulation fails, perfusion is dependent on what and what conditions would complicate this? - ANSWER-MAP, hemorrhage and hypovolemia Early assessment findings of ICP include. - ANSWER-Headache, N&V, amnesia, behavior changes, altered loc Late assessment findings of ICP include. - ANSWER-Dilated nonreactive pupils, unresponsive to stimuli, abnormal posturing, widening pulse pressure, reflex bradycardia, decreased respiratory effort. A unilaterally fixed and dilated pupil may indicate what? - ANSWER-Oculomotor nerve compression from increased ICP. Bilaterally fixed and pinpoint pupils may indicate an injury where? - ANSWER-At the pons. A moderately dilated pupil with sluggish response may be an early sign of what? - ANSWER-Herniation syndrome. What test provides greater neurologic detail than the GCS and what does it include? - ANSWER-FOUR Score, eye response, motor response, brainstem reflexes, respiration Assessment findings of an Intracerebral Hematoma include. - ANSWER-Progressive and often rapid decline in LOC, headache, signs of increasing ICP, pupil abnormalities, himiparesis or hemiplegia. Assessment findings of an Epidural Hematoma include. - ANSWER-Transient LOC followed by a lucid period, headache, dizziness, N&V, hemiparesis, hemiplegia. Assessment findings of an Coup/Contracoup injury include. - ANSWER-Altered loc, behavioral motor or speech deficit, abnormal posturing, signs of increased ICP Assessment findings of acute subdural hematoma include. - ANSWER-Severe headache, changes in LOC, ipsilateral dilated or nonreactive pupil, contralateral hemiparesis How long does it take for symptoms to manifest in both acute and chronic subdural hematomas? - ANSWER-Acute- within 72 hours Chronic- up to 2 weeks Assessment findings of chronic subdural hematomas include. - ANSWER-Altered or steady decline in LOC, headache, loss of memory, altered reasoning, motor deficit, aphasia, ipsilateral unilateral fixed adn dilated pupil, incontinence, seizures What is herniation syndrome? - ANSWER-Shifting of brain tissue with displacement into another compartment. Herniation syndrome assessment findings include. - ANSWER-Asymmetric pupillary reactivity, unilateral or bilateral pupillary dilation, abnormal motor posturing, neurologic deterioration. What are the 2 major types of supratentorial herniation? - ANSWER-Uncal- Lateral push Central- Downward push on brain stem What is the GCS score for mild traumatic brain injury? - ANSWER-13-15 What is the GCS score for moderate traumatic brain injury? - ANSWER-9-12 What is the GCS score for severe traumatic brain injury? - ANSWER-8 or less What is second impact syndrome? - ANSWER-When a patient suffers a 2nd mild TBI before recovery from the first. The 2nd impact causes a loss of autoregulation leading to cerebral edema. What is diffuse axonal injury? - ANSWER-Widespread microscopic damage, primarily to the axons. Depending on severity can lead to persistent vegetative state. How should a patient with head trauma be positioned? - ANSWER-Either with the head of the bed elevated 30 deg or or reverse Trendelenberg 30 deg if boarded. What medications can be administered with traumatic brain injury and when would it be contraindicated? - ANSWER-Mannitol- contraindicated if active intracranial bleed. Anticonvulsant Assessment findings for corneal abrasions include. - ANSWER-Photophobia, pain, redness, lid swelling Assessment findings for corneal lacerations include. - ANSWER-Pain, decreased vision What is hyphema? - ANSWER-Hyphema is a collection of blood in the anterior chamber of the eye. What assessment finding is indicative of retrobulbar hematoma? - ANSWER-IOP greater than 40 mmHg What is a normal intraoccular pressure? - ANSWER-10-20 mmHg What assessment finding is indicative of globe rupture? - ANSWER-Anterior chamber appears flat or shallow and teardrop shaped pupils. Ocular burn findings include. - ANSWER-Swelling of sclera, conjunctival irritaion, corneal clouding, pain. What is normal pH of the eye? - ANSWER-7.0 - 7.3 Describe pulsus paradoxus with regards to cardiac tamponade. - ANSWER-At some point in the accumulation of fluid (around 250-300 ml), the pericardium reaches maximal distension and results in a phenomenon called pulsus paradoxus. Basically, the two ventricles are competing for space within the pericardial sac, so any increase in right ventricular volume (increased venous return during inspiration) results in the interatrial/ventricular septae to bulge leftwards. The opposite happens during expiration. This can be observed on the blood pressure waveform (defined by a drop in systolic blood pressure exceeding 10 mm Hg during inspiration), and on echocardiography. What is the appropriate intervention for cardiac tamponade? - ANSWER-Pericardial decompression. 3-4 cm incision is made just to the left of the xiphoid process. What injuries are seen with aortic disruption? - ANSWER-Fx of sternum, 1st or 2nd rib or scapula. What are the main assessment finding and interventions with aortic disruption? - ANSWER-Back or chest pain, unequal extremity pulse or BP, hypotension, paraplegia. Prep for surgery, consider a massive transfusion. Penetrating trauma below which intercostal space indicates a potential for ruptured diaphragm? - ANSWER-4th What assessment findings are seen with a ruptured diaphragm and what is the intervention? - ANSWER- Dyspnea, dysphagia, Kehr's sign, bowel sounds heard in the lung fields. Prepare for surgery Describe Kehr's sign. - ANSWER-Sharp epigastric or chest pain radiating to the L shoulder. What is the leading cause of preventable death in the trauma patient? - ANSWER-Hemorrhage What findings would you see on a patient with a hepatic injury? - ANSWER-Ecchymosis around the umbilicus or in RUQ, tenderness in RUQ, elevated LFT. A fracture of the 9-12 ribs would be indicative of what injury? - ANSWER-Hepatic What assessments are found in a splenic injury? - ANSWER-Ecchymoses and tenderness in LUQ, abdominal distention, pain in L shoulder while lying supine. How can a pancreatic injury be confirmed? - ANSWER-Serial serum amylase levels and abdominal examinations. What are assessment findings of small bowel injuries? - ANSWER-Seatbelt sign, rebound tenderness, guarding When would a patient with small bowel injury need operative management? - ANSWER-Peritonitis or hemodynamic instability What are assessment findings for large bowel injuries? - ANSWER-Peritoneal irritation, hypovolemic shock, evisceration of bowel What assessment findings are expected for a patient with rectal injury? - ANSWER-Bleeding from and around rectum, scrotal hematoma, foreign objects What assessment findings are expected for a patient with a gastric injury and what is the intervention? - ANSWER-Tenderness in epigastric area, bloody drainage from OG or NG. Prep for surgery Bladder and urethral injuries are often accompanied by what other injury? - ANSWER-Pelvic fracture What are assessment findings for bladder or urethral injury? - ANSWER-Urge but inability to void and blood at the urethral meatus. What is the difference in care for extraperitoneal bladder injuries and intraperitoneal? - ANSWER- Extraperitoneal treated with catheter drainage. Intraperitoneal requires surgical intervention to close the multilayer injury. What are the 2 types of pelvic fractures and what criteria is used to classify them? - ANSWER-Stable fx do not involve the pelvic ring or have minimal displacement. Unstable have 2 or more fx of the pelvic ring that have outward rotational displacement. What is the correct technique when palpating the pelvis? - ANSWER-Apply gentle pressure over the iliac wins downward and medially. Unstable pelvic fx increase the volume of the pelvic cavity, combined with what other injuries can this become life threatening? - ANSWER-Large volume blood loss and/or injury to the genitourinary system. What assessment findings are expected in a pelvic fx? - ANSWER-Shortening and external rotation of the leg, blood at the urinary meatus, pelvic instability, unexplained hypotension or evidence of hypovolemic shock. What intervention can help to control hemorrhage with a pelvic fx? - ANSWER-A folded sheet tied around the pelvis. What is Turner's sign? - ANSWER-Ecchymosis over the flank at the 11th and 12th ribs What findings are expected on a patient with a renal injury? - ANSWER-Turners sign, hematuria, flank tenderness Give examples of Primary Spinal Cord Injury? - ANSWER-Laceration or puncture of the cord from displaced bone fragments, crushed or contused disc material, stretching or crushing of spinal cord, bleeding into vertebral column. Describe cord concussion. - ANSWER-Transient dysfunction lasting 24-48 hours. Describe cord contusion. - ANSWER-Bruising of the neural tissue causing edema, ischemia and possible infarction of tissue from cord compression. Describe cord transection. - ANSWER-Complete disruption of the neural elements. All cord mediated functions below the level of the injury are permanently lost. Describe a Level 3 High energy open fracture. - ANSWER-High degree of contamination, severe comminution and instability, extensive damage to muscle skin and neurovascular structures. Describe a Level 3 A, B, and C open fracture. - ANSWER-A- Soft tissue coverage of fracture is adequate B- Extensive injury to or loss of soft tissue, bone exposure C- Any open fracture associated with arterial injury Assessment findings of an amputation would include. - ANSWER-Tissue loss, pain, controlled or severe bleeding, possible evidence of hypovolemic shock. Crush injuries can result in what complications? - ANSWER-Compartment syndrome, hyperkalemia, rhabdomyolysis What are the most common sites of compartment syndrome? - ANSWER-Lower leg and forearm Describe compartment syndrome. - ANSWER-Elevated compartment pressures are commonly caused by hematoma formation secondary to fractures from increased pressure or decreased space. What are the 6 P's of compartment syndrome? - ANSWER-Pain, Pressure, Pallor, Pulses, Paresthesia, Paralysis How long does it take muscle necrosis to occur in compartment syndrome? - ANSWER-4-6 hours How long does it take for peak hyperkalemia following compartment syndrome? - ANSWER-12 hours How can compartment syndrome lead to rhabdomyolysis and what are the symptoms? - ANSWER- Cellular destruction releases myoglobin which is excreted by the kidneys posing a potential risk for acute renal failure. Symptoms are muscle pain, numbness, muscle weakness and dark red/brown urine. Assessment findings of joint dislocations include... - ANSWER-Inability to move affected joint, joint deformity, pain, edema, abnormal range of motion, diminished or absent pulses and diminished sensory function Complications of hip dislocations are. - ANSWER-Avascular necrosis of femoral head, sciatic nerve compression -reduction of hip is a priority Complications of ankle dislocations are. - ANSWER-May require realignment to restore circulation. Complications of knee dislocations are. - ANSWER-Nerve damage, constriction of popliteal artery and vein. Popliteal artery damage may not become apparent for hours. Describe an abrasion. - ANSWER-A partial or full thickness wound that denudes the skin. Describe an avulsion. - ANSWER-A full thickness wound caused by a tearing or ripping of skin and soft tissue. The wound edges are not well approximated. Describe a degloving. - ANSWER-An avulsion where the skin and tissue is removed exposing underlying structures. What are the risk factors for infection with puncture wounds? - ANSWER-Large or deep wounds, contaminated (bite), wounds with osseous involvement, high pressure injuries, wounds more than 6 hours old Describe the 3 levels of frostbite. - ANSWER-Partial thickness: skin becomes hyperemic and edematous Deep partial thickness: clear blisters begin to form. If blood is present in the blister it may suggest full thickness Full thickness: Total skin necrosis reaches into the subcutaneous tissue and involves muscle and bone. Skin turns black and dry hard eschar forms. What are appropriate interventions for frostbite? - ANSWER-Quickly rewarm over 30 minutes in 40 deg water. Admin pain medication. Extract fluid from clear blisters. Do not rub the skin. What are the 4 classifications of burns? - ANSWER-Thermal, Chemical, Electrical, Radiation In a burn patient, a hoarse voice, carbonaceous sputum, burns around the mouth or nares or stridor can be indicative of what? - ANSWER-Airway edema secondary to burn What condition does a burn patient need to be monitored for if they complain of headache, nausea or confusion? - ANSWER-CO poisoning Describe pulmonary injury in a burn patient and how it can complicate treatment. - ANSWER-Inhalation of fumes damages bronchioles which increases permeability of cell membranes allowing leakage which empairs gas exchange. What is capillary leak syndrome? - ANSWER-Inflammatory response happens throughout the body resulting in third spacing. During this phase almost half of resuscitation fluids can leak from the veins into the tissue. What percent of body surface burn puts you at risk for capillary leak syndrome? - ANSWER-20% How long can capillary leak syndrome last? - ANSWER-6-12 hours The inflammatory response in burn patients can potentially lead to cardiac collapse, how? - ANSWER- Histamine and prostaglandin leads to vasodilation and Bradykinin causes increased permeability of venules Circumferential burns to the chest reduce the patients ability to do what? - ANSWER-Breathe deeply What are the 3 burn zones of injury? - ANSWER-Zone of Coagulation Zone of Stasis Zone of hyperemia Describe the zone of coagulation. - ANSWER-Most severely damaged area, debridement is necessary for healing, skin grafts are considered.