Trauma Assessment and Management, Exams of Nursing

Download Trauma Assessment and Management and more Exams Nursing in PDF only on Docsity!

TNCC EXAM PREVIEW 2024/

WITH 100% VERIFIED SOLUTIONS

|GRADE A+

Expedite transfer to the closest trauma center A 56 y/o M pt involved in a motor vehicle crash is brought to the ED of a rural critical access facility. He complains of neck pain, SOB, and diffuse abd pain. His GCS is 15. His VS: BP 98/71, HR 125, RR 26, SpO2 94% on high-flow O2 via NRB mask. Which of the following is the priority intervention for this patient? a pertinent medical hx is crucial Which of the following considerations is the most important when caring for a geriatric trauma pt? Mitigation 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 a future disaster. Which phase of the disaster life cycle does this describe? Multiple requests for water EMS brings a pt who fell while riding his bicycle. Using the American College of Surgeobs screening guidelines, which assessment finding would prompt the RN to prepare the pt for a radiologic spine clearance? hemoglobin does not readily release O2 for use by the tissues What is the effect of hypothermia on the oxyhemoglobin dissociation curve? acidosis Which of the following is a component of the trauma triad of death?

Complete EMS brings a pt from MVC. VS: BP 90/49, HR 48, RR 12, temp 97.2F (36.2 C). The pt exhibits urinary incontinence and priapism. These assessment findings are most consistent with which of the following types of spinal cord injury? fluctuation in the water seal chamber Which of the following is an expected finding in a pt with a tube thoracstomy connected to a chest drainage system? insert an oropharyngeal airway if there is no gag reflex During the primary survey of an unconscious pt with multi-system trauma, the nurse notes snoring respirations. What priority nursing interventions should be preformed next? globe rupture A 35 y/o M presents with facial trauma after being struck in the face with a baseball. A teardrop-shaped left pupil is noted on exam. What type of injury is suspected? compensated A trauma pt is restless and repeatedly asking "where am i?" VS upon arrival: BP 110/60, HR96, RR 24. Her skin is cool and dry. Current VS are BP 104/84, HR 108, RR

28. The pt is demonstrating s/sx of which stage of shock? ventilate with a bag mask device An unresponsive trauma pt has an oropharygeal airway in place, shallow and labored respirations, 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? within 24 hrs of trauma

placental abruption You are caring for a pt who was involved in a MVC and is 32 weeks pregnant. Findings of your secondary survey include abd pain on palpation, fundal ht at the costal margin, and some dark bloody show. Varying accelerations and decelerations are noted on cariocgraphy. These findings are most consistent with which of the following? it can worsen cord damage from an unstable spinal injury Which of the following is true about the log-roll? defusings All of these are considered a critical communication point in trauma care EXCEPT which of the following? pulse oximetry and capnography What bedside monitoring parameters are used to assess for adequacy of O2 and effectiveness of ventilation? padding the upper back while stabilizing the cervical spine Caregivers carry in a 2 y/o into the ED who fell out of a second-story window. The pt is awake and crying with increased work of breathing and pale skin. Which of the following interventions has the highest priority? bowel Which of the following injuries is LEAST likely to be promptly identified?

Initiate transfer to a trauma center A pt is brought to the ED of a rural hospital following a high-speed MVC. When significant abd and pelvic injuries are noted in the primary survey, which of the following is the priority interventions? bardycardia and absent motor function below the level of injury A pt with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? apply splint and elevate above the level of the heart a 37 y/o F has a deformity of the L wrist after a fall. She is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention? the aorta is torn at its attachment with the ligamentum arteriosum which of the following occurs during the third impact of a motor vehicle crash? Report your suspicion of maltreatment in accordance with local regulations a 5 y/o child presents to the ED with bruises to the upper arm 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 survey. Which of the following is the priority nursing intervention?

nausea and vomiting Which of the following is a late sign of increased intracranial pressure? serial FAST exams a 49 y/o restrained driver involved in a MVC presents to the trauma center complaining of abd, pelvic, and bilateral lower extremity pain. VS are stable. The nurse can anticipate all of these after a negative FAST exam EXCEPT which of the following? pericardiocentesis Which of the following is NOT considered goal-directed therapy for cardiogenic shock? endotracheal tube The trauma nurse knows that placing a bariatric patient in a ramped position providers better visualization during the insertion of which device? increased work of breathing? which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax? calcium if a pt has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation?

identifying individuals who made mistakes during the traumatic event Which of the following is NOT considered a benefit of debriefings? 500 mL/hr You are treating a 27 y/o M in respiratory distress who was involved in a house fire. Calculating TBSA burned is deferred due to the need for emergent intubation. At what rate should you begin fluid resuscitation? advanced age Which of the following is most likely to contribute to inadequate oxygenation and ventilation? a 52 y/o diabetic male with a partial thickness burn to the left lower leg Which of the following patients warrants referral to a burn center? dressing removal A patient arrives with a large open chest wound after being assaulted with a machete. Prehospital providers placed a nonporous dressing over the chest wound and taped it on three 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 immediate intervention? after a physical examination if the pt has no radiologic abnormalities on CT

KE equals 1/2 the mass (M) multiplied by the velocity squared. What is the Mnemonic for the Initial Assessment? A = Airway with simultaneous cervical spine protection B = Breathing C = Circulation D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm) What is the Mnemonic for the Secondary Assessment? F = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain). H = Hx and Head-to-toe assessment I = Inspect posterior surfaces Where do you listen to auscultate breath sounds? Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line. What are the late signs of breathing compromise?

• Tracheal deviation
• JVD

What are signs of ineffective breathing?

• 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? A tight-fitting nonrebreather mask at 12 - 15 lpm. We have an expert-written solution to this problem! What intervention should be done if a pt presents with effective circulation?
• Insert 2 large caliber IV's
• Administer warmed isotonic crystalloid solution at an appropriate rate What are signs of ineffective circulation?
• Tachycardia
• AMS
• Uncontrolled external bleeding

P = Pain U = Unresponsive

• GCS
• PERRL?
• Determine presence of lateralizing signs including:
• Unilateral deterioration in motor movements or unequal pupils
• Symptoms that help to locate area of injury in brain What are the interventions for Disability?
• If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments
• If pt is not alert or verbal, continue to monitor for any compromise to ABC's
• If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation. What is assessed and intervened for Expose/Environmental Controls?
• Remove clothing
• Ensure appropriate decontamination if exposed to hazardous material
• Keep pt warm
• Keep clothing for evidence What is the first thing assessed under the Secondary Assessment? FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE
• ABCDE should be completed
• Labs, X-rays, CT, Foley,

• Family Presence What is the second thing assessed under the Secondary Assessment? GIVE COMFORT MEASURES
• Talking to pt
• Pharmacologic/Nonpharmacologic pain management
• Observe for physical signs of pain What is assessed under the Mnemonic "H"? HISTORY / HEAD-TO-TOE ASSESSMENT
• MIVT
• M = Mechanism of injury
• I = Injuries sustained
• V = Vital Signs
• T = Treatment
• Pt generated information
• PMH
• Head-to-toe assessment What is assessed under the Mnemonic "I"? INSPECT POSTERIOR SURFACES
• While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs.
• Palpate vertebral column for deformity and areas of tenderness
• Assess rectum for presence/absence of tone, presence of blood

D = Defasiculating agents What are the Rapid Sequence Intubation Steps? 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.
• After intubation, inflate the cuff
• Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT:
• Secure ET tube
• Set ventilator settings
• Obtain Chest x-ray
• Continue to medicate
• Recheck VS and pulse oxtimetry

What is a Combitube? A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult. What is a Laryngeal Mask Airway? Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. What is Needle Cricothyrotomy Percutaneous transtracheal ventilation. (temporary) Complications include:

• inadequate ventilation causing hypoxia
• hematoma formation
• esophageal perforation
• aspiration
• thyroid perforation
• subcutaneous emphysema What is Surgical Cricothyrotomy? Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated.

What are you looking for when auscultating lung sounds? 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? Dullness:
• hemothorax Hyperresonance
• Pneumothorax What are you looking for when palpating the chest wall, clavicles and neck?
• 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?

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. 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. Syndrome that results from ineffective perfusion caused by ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes:
• MI
• Blunt cardiac injury
• Mitral valve insufficiency
• dysrhythmias
• Cardiac Failure