Trauma Nurse Core Course: Principles and Procedures, Exams of Nursing

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Trauma Nurse Core Course (TNCC)

C What are the primary benefits of a team approach to trauma care - it provides a systemic approach to care and organizes care A In the primary survey AVPU is performed to determine if the patient can: - Protect their aiway B WHich may lead to unreliable pulse ox reading - carboxyhemoglobin A The systemic inflammatory response is a normal part of the body's response to shock from traumatic injury. what best describes this response - it is activated by tissue hypoxia and sends neutrophils to injury site A what is an early assessment finding to increased ICP in pt with a brain injury - vomiting A an unrestrained driver was involved in a frontal collision without airbag deployment. he is hypotensive and tachycardic with shallow respirations, distended JVD and muffled heart tones the nurse prepare for what - pericardiocentesis D An unrestrained driver is brought into the emergency department following a frontal impact MVC. she is pale, anxious, and c/o SOB. what is the potential injury - Lumbar fx B pt to ER after being pinned to brick retaining wall. knwoing crushing injuries can result to significant damage to muslces the priority asessment for trauma nruse is for - myoglobinemia nd renal failure

A the nurse is preparing to cleanse an extensive abrasion contaminated with dirt and gravel. which of the following intervention is indicated - us copious amounts of NS A when providing care for the pedicatric pt with burns the post resuscitation care, how are fluids delivered - parkland formula with maintainence fluidss B thinning skin and diminished autonomic response in older adult can have what effect on primary assessment - compromised thermoregulation A in mass casualty "doing the greatest good for the greatest number of people refers to a situation where - there may be more patients than resources C effective pain management in hte pt iwth rib fxwill promote what - cough with ability to clear secretions Bduring the primary survery which of the following has the greatest priority - cervical spine injury D restrained driver is involved in a severe head on MVC and presnts with a seatbelt mark along the neck and upper chest area. bilateral decreased breath sounds, hemoptysis and diffuse sub q emphysemato the neck and upper chest area - tracheobronchial injury B a pt involved in an MVC develops asymmetric pupillary reactivity, bilateral pupillary dilation and abnormal motor posturing. what does the nurse suspect as the most likely cause - herniation syndrome

B which of the following hemodynamic support strategies is the prioririty intervention for a pt with traumatic pulmonary contusion - judicios use of IV fluids B the unrestrained fron seat passenger in a MVC develops echymosis around umbillicus. this assessment finding is most commonly associated with: - bleeding in the peritoneal cavity D elevated comaprtment pressure can be the result of - hemorrhage from within the muscle A prego trauma pt develops tachy, hypotension, a rigide board like uterus, and dark, red vaginal bleeding. she reports constant back pain which is increasing. the most likely cause of s/s is - placental abruption A for a ptwho has undergone recent bariatric surgery, flouroscopy is recommended to place - NG tube A identification of vulnerabilities is an example of what phase of disaster management - mitigation A which of the following structures would be hte most affected by teh concept of caviation - Liver B the most common cause of shock in the trauma pt is - loss of circ volume B a pt with injury to the middle meningeal artery is at risk for which of the following - epidural hematoma

C what organ might be injured in left lower rib fx - spleen D pt with amputation of an index finger with a knife. amputaiton is brought in with pt. it is wrapped in sterile gauze with saline and sealed in a plastic bag. the next step amputation care is - place the bag on ice D which physiological change in airway of an odler adult pt places the pt at risk for difficult intubation - cervical arthritis Cthe term worried well when refering to disaster preparedness planning refers to: - individuals hwo think they have been affected by the event but are asymptomatic C which of the following would be priority intervention for a pt with multiple rib fractures and chest wall instability follwoing a mvc collision - assist with endotracheal intubation A a 22 yr old was struck by a vehicle while crossing the street, sustaining multiple fx she is alert and answering qestions and crying what is the best method for initial pain assessment for this pt - self report scale D which of the following diagnostic intervention is most appropriate for the unstable pt with a suspectedinternal hemorrhage - focused assessment with sonography for trauma C an adult pt involved in a brush fire arrives to the er. upon initial assessment in the er the most concerning finding is - hoarse voice and repeatedly decides to clear throat. C a college student presents to the er stating afterarriving at a party , she awoke in a dorm rom. she didnt recognize with no memory of the previous evening the trauma nurse prepare for what exam. -

sexual assult B when assessing a pt following a MVC the nurses asks how fsat the car was going - when volocity is doubled speed is quadroupled B which of hte following significant assessment findigns is frequently found in a patient with complete cransiofacial separation involving the maxilla, zygoma, orbits, and bones of the cranial base. - diplopia A in neurogenic shock, alterations in vital signs include hypotension and which other abnormal VS - bradycardia C an older adult pt fell in the bathtub 3 days ago. now she is exihibiting decreasd LOC and difficulty with speaking and walking. which of the following injuries is most effective - subdural hematoma A which of the following values is within the acceptable limits for trauma pt - end tidal CO2 of 40 B an occlusive dressing has been applied to a pt with a penetrating injury to the chest. upon assessment the nurse notes that the patient is in respiratory distress nad has absnet breath sounds on hte affected side. what is the priroruty intervention - remove the dressing to the wound C properly restrained 6 wk old kid was involved in a MVC. after the assessment and stabilization the pt becomes more difficult to rouse. responding with a weak cry to painful stimuli. the pupils remain brisk and reactive. the anterior fontanel is soft and flat. what is the most likely cause and pririty interventions

• hypoglycemia Cthe trauma nurse would prepare for a definitive airwya for which of the following condition. -

GCS of 8 or ls A during assessment of an extremety with suspected pulses are - can be normal A several groups of people are at higher risk for maltreatment including children, elderly, prego, and ... - pt's with disability C which of the follwoing is a risk factor for DVT in the trauma pt. - pelvic fx A a pt sustrained a penetrating injury of his upper leg. the pre hospital personnel states a large amount of blood loss before hemostasiswas achieved. he presents to the ER responding to painful stimuli with moaning. he is tachy 142 b/p 104/96 and RR 24 - decompensated A which of hte following nursing interventions would be best for traumitc __________ - HOB 30 degrees B an unrestrained driver inlvolved in a MVC in which alcohol was involed. he denies any pain and numbness and tinlging. according to NEXUS critera which factors indicate need for radiological - suspected alcohol abuse C 32 wk pregnant lady arrives in er after trapped in a car that flipped. the initial assessment reveals s/s of shock, vaginal bleeding, a palpable asymmetrical uterus, and slowing fetal heart tones what is the most likely cause - uterine rupture B a pt father arrives in teh ER and needs to be told his son was severely injured in a MVC and is in surgery, the father si agitated, yelling, and smells of alcohol. in planning to talk with the father the trauma nurse will -

deliver information regarding the son;s care in a calm voice