TNCC Written Exam Questions and Answers 2024, Exams of Nursing

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TNCC Written Exam Questions with 100% Correct Answers 2024

What are the late signs of breathing compromise? - Answer--- Tracheal deviation

• JVD What are signs of ineffective breathing? - Answer--- AMS
• Cyanosis, especially around the mouth
• Asymmetric expansion of chest wall
• Paradoxical movement of the chest wall during inspiration and expiration
• Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
• Sucking chest wounds
• Absent or diminished breath sounds
• Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
• Anticipate definitive airway management to support ventilation. Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - Answer--A tight-fitting nonrebreather mask at 12 - 15 lpm. What intervention should be done if a pt presents with effective circulation? - Answer--- Insert 2 large caliber IV's
• Administer warmed isotonic crystalloid solution at an appropriate rate What are signs of ineffective circulation? - Answer--- Tachycardia
• AMS
• Uncontrolled external bleeding
• Pale, cool, moist skin
• Distended or abnormally flattened external jugular veins
• Distant heart sounds What are the interventions for Effective/Ineffective Circulation? - Answer--- Control any uncontrolled external bleeding by:

• Applying direct pressure over bleeding site
• Elevating bleeding extremity
• Applying pressure over arterial pressure points
• Using tourniquet (last resort).
• Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution
• Use warmed solution
• Use pressure bags to increase speed of IVF infusion
• Use blood administration tubing for possible administration of blood
• Use rapid infusion device based on protocol
• Use NS 0.9% in same tubing as blood product
• IV = surgical cut-down, central line, or both.
• Blood sample to determine ABO and Rh group
• IO in sternum, legs, arms or pelvis
• Administer blood products
• PASG (without interfering with fluid resuscitation) What are factors that contribute to ineffective ventilation? - Answer--- AMS
• LOC
• Neurologic injury
• Spinal Cord Injury
• Intracranial Injury
• Blunt trauma
• Pain caused by rib fractures
• Penetrating Trauma
• Preexisting hx of respiratory diseases
• Increased age What medications are used during intubation? - Answer--LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? - Answer--PREPARATION:
• gather equipment, staffing, etc. PREOXYGENATION:
• Use 100% O2 (prevent risk of aspiration). PRETREATMENT:
• Decrease S/E's of intubation PARALYSIS WITH INDUCTION:
• Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING:
• Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF
• Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30 - 60 seconds between attempts.

• Listening to breath sounds over the epigastrum and chest walls while ventilating the pt
• CO2 detector
• Esophageal detection device
• Chest x-ray How do you inspect the chest for adequate ventilation? - Answer--Observe:
• mental status
• RR and pattern
• chest wall symmetry
• any injuries
• patient's skin color (cyanosis?)
• JVD or tracheal deviation? (Tension pneumothorax) What are you looking for when auscultating lung sounds? - Answer--Absence of BS:
• Pneumothorax
• Hemothorax
• Airway Obstruction Diminished BS:
• Splinting or shallow BS may be a result of pain What are you looking for when percussing the chest? - Answer--Dullness:
• hemothorax Hyperresonance
• Pneumothorax What are you looking for when palpating the chest wall, clavicles and neck? - Answer--- Tenderness
• Swelling
• subcutaneous emphysema
• step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax. What is the DOPE mnemonic? - Answer--D - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing Explain Hypovolemic Shock. - Answer--Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn).

Some causes:

• Blood loss
• Burns, etc. Explain Cardiogenic Shock. - Answer--Syndrome that results from ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes: MI, Blunt cardiac injury, Mitral valve insufficiency, dysrhythmias, Cardiac Failure Explain Obstructive Shock. - Answer--Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes:
• Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume).
• Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium.
• Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock Explain Distributive Shock. - Answer--Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. What is vascular response? - Answer--As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. What is renal response? - Answer--Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes:

• decreased coronary artery perfusion
• Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage. How would you assess a pt in hypovolemic shock? - Answer--(Use Initial Assessment) and then: Inspect:
• LOC
• Rate and quality of respirations
• External bleeding?
• Skin color and moisture
• Assess jugular veins and peripheral veins Auscultate:
• BP
• Pulse pressure
• Breath sounds
• Heart sounds
• Bowel sounds Percuss:
• Chest and abdomen Palpate:
• Central pulse (carotid or femoral)
• Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse
• Palpate peripheral pulses
• Palpate skin temp and moisture Diagnostic Procedures:
• Xrays and other studies
• Labs Planning and Implementation
• Oxygen
• IV's with warmed replacement fluids
• Control external bleeding with direct pressure
• Elevate LE's
• NGT
• Foley
• Monitor and pulse oximeter
• Monitor for development of coagulopathies
• Surgery? ICP is a reflection of what three volumes? What happens when one increases? - Answer--1. Brain

2. CSF
3. Blood within the nonexpansible cranial vault

As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. What are the early signs and symptoms of increased ICP? - Answer--- Headache

• N/V
• Amnesia regarding events around the injury
• Altered LOC
• Restlessness, drowsiness, changes in speech, or loss of judgement What are the late observable signs of symptoms of increased ICP? - Answer--- Dilated, nonreactive pupil
• Unresponsiveness to verbal or painful stimuli
• Abnormal motor posturing patterns
• Widening pulse pressure
• Increased systolic blood pressure
• Changes in RR and pattern
• Bradycardia What is Cushing's phenomenon or Cushing's Reflex? - Answer--Triad of progressive HTN, bradycardia and diminished respiratory effort. What are the two types of herniation that occurs with ICP? - Answer--1. Uncal herniation

2. Central or transtentorial herniation Why does herniation occur? What are the symptoms? - Answer--Because of uncontrolled increases in ICP. S/E's

• Unilateral or bilateral pupillary dilation
• AsyDimmetric pupillary reactivity
• Abnormal motor posturing
• Other evidence of neurologic deterioration Define uncal herniation. - Answer--The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes.

What is diffuse axonal injury and its signs and symptoms? - Answer--(DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. S/S:

• Immediate unconsciousness
• mild DAI, coma = 6 - 24 hrs
• severe DAI, coma = weeks/months or persistent vegetative state
• Elevated ICP
• Abnormal posturing
• HTN
• Hyperthermia
• Excessive sweating because of autonomic dysfunction
• Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits What is a cerebral contusion and its S/S? - Answer--A common focal brain injury in which brain tissue is bruised and damaged in a local area. Mainly located in frontal and temporal lobes. May cause hemorrhage, infarction, necrosis and edema. Max effects of bleeding & edema peak 18- 36 post injury. S/S:
• Alteration in LOC
• Behavior, motor or speech deficits
• Abnormal motor posturing
• Signs of increased ICP What is an epidural hematoma and its S/S? - Answer--Results when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly:
• Compression of underlying brain
• rapid increase in ICP
• Decreased CBF
• Secondary brain injury

• Usually requires surgical intervention S/S:

• Transient LOC
• Lucid period lasting a few minutes to several hours
• Rapid deterioration in neurologic status
• Severe H/A
• Sleepiness
• Dizziness
• N/V
• Hemiparesis or hemiplegia on opposite side of hematoma
• Unilateral fixed and dilated pupil on same side of hematoma

What is a subdural hematoma and its S/S? - Answer--A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S:

• Altered LOC or steady decline in LOC
• S/S of increased ICP
• Hemiparesis or hemiplegia on opposite side of hematoma
• Unilateral fixed and dilated pupil on same side of hematoma Chronic pt's " " up to 2 wks post injury
• H/A
• Progressive decrease in LOC
• Ataxia
• Incontinence
• Sz's What are intracerebral hematoma's and its S/S? - Answer--Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S:
• Progressive and often rapid decline in LOC
• H/A
• Signs of increasing ICP
• Pupil abnormalities
• Contralateral hemiplegia What are the S/S of a linear skull fx? - Answer--- H/A
• Possible decreased LOC What are the S/S of a depressed skull fx? - Answer--- H/A
• Possible decreased LOC
• Possible open fx
• Palpable depression of skull over the fx site What are the S/S of a basilar skull fx? - Answer--- H/A
• Altered LOC
• Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum)
• Facial nerve (VII) palsy
• CSF rhinorrhea or otorrhea How would you assess a pt with a cranial injury? - Answer--(Initial assessment) INSPECTION:

• Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction.
• Hyperoxygenate pt with 100% O2 via bag-mask
• Apply direct pressure to bleeding sites except depressed skull fractures
• Cannulate 2 large IV's
• Hypotension doubles pt's death rate (w/severe head trauma)
• Vasopressors used to maintain CPP.
• Insert OG or NGT. OG should be used with severe facial trauma.
• Position pt, elevate head to decrease ICP (but may also reduce CPP).
• Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain
• Prepare for ICP monitoring device
• Administer mannitol as prescribed.
• Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys.
• Administer anticonvulsant
• Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis:
• Depressed skull fx
• Sz at time of injury
• Sz on arrival to ED
• Hx of sz's
• Penetrating brain injury
• Acute subdural/epidural hematoma
• Administer antipyretic med/Cooling blanket
• Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP
• Do not pack ears/nose if CSF leak suspected
• Admin tetanus prophylaxis
• Wound repair for facial/scalp Lac's
• Admin other meds
• Analgesics, sedatives, narcan, romazicon, etc.
• Admin antibiotics
• Pt's w/basilar skull fx need prophylaxis against meningitis
• Prepare pt for OR, hospital admin or transfer. What are signs of a serious eye injury? - Answer--- Visual disturbances
• Pain
• Redness and ecchymosis of the eye
• Periorbital ecchymosis
• Increased intraocular pressure What is hyphema and its S/S? - Answer--Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire

anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S:

• Blood in anterior chamber
• Deep, aching pain
• Mild to severe diminished visual acuity
• Increased intraocular pressure What are s/s of chemical burns to the eye? - Answer--Chemical injuries require immediate intervention if it is to be preserved. S/S:
• Pain
• Corneal Opacification
• Coexisting chemical burn and swelling of lids What are S/S of penetrating trauma/open or ruptured globe? - Answer--- Marked visual impairments
• Extrusion of intraocular contents
• Flattened or shallow anterior chamber
• Subconjunctival hemorrhage, hyphema
• Decreased intraocular pressure
• Restriction of extraocular movements What are the S/S of orbital fracture (orbital blowout fracture)? - Answer--- Diplopia (double vision)
• Loss of vision
• Altered extraocular eye movements
• Enophthalmos (displacement of the eye backward into the socket)
• Subconjunctival hemorrhage or ecchymosis of the eyelid
• Infraorbital pain or loss of sensation
• Orbital bony deformity What is LeFort I fracture and its S/S? - Answer--Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S:
• Slight swelling of maxillary area
• Possible lip lac's or fractured teeth
• Independent movement of the maxilla from rest of face
• Malocclusion What is LeFort II fracture and its S/S? - Answer--Pyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S:

• Pt restrained? Airbags deployed? Etc.
• What are the pt's complaints?
• Pt normally wear glasses or contacts?
• Pt have hx of eye problems?
• Pt ever have eye surgery?
• Pt have visual or ocular changes associated with chronic illness? PHYSICAL INSPECTION:
• Inspect eye, orbits, face and neck
• Check for symmetry, edema, ecchymosis, ptosis, lacerations and hematomas
• Inspect globe for lacerations, large corneal abrasions, hyphema, and extrusion or prolapse of intraocular contents
• Determine whether lid lac's
• Assess pupil's (PERRL)
• Unilateral fixed and dilated pupil may indicate oculomotor nerve compression as a result of ICP + herniation syndrome
• Bilateral fixed and pinpoint pupils = pontine lesion or drugs
• Mildly dilated pupil w/sluggish response may early sign of herniation syndrome
• Widely dilated pupil occasionally occurs w/direct trauma to globe of eye
• Assess for consensual response
• Assess redness, eye watering, blepharospasm
• Assess extraocular movement, except when an open globe injury is known or suspected.
• Limitation range of ocular motion may indicate orbital rim fx w/entrapment or paralysis of cranial nerve or ocular muscle
• Perform visual acuity exam
• Use Snellen or handheld chart. Check uninjured eye first
• Assess for blurred or double vision with injured eye and then with both eyes open
• Inspect for rhinorrhea or otorrhea
• If drng present, may indicate CSF leak
• Observe for impaled objects
• Assess occlusion of mandible and maxilla
• Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx
• Observe for uncontrolled bleeding PALPATION
• Palpate periorbital area, face and neck for:
• Tenderness
• Edema
• Step-off defects or depressions
• Subcutaneous emphysema (esophageal or tracheal tear)
• Palpate trachea above suprasternal notch
• Trach deviation = late indication of tension pneumothorax or massive hemothorax
• Assess sensory fx of perioribital areas, face and neck
• Facial fx's can impinge on infraorbital nerve, causing numbness of inferior eyelid, lateral nose, cheek, or upper lip on affected side.

• Check position of trachea DIAGNOSTIC STUDIES:
• Xrays, CT scans, MRI's
• Fluorescein staining
• Slit-lamp exam
• tonometry (measures intraocular pressure)
• Bronchoscopy or esophagoscopy What are the nursing interventions for a pt with an ocular injury? - Answer--- Assess visual acuity & reassess
• Elevate HOB to minimize intraocular pressure
• Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure
• Assist w/removal of foreign bodies as indicated; stabilize impaled objects
• Apply cool packs to decrease pain + periorbital swelling
• Admin medications
• Instill prescribed topical anesthetic drops for pain
• Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration
• Antibiotics topically or systemically
• Admin tetanus prophylactically
• Use an eye patch to affected eye
• Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries
• Patch, shield or cover w/cool pack
• Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe.
• Provide psychosocial support
• Obtain an ophthalmology consultation
• Provide d/c instructions:
• Importance of protective eyewear
• No driving w/eye patch on
• Wear sunglasses to prevent tearing, aid photophobia
• Prepare for admission, OR or transfer What are the nursing interventions for a patient with a maxillofacial or neck injury? - Answer--- Administer oxygen
• For facial trauma, place pt in high-fowler's position if no spinal injury is present.
• Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected
• Monitor for progressive airway assessment
• Prepare for intubation, PRN.
• Cannulate 2 large IV's, initiate isotonic crystalloid IV solution
• Control external bleeding w/direct pressure
• Monitor for continued bleeding + expanding hematomas
• Apply cold compresses to face to minimize edema
• Assist w/repair of oral lac's, PRN

• Hyerresonance (increased echo produced by percussion over the lung field) on the injured side
• Decreased or absent breath sounds on the injured side
• Chest pain
• Open, sucking wound on inspiration (open pneumothorax) Define tension pneumothorax. - Answer--Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results. Immediate decompression should be performed. Treatment should not be delayed. What are the S/S of a tension pneumothorax? - Answer--- Severe respiratory distress
• Markedly diminished or absent breath sounds on affected side
• hypotension
• Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present
• Tracheal deviation - shift toward uninjured side (LATE sign)
• Cyanosis (LATE sign) Define Hemothorax. - Answer--Accumulation of blood in the pleural space. What are the S/S of Hemothorax? - Answer--- Dyspnea, tachypnea
• Chest pain
• Signs of shock
• Decreased breath sounds on injured side
• Dullness to percussion on the injured side What is a pulmonary contusion? - Answer--They occur as a result of direct impact, deceleration or high-velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately. What are the S/S of pulmonary contusion? - Answer--- Dyspnea
• Ineffective cough
• Hemoptysis
• Hypoxia
• Chest pain
• Chest wall contusion or abrasions What happens to a ruptured diaphragm? - Answer--Potentially life-threatening, results from forces that penetrate the body. Left hemidiaphragm is more susceptible to injury because the right side is protected by the liver.
• Herniation of abdominal contents

• Respiratory compromise b/c impaired lung capacity + displacement of normal tissue.
• Mediastinal structures may shift to opposite side of injury What are S/S of a ruptured diaphragm? - Answer--(Anything below the nipple line and should be evaluated for potential diaphragmatic injury).
• Dyspnea or orthopnea
• Dysphagia
• Abdominal pain
• Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign)
• Bowel sounds heard in lower middle chest
• Decreased breath sounds on injured side What are S/S with tracheobronchial injury? - Answer--Blunt trauma. "Clothesline-type" injuries.
• Dyspnea, tachypnea
• Hoarseness
• Hemoptysis
• Subcutaneous emphysema in neck, face, or suprasternal area
• Decreased or absent breath sounds
• S/S of airway obstruction What are S/S with blunt cardiac injury? - Answer--"Cardiac contusion" or "concussion." Common with MVC or falls from heights.
• ECG (sinus tach, PVC's, AV blocks)
• Chest pain
• Chest wall ecchymosis What are the S/S of pericardial tamponade? - Answer--A collection of blood in pericardial sac. As blood accumulates, it exerts pressure on the heart, inhibiting or compromising ventricular filling.
• Hyotension
• Tachycardia or PEA
• Dyspnea
• Cyanosis
• Beck's Triad (hypotension, distended neck veins + muffled heart sounds)
• Progressive decreased voltage of conduction complexes on ECG What are aortic injuries S/S? - Answer--- Hypotension
• Decreased LOC
• Hypertension in UE's
• Decreased quality (amplitude) of femoral pulses compared to UE pulses
• Loud systolic murmur in parascapular region
• Chest pain
• Chest wall ecchymosis
• Widened mediastinum on chest xray
• Paraplegia