Trauma Nursing: Principles and Practices, Exams of Nursing

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TCRN Test 150 Questions with Verified Answers

Fluid resuscitation is administered to a traumatically injured patient. After resuscitation, the trauma nurse evaluates the patient's response to that resuscitation to determine whether additional fluids should be administered. Which of the following factors is most likely to impact this evaluation? - CORRECT ANSWER Beta-blockers blunt changes in the pulse and blood pressure. This may both reduce changes associated with recognizing hypovolemia but it can also reduce changes associated with the response to treatment. Many times the blood pressure falls and the pulse rises with hypovolemia and the opposite happens after fluid resuscitation. When the patient is on beta-blockers, these changes may not occur. Although it is more difficult to assess for changes in skin color in dark- skinned individuals, skin changes are generally not used to evaluate the effectiveness of fluid resuscitation and further resuscitation would not be based on changes in skin color. The presence of lower extremity trauma does not influence evaluation of fluid resuscitation nor the need for additional fluids. A body mass index of 21 kg/m2 is within normal limits and is unlikely to affect resuscitation or the evaluation of resuscitation 50% polyethylene glycol will be used as part of the treatment for: - CORRECT ANSWER 50% polyethylene glycol is known to increase the solubility of phenols in water and should be used as part of the decontamination process in patients exposed to phenols. It will have no therapeutic effect for patients with pancreatic trauma, carbon monoxide poisoning (treated with 100% oxygen) or acute respiratory distress syndrome (treated with appropriate ventilator management and prone positioning) A reagent strip that tests for glucose is used in the assessment of a traumatically injured patient. What injury is likely suspected? - CORRECT ANSWER A basilar skull fracture may result in leakage of cerebrospinal fluid, which is rich in glucose. Reagent strips that test for glucose can be used to assist the diagnosis of basilar skull fracture by checking fluid coming from the nose or ears for glucose. A reagent strip that tests for glucose will not be therapeutic in assessing for a bladder rupture, diffuse axonal injury or a ruptured amniotic sac.

When administering large volumes of blood products, the trauma nurse should monitor for which of the following findings which could indicate hypocalcemia? - CORRECT ANSWER A classic finding associated with hypocalcemia is QT prolongation. ST elevation is more common with cardiac ischemia and not associated with hypocalcemia. Tall peaked T waves and flattening of the P wave are both associated with hyperkalemia, not hypocalcemia The trauma nurse knows that treatment for a patient with non-operative abdominal trauma has been effective if: - CORRECT ANSWER A goal of treatment after abdominal trauma is a return of the base deficit to normal. This indicates adequate fluid resuscitation and is associated with positive outcomes. Although serum amylase levels should be monitored because elevations in these levels may indicate pancreatic or bowel trauma, changes in serum amylase levels are not associated with effective treatment, but rather associated with the injuries themselves. Intraabdominal pressures should be below 10 mm Hg. An intaabdominal pressure above 12 mm Hg indicates intraabominal hypertension, indicating a need for further. Hyperrresonance to percussion in the abdomen is an indication of hollow organ injury and is not a goal of treatment Which of the following statements, made by a patient being discharged home with the diagnosis of a hyphema, indicates FURTHER teaching is warranted? - CORRECT ANSWER A hyphema is a collection of blood in the anterior chamber of the eye. An isolated hyphema may be treated at home but the patient should be encouraged to rest and avoid any activities which could increase intraocular pressure and cause further bleeding. Patients will be encouraged to keep their head elevated 30 to 45 degrees on pillows, to rest their eyes (avoid activities such as watching television or reading) and to watch for signs of new bleeding (which can include vagal stimulation in the form of nausea and vomiting.) Ibuprofen and other medications which can increase the risk of bleeding should be avoided. A Kleihauer-Betke test may be used to determine: - CORRECT ANSWER A Kleihauer-Betke test is used to determine the presence of fetal blood in maternal circulation and is often positive in patients with placental abruption. The Kleihauer-Betke test is not useful in determining pain levels nor will it help determine the presence of pancreatic trauma. It is not associated with acute respiratory distress syndrome

Adoption of a mass transfusion protocol should help reduce the incidence of: - CORRECT ANSWER A mass transfusion protocol may prevent the onset of a systemic inflammatory response syndrome (SIRS). The onset of SIRS is related to tissue trauma and prolonged tissue hypoxia. Early, aggressive fluid and blood resuscitation may decrease tissue hypoxia. Fat emboli are the result of a large bone fracture and the incidence of these is not affected by MTP. Post-renal failure is caused by obstructions in the lower genitourinary tract and the incidence of this complication is not altered by MTP. Abdominal compartment syndrome is the result of excessive fluid in the peritoneum. While MTP is not directly associated with abdominal compartment syndrome, the fluids administered during activation of MTP could worsen rather than reduce the incidence of abdominal compartment syndrome Which of the following goals of care is most appropriate for a patient with a maxillary fracture? - CORRECT ANSWER A maxillary fracture causes loss of bony structure to the mid-face which can cause loss of integrity of the airway. This can be exacerbated by bleeding and edema in the airway, further putting the ability to maintain the airway in jeopardy. When caring for patients with a maxillary fracture, maintenance of airway is always a high priority. Alterations in visual acuity associated with maxillary fractures likely occurred at the time of injury and treatment is unlikely to alter this outcome. Maxillary fractures are not splinted, they are surgically repaired. Treatment will not reduce cerebrospinal fluid leakage; therefore, this is not a goal of care Which of the following blood urea nitrogen ratios is associated with effective fluid resuscitation? - CORRECT ANSWER A normal blood urea nitrogen (BUN) to creatinine ratio is 10:1 and indicates effective renal functioning. If the BUN to creatinine ratio increases, that is an indication of hypovolemia (e.g. 20:1, 30:1 or 40:1) One goal of an effective performance improvement program would be to reduce the: - CORRECT ANSWER A performance improvement program is meant to improve the care delivered. Improvement in care is measured differently by different people. Patients tend to measure success by improving quality outcomes (not reducing quantities of outcomes). Care providers tend to measure success by increasing the quality of the care delivery process (not reducing the quality of the

process). Payors tend to measure success through reduced costs. Reducing the number of providers is not a direct goal of the performance improvement process The highest priority intervention for a patient with indications of a ruptured uterus is: - CORRECT ANSWER A ruptured uterus causes significant blood loss resulting in life-threatening blood loss. Therefore, the priority intervention would be initiation of an intravenous line so that fluid resuscitation can be commenced. Transfer to the surgical suite will also be required but this does not constitute a higher priority than initiation of an intravenous line. Terbutaline may be used to abate premature labor but has no therapeutic effect for a ruptured uterus. Cardiotocographic monitoring is not indicated for a ruptured uterus and is not a higher priority than initiation of an intravenous line Which activity must proceed measurement of bladder pressures used to monitor abdominal compartment syndrome? - CORRECT ANSWER A set amount of fluid must be administered into the bladder before bladder pressures can be measured. Once the fluid is instilled, the catheter must be clamped until the measurement is complete. Although administration of analgesia is not contraindicated, it is not required to obtain a bladder pressure. The head of the bed should be flat, not elevated 30 degrees in order to measure bladder pressures. There is no need to administer 500 mL boluses of crystalloid solution prior to measuring bladder pressure The trauma nurse knows that the best way to increase fibrinogen levels in a patient with coagulopathies is to administer: - CORRECT ANSWER A single bag of cryoprecipitate contains 350 mg of fibrinogen. Administering either Vitamin K or platelets will not elevate fibrinogen levels. Although fresh frozen plasma may have some fibrinogen in it, this blood product does not contain as much fibrinogen as cryoprecipitate. Which of the following findings indicates that the family member of a traumatically injured patient has entered a state of crisis? - CORRECT ANSWER A state of crisis is marked by failure of usual coping mechanisms. The individual can no longer function normally, often becoming anxious, disorganized and panicky. They may regress and become paralyzed, being unable to make simple decisions (like deciding what to eat for a meal). They may digress to less functional behaviors like violence or substance abuse. Complaints of nausea and lack of

appetite, bad dreams interrupting sleep and verbalizing a strong desire to stay close to an injured loved one are all expected responses that may occur after learning of a loved one being traumatically injured and are not specific symptoms of a state of crisis Performing a tertiary exam on a traumatically injured patient serves the purpose of: - CORRECT ANSWER A tertiary exam is carried out 24 to 72 hours after admission (and may be repeated especially if a patient regains consciousness). It involves a repeat of the primary and secondary survey as well as a review of the patient's diagnostic studies and is useful in identifying injuries that may have been missed during the initial resuscitation. The control of hemorrhage should have been accomplished as part of the primary survey. If a patient continues to hemorrhage at the time of the tertiary exam, then their condition is likely very poor. Radiographic studies should be facilitated as part of the secondary exam and will then be reviewed as part of the tertiary exam. The purpose of the tertiary exam is not to recognize psychosocial trauma A percutaneous drain is most likely to be inserted for the treatment of a: - CORRECT ANSWER A urinoma is a collection of urine in tissue outside of the renal system and often follows an injury to the genitourinary system. Although small urinomas may reabsorb without treatment, others can go on to become infected or cause electrolyte disturbances and will need to be drained via insertion of a percutaneous drain. A hyphema is a collection of blood in the anterior chamber of the eye and is usually allowed to reabsorb over time rather than being drained. Fat emboli cannot be reduced with a drain and are treated with high flow oxygen or intubation with mechanical ventilation. A diaphragmatic rupture will require surgical intervention for repair and cannot be managed by a drain Abdominal perfusion pressures decrease. This is most likely due to an increase in:

• CORRECT ANSWER Abdominal perfusion pressures are measured by subtracting the mean arterial pressure from the intraabdominal pressure. The lower the mean arterial pressure drops and the higher the intraabdominal pressure climbs, the lower the abdominal perfusion pressure. Therefore, an increase in intraabdominal pressure would cause a decrease in abdominal perfusion pressure. An increase in systolic blood pressure and central venous pressure would all cause the mean arterial pressure to climb, and an elevated mean

arterial pressure causes abdominal perfusion pressure to increase rather than decrease According to the Health Insurance Portability and Accountability Act (HIPAA), release of a patient's protected health information without patient consent is: - CORRECT ANSWER According to HIPAA, protected health information may be released to meet statutory reporting requirements (such as mandatory reporting of suspected abuse). This is one of a number of instances when protected health information can legally be released without fear of fines or imprisonment. Patient consent is required before protected health information is released to lawyers, even in cases of civil litigation. Although protected health information may be released to law enforcement officers, there are limits in when the information may be released and how much may be released. Not all protected health information can be released to law enforcement in all cases Treatment for acute kidney injury is undertaken in the trauma unit. Which of the following findings indicates that this treatment is having its intended effect? - CORRECT ANSWER Acute kidney injury results in renal insufficiency. This in turn causes elevated potassium, a classic sign of acute kidney injury. Effective treatment should therefore reduce serum potassium. Flank pain is not associated with acute kidney injury and treatment will therefore not reduce this pain. Acute kidney injury causes the retention of fluid, often resulting in the elevation of the blood pressure, so treatment would reduce instead of elevate the mean arterial pressure. The BUN to creatinine ratio should remain unaffected at approximately 10:1 in acute kidney injury, therefore an increase in the BUN to creatinine ratio is not an indication of effective treatment A patient with known carbon monoxide poisoning has been given 100% oxygen via non-rebreather mask for one hour but no other treatments have been undertaken. The patient's carboxyhemoglobin level is drawn and determined to be 20%. Based on this information, what was the patient's carboxyhemoglobin level when the oxygen therapy was initiated? - CORRECT ANSWER Although carboxyhemoglobin has a half-life of 4 - 6 hours on room air, that half-life diminishes to one hour on 100% oxygen. Therefore, if a patient's carboxyhemoglobin level is 20% after being on 100% oxygen for one hour and the half-life is one hour, the original carboxyhemoglobin level was likely about 40%. If

oxygen therapy is continued for an additional hour, the patient's carboxyhemoglobin will likely be 10% Which of the following factors is most likely to exacerbate coagulopathies associated with trauma? - CORRECT ANSWER Although coagulopathies are believed to be initiated shortly after a traumatic event by activation of the inflammatory cascade, factors such as acidosis (such as with a serum pH of 7.08), hypothermia and dilution with crystalloid fluids are all known to exacerbate the condition. Tachycardia is not associated with worsening of coagulopathies. Although it is important to manage a trauma patient's pain, failure to manage that pain is not associated with coagulopathies. Similarly, exposure to high concentrations of oxygen can lead to oxygen toxicity which is not desirable, but oxygen toxicity does not directly exacerbate coagulopathies Which of the following complications is most likely in a patient who sustains deep abrasions to more than 20% of the body surface area? - CORRECT ANSWER An abrasion, especially a deep one, causes loss of skin. One of the purposes of skin is temperature maintenance, so loss of a large amount of skin may cause evaporative heat loss and hypothermia. Sodium levels are generally not affected by abrasions, but fluid losses associated with a large abrasion may cause dehydration which leads to hypernatremia not hyponatremia. Rhabdomyolysis is caused by the destruction of a large amount of muscle but an abrasion affects skin, not muscle. Compartment syndrome requires intact skin over the area to collect fluid. With an abrasion, the skin cannot hold fluid making compartment syndrome unlikely An appropriately applied splint for a forearm fracture will immobilize the: - CORRECT ANSWER An effective splint immobilizes the joints above and below a fracture when possible. For a forearm fracture, this includes the wrist and elbow. By allowing mobility of one of the joints, there is increased risk of movement around the fracture which can cause further bleeding, neurovascular damage and increase the risk of fat emboli Assessment of a patient suspected of having an epidural bleed under the left parietal bone is most likely to reveal: - CORRECT ANSWER An epidural bleed on the left side of the head will result in ipsilateral weakness to the left side of the body above the neck as well as left sided pupillary changes (as opposed to right

sided pupillary changes). Areas of the body below the neck (e.g. pronator drift and leg lifts) will occur on the contralateral or opposite side as the epidural bleed (the right side in this example) A trauma nurse is developing a trauma injury prevention program and notes that a specific mechanism of injury has a high incidence rate but a very low prevalence rate within the community. What is the significance of this finding? - CORRECT ANSWER An incidence rate measures how frequently an injury occurs within a population during a specific time period. Prevalence is the number of persons affected by a specific mechanism of injury divided by the total number of people in the population. If prevalence is high, one can summarize that many people survived the injury; if prevalence is low, the injury had a lower survivability. A high incidence rate indicates a large portion of the population was affected by the mechanism of injury. If patients survived the injury, then the prevalence would also be high. But because the incidence is high and the prevalence is low, one can surmise a high mortality rate. An injury prevention program focusing on this mechanism of injury would save lives and potentially reduce healthcare costs Application of a splint is most likely to be considered for which of the following injuries? - CORRECT ANSWER An injury to the back of the hand that occurs from a tooth puncturing the skin when one person punches another is known as a "closed fist injury." This injury has a high rate of infection because bacteria transfers from the other person's mouth to the wound, and then movement of the hand pulls the bacteria along the tendon sheaths deep in the hand. It is common to splint the patient's hand with a closed fist injury in anatomical position to reduce the incidence of bacteria being pulled deeper into the hand. Splints are not used for LeFort fractures, orbital fracture and flail chest segments The most likely level of consciousness associated with an intracranial pressure of 50 mm Hg is: - CORRECT ANSWER An intracranial pressure above 40 mm Hg is considered a severe elevation and will result in unresponsiveness. Pressures below 20 mm Hg are considered normal and the patient will be alert and oriented. Pressures between 20 and 40 mm Hg are abnormally high and will result in altered levels of consciousness, such as lethargy or being obtunded "Halo sign" (blood surrounded by yellow fluid) is noted on the sheet underneath a patient who has head trauma. This should alert the trauma nurse to the strong

possibility of: - CORRECT ANSWER An open skull fracture is an injury that results in both a skull fracture and a scalp laceration. These fractures can also result in a dural tear. A tear in the dura would allow cerebrospinal fluid to leak from the fracture site. Since blood is made from water but cerebrospinal fluid is oily, they separate, causing a halo sign (blood in the center surrounded by the oily cerebrospinal fluid that appears yellow). Coagulopathies may cause excessive bleeding but will not cause cerebrospinal fluid leakage and a halo sign. A ruptured globe may result in visual disturbances and an odd shaped pupil but does not cause a halo sign. Damage to the parotid gland may cause saliva to collect outside of the mouth but saliva is clear colored or blood-tinged, not yellow or oily A patient sustains a laceration to the calf from the spokes of a bicycle. The wound is closed via primary intention with sutures. The trauma nurse should encourage the patient to have the sutures removed in what time frame after initial treatment? - CORRECT ANSWER Areas of the body with lower blood flow tend to heal slower and sutures should remain in place for longer periods of time. The surface of the arms and legs have less blood flow and may heal slower than other areas of the body, therefore sutures should remain in place for at least 10 - 14 days. Sutures of the face can often be removed in 3 - 5 days as the face is very vascular. Sutures on the scalp and trunk can be removed in 7 - 10 days Which of the following interventions is most appropriate in a patient with burns on both the hands caused by contact with an electrical source? - CORRECT ANSWER As many a 25% of patients who sustain significant electrical burns may develop arrythmias following the burn. Although most of these arrythmias are benign and occur right after the burn, some may be more serious and can start as long as 12 hours after the burn. Therefore, patients with significant burns from an electrical source should have continuous cardiac monitoring. Electrical burns cause fluid extravasation resulting hypovolemia and possible vasoconstriction. Therefore, dopamine would not be indicated as this would worsen vasoconstriction and oxygen delivery to the tissues. Ice should not be applied to burn as it reduces blood flow to an area that is already receiving inadequate oxygen. Limbs affected by electrical burns are at risk for compartment syndrome and should not be elevated above the level of the heart—they should only be elevated to the level of the heart

Which of the following injuries is most likely to be painless on initial presentation to the resuscitation room? - CORRECT ANSWER As many as 30 - 50% of patients with aortic injuries that survive to the resuscitation room will be pain-free on arrival. Scapular fractures and ruptures of the globe are associated with pain. Patients with blunt cardiac injuries experience chest pain The trauma nurse knows that the use of a hydrocolloid dressing encourages which type of wound debridement? - CORRECT ANSWER Autolytic debridement involves keeping a wound moist with dressings. This softens the underlying eschar which may then be removed with the dressing. Dressings, such as hydrocolloid or hydrogel, facilitate this. Biologic debridement involves the use of enzymes (e.g. collagenase) or maggots. Surgical debridement involves removal of the tissue using a sharp instrument such as a scalpel. Mechanical debridement involves application of dressings that are then allowed to dry and when removed, the eschar is pulled away with the dressing A pericardiocentesis is being performed for a pericardial tamponade. The trauma nurse knows that which of the following findings is associated with resolution of this condition? - CORRECT ANSWER Because a pericardial tamponade is a form of obstructive shock, it causes narrow pulse pressures and relief of this condition should cause the pulse pressure to widen and normalize. Similarly, obstructive shock causes an increase in central venous pressures, therefore an increased central venous pressure indicates that the treatment is not effective. A pericardial tamponade is not generally associated with pain therefore a relief of pain is not an indication of successful treatment. Although the QRS may become smaller with a pericardial tamponade, it does not become narrower, therefore a decrease in the width of the QRS is not associated with effective treatment. A patient complains of acute pain in the right upper quadrant. During the abdominal assessment, the trauma nurse should start palpating in the: - CORRECT ANSWER Because pain can be referred from one quadrant to another during palpation, it is best to start palpating in the quadrant furthest from known pain. In this example, because the pain is in the right upper quadrant, the most distal quadrant is the left lower quadrant, therefore palpation should begin in that quadrant, working towards the right upper quadrant

Beta-blockers are used to temporarily stabilize a patient with an aortic injury awaiting surgical intervention. Which of the following parameters indicates this treatment is having its intended effect? - CORRECT ANSWER Beta-blockers such as Labetalol may be used to reduce pressure in the aorta for patients with aortic injuries. The goals of treatment are a systolic blood pressure of 100 - 120 mm Hg, a mean arterial pressure of 80 mm Hg, and a heart rate between 60 and 80. Manipulation of the pulse pressure is not a goal of treatment. A lower diastolic pressure would reduce pressure in the aorta. A diastolic pressure of 90 mm Hg is higher than normal and would be unwanted Betamethasone is prescribed for a traumatically injured patient. Which of the following conditions does this patient most likely have? - CORRECT ANSWER Betamethasone is considered for pregnant patients greater than 24 weeks gestation, especially if they may deliver their baby prematurely. This medication assists with fetal lung maturity. This medication will have no therapeutic effect for patients with spinal cord injury, a diffuse axonal injury or acute respiratory distress syndrome Which of the following findings is most likely to be noted initially in a patient with pancreatic trauma? - CORRECT ANSWER Bleeding associated with pancreatic trauma may cause hypotension, tachycardia ad other signs of hypovolemia. These may show up shortly after the traumatic injury. Elevated amylase levels, bruising on the abdominal wall and epigastric pain tend to be delayed findings A patient verbalizes seeing "cobwebs" in the visual field after being punched in the face. This should alert the trauma nurse to which of the following injuries? - CORRECT ANSWER Bleeding in the eye (e.g. a vitreous hemorrhage) can result in disturbances in the visual field that may be described as either "floaters" or "cobwebs." A hyphema is bleeding in the anterior chamber of the eye and is more likely to cause a reddish hue to the vision or cloudy vision as opposed to "cobwebs" in the visual field. A retrobulbar hematoma is a collection of blood behind the eye that pushes the eye forward causing protrusion of the eye and possible loss of vision, not "cobwebs" in the visual field. The third cranial nerve is involved in eye movement rather than vision and will not cause "cobwebs" in the visual field

What do a "living will" and a "durable power of attorney for healthcare" have in common? - CORRECT ANSWER Both a "living will" and a "durable power of attorney for healthcare" are prepared while a patient has decisional capacity, therefore they represent informed consent. Neither of these documents requires a physician signature, unlike a "do not resuscitate.". Both documents provide guidance on what a patient would want if they become incapacitated or who they would want to make decisions on their behalf if they are incapacitated. A durable power of attorney for healthcare identifies someone to make decisions on behalf of the patient in the case of cardiac or respiratory arrest but does not necessarily provide that guidance. Both documents may be used in cases of traumatic injury if they are available and the patient's condition match descriptions within the document Which of the following findings is most likely to be noted in conjunction with bruising around the umbilicus? - CORRECT ANSWER Bruising around the umbilicus and bruising to the flanks are both associated with retroperitoneal bleeding. While they can occur independently, they may also occur together. There is no direct association between bruising around the umbilicus and blood in the urinary meatus (often related to bladder or urethral trauma), loss of bowel or bladder control (often associated with a spinal cord injury) or subcutaneous emphysema of the chest and neck (often associated with tracheal or esophageal injuries or a pneumothorax) The trauma nurse knows that a patient with bruising in the rectal area which assumes the shape of a butterfly may also have which symptom often associated with this? - CORRECT ANSWER Bruising in the rectum that assumes the shape of a butterfly is a sign of bleeding into the pelvic space, especially with injuries to the urethra or bladder. Injuries to the urethra and bladder are also associated with hematuria. Intrascapular pain may be associated with cardiac ischemia or back injuries but is not associated with peri-rectal bruising. Peri-rectal bruising indicates blood loss and blood loss causes a narrowed, rather than widening pulse pressure. The loss of ability to dorsiflex the foot is associated with peroneal nerve damage which in turn is associated with injury to the lower leg but is not associated with peri-rectal bleeding A patient's cerebral perfusion pressure is measured at 60 mm Hg. The trauma nurse knows this is: - CORRECT ANSWER Cerebral perfusion pressure is an indirect

measurement of oxygenation of the brain and is determined by subtracting a patient's intracranial pressure from their mean arterial pressure. Ideally, cerebral perfusion pressure should exceed 80 mm Hg. In brain injured patients, the goal is to maintain it above 70 mm Hg. Therefore 60 mm Hg is considered too low and indicates a reduction in cerebral blood flow. Cerebral perfusion pressure is a significant pressure to trend as it directly correlates to cerebral oxygenation and patient outcome Education and supportive leadership are known to reduce: - CORRECT ANSWER Compassion fatigue, secondary traumatic stress and burnout may all be reduced by education of healthcare workers about how to recognize and avoid these syndromes and supportive leadership that ensures that resources are available to reduce these syndromes. Education and supportive leadership are unlikely to have any effect on the need for pain medication. Although education may help individuals work through the grief stage after trauma, effective leadership is unlikely to influence this. Education and effective leadership do not influence the onset of the systemic inflammatory response syndrome A patient presents to the resuscitation room with a compound fracture of the lower leg. The bone remains exposed at the site of injury. The most appropriate way to handle this wound until definitive treatment is initiated is: - CORRECT ANSWER Compound fractures should be covered with a dressing soaked with saline or another crystalloid solution to prevent further contamination of the wound and to keep the tissue moist. A dry dressing is not indicated as this can dry out the wound and may also stick to the wound and bone edges, making removal more difficult. The wound should not be left exposed as this increases the risk of infection. Solutions such as iodine, peroxide or chlorhexidine should not be applied to wounds, especially wounds that may have exposed bone ends because these solutions may delay or prevent healing of bone ends A traumatically injured patient develops alcohol withdrawal in the trauma intensive care unit. The trauma nurse knows that this may make the recognition of which complication more difficult? - CORRECT ANSWER Continued bleeding would normally cause symptoms of hypovolemia like hypotension, diaphoresis and tachycardia to become more pronounced. But hypotension, diaphoresis and tachycardia are associated with withdrawal and may mask the symptoms of hypovolemia. Wound infections are usually evident by increased redness or

exudate in the area and this is not likely to be altered by alcohol withdrawal. Trauma-induced coagulopathies are likely to be noted by changes in the coagulation blood studies and this is not affected by alcohol withdrawal. Acute respiratory distress syndrome is marked by increased dyspnea and failing oxygen saturation, which is unlikely to be affected by alcohol withdrawal A traumatically injured patient is declared brain dead and is awaiting the arrival of the organ procurement team. Which of the following interventions is most appropriate in this scenario? - CORRECT ANSWER Depletion of catecholamines following brain death can result in variable blood pressures. The blood pressure frequently drops and fluids and vasopressors are often needed to maintain a systolic blood pressure of at least 100 mm Hg. There is no need to put the patient's head in Trendelenburg's position. This may increase intrathoracic pressure, making appropriate ventilation more difficult. Although serum electrolytes may become altered after brain death and should be monitored and corrected, hourly monitoring is not required. Tidal volume is used to correct serum carbon dioxide rather than serum oxygen levels. Higher tidal volumes are generally not required in patients who have experienced brain death and are awaiting organ procurement Which of the following forms of shock would have a decreased preload as one its initial findings? - CORRECT ANSWER Distributive shock (anaphylaxis, sepsis and neurogenic shock) is caused by vasodilation of arteries and veins. Vasodilation of the arterial system decreases the return of blood to the heart (preload). Obstructive shock, cardiogenic shock and hypovolemic shock all cause vasoconstriction of the venous system, which would increase rather than decrease preload, especially initially. [as these forms of shock progress, loss of volume (hypovolemia), loss of contractility (cardiogenic) and obstruction (obstructive) may cause a loss of preload, but these would be later findings rather than initial. Draining excessive cerebrospinal fluid from an extra-ventricular device may cause:

• CORRECT ANSWER Draining cerebrospinal fluid from an extra-ventricular device can be used to reduce intracranial pressure. Excessive drainage however, can cause collapse of the ventricles that may cause tearing of the bridging veins of the brain, resulting in headache, pneumocephalus, subdural hematoma and death. Periorbital hematomas are associated with frontal skull fractures but are not

associated with over-drainage of cerebrospinal fluid. Damage to the optic disc is more likely from intraocular pressure but is not associated with overdrainage of cerebrospinal fluid. Over-drainage of cerebrospinal fluid causes collapse of the ventricles that would prevent rather than cause cerebral herniation A patient presents with a dry powdered chemical on his clothing and skin. The patient complains of feeling short of breath and is dyspneic. The appropriate treatment for this patient is to redirect the patient to the decontamination area, remove all clothing then: - CORRECT ANSWER Dry chemicals should be brushed off before beginning the showering process. Some dry chemicals can react with water causing a thermal reaction that can cause a thermal burn on top of a chemical burn. Aside from brushing off the chemical, it is essential that the patient be showered before being moved to the resuscitation area to stop burning on the skin and to reduce the risk of exposing rescuers to the chemical Which of the following interventions is most likely to reduce intracranial pressure? - CORRECT ANSWER Elevated serum glucose levels are associated with elevated intracranial pressure. Intravenous insulin is administered with the goal of maintaining serum glucose levels between 80 and 120 mg/dL. Patients with intracranial trauma often have elevated temperatures. Normalization of those temperatures, rather than warming measures, are used to decrease intracranial pressure. Flexion of the hips is associated with increased intraabdominal pressure, which in turn is associated with increased intrathoracic pressure. Increased intrathoracic pressure causes increased intracranial pressure. Therefore, flexion of the knees will increase rather than decrease intracranial pressure. Reducing mean arterial pressure does not decrease intracranial pressure but it can exacerbate hypoxia and extend brain damage, therefore this is an inappropriate intervention When possible, enteral feedings, as opposed to parenteral feedings, are preferred in the traumatically injured patient to: - CORRECT ANSWER Enteral feedings improve gut barrier protection and immunity, reduce bacterial translocation reducing the risk of infections and sepsis. Parenteral feedings also increase the risk of intravenous line infections and sepsis. Although early nutrition is associated with improved wound healing, this is not affected by enteral as opposed to parenteral feedings. Enteral feedings do not reduce the need for analgesia and are not associated with decreases in ventilator assisted pneumonia

Which of the following injuries is most likely to cause the quickest elevation in intracranial pressure? - CORRECT ANSWER Epidural bleeds are arterial and cause accumulation of blood within the skull in hours. Signs of increased intracranial pressure often appear within hours as well. Subdural bleeding is venous and often takes much longer, sometimes weeks, to become obvious. Concussions do not tend to cause elevation in intracranial pressure. Although a diffuse axonal injury may cause elevation in intracranial pressure, it is often delayed much longer than would be seen with an epidural bleed The trauma nurse includes the following statement when discharging a patient: "Because of your injury, you are at a higher risk of developing intermittent hypertension. You should have your blood pressure checked regularly and see a provider if you develop headaches or other signs of high blood pressure." Based on this discharge instruction, what injury did the patient likely sustain? - CORRECT ANSWER Excess renin excretion caused by kidney injury or scarring may cause intermittent hypertensive episodes for as long as ten years post renal injury and may need to be treated with anti-hypertensive medication. Therefore, this should be included in a patient's discharge instructions. Intermittent hypertension is not associated with electrical burns, blunt cardiac injuries or subarachnoid bleeds and it would not be appropriate to include this teaching for these injuries The trauma nurse knows that a fistula is a complication that is most likely to occur after trauma to the: - CORRECT ANSWER Fistulas are complications associated with trauma to hollow organs, especially organs of the gastrointestinal tract (e.g. esophagus, stomach, small and large bowel). Fistulas are not common after injuries to the heart, joint spaces or the anterior chamber of the eye Effective fluid resuscitation in a 4-year-old child weighing 16 kg with burns to 45% of the body surface area would be evidenced by a: - CORRECT ANSWER Goals of fluid resuscitation after a burn include a normal hematocrit, which should be approximately 40% in a 4-year-old child. A hematocrit of 52% indicates vascular dehydration. Normal pulse rates in a 4-year-old child are about 80 - 120 beats per minute, so a pulse of 140 beats per minute is tachycardia and is indicative of ongoing dehydration and inadequate fluid resuscitation. One goal of fluid resuscitation in burned pediatric patients is a urinary output of at least 1. mL/kg/hour. For a 16 kg child, this would be a urinary output of at least 16

mL/hour, therefore a urinary output of 20 mL is an indication of successful treatment. Another goal of fluid resuscitation is normal acid-base balance. A serum bicarbonate of 17 mEq/L is below normal (22 - 26 mEq/L) and does not indicate normal acid base balance Which of the following injuries is most likely to cause hyperresonance to percussion throughout the abdomen? - CORRECT ANSWER Hyperresonance over the abdomen is due to the rupture of a hollow organ within the peritoneum, such as the small bowel. Although the esophagus is a hollow organ, it is in the thoracic cavity, therefore a rupture would cause subcutaneous emphysema of the chest and neck as opposed to hyperresonance over the abdomen. The liver and pancreas are solid organs and would not cause the release of air into the peritoneum, therefore they are not associated with hyperresonance to percussion over the abdomen 23.4% saline is being administered to a trauma patient in the trauma intensive care unit. What is the most likely injury this patient is being treated for? - CORRECT ANSWER Hypertonic saline (e.g. 23.4% saline) can be used as an alternative to an osmotic diuretic to reduce intracranial pressure. The hypertonic saline draws fluid into the intravascular bed and out of the cranial compartment and can significantly reduce intracranial pressure. The increase in intravascular fluid with this treatment might exacerbate heart failure associated with a blunt cardiac injury and could increase interstitial fluid in patients with pulmonary contusions, therefore it would not be appropriate for these patients. Hypertonic saline may exacerbate, rather than be used as a treatment for trauma induced coagulopathies Hyperventilation with the purpose of reducing PaCO2 is reserved for patients with: - CORRECT ANSWER Hyperventilation (with the purpose of reducing the PaCO2) may be considered for patients with impending or actual herniation of the brain. A reduction in the PaCO2 is also known to reduce oxygen delivery to the brain, so this treatment is considered a last-ditch effort to reduce intracranial pressure when all other methods have failed. and should only be used temporarily. Hyperventilation has no therapeutic effect in patients with fat emboli. Hyperventilation would worsen a metabolic alkalosis rather than improve it, therefore it is not indicated for this condition. Increasing peak end expiratory

pressure is the treatment for patients with acute respiratory distress syndrome that do not respond to increasing FiO2 levels rather than hyperventilation A patient is brought to the trauma unit with multiple injuries to the head and chest. The right pupil is dilated and responds minimally to light. The patient was intubated prior to arrival and is receiving oxygen without difficulty via a bag-mask device, however, subcutaneous emphysema is noted on the left chest wall. The patient's vital signs are as follows: Pulse: 66 beats per minute, full and bounding Blood pressure: 86/48 mm Hg Respirations: assisted at 14 breaths per minute Oxygen saturation: 95% Temperature: 96.8 F (36 C) Which of the following findings in this scenario should be given the highest priority when determining a plan of care? - CORRECT ANSWER Hypotension in a brain-injured patient can have deleterious effects. A systolic blood pressure below 90 mmHg has twice the mortality in brain-injured patients as systolic blood pressures above 90 mm Hg. Therefore, elevating the blood pressure should be the highest priority in this patient. Bradycardia is expected with increased intracranial pressure and while this finding should be considered and treated, it does not constitute a higher priority than the low blood pressure. Similarly, the subcutaneous emphysema will need further investigation, but the fact that oxygen is being delivered via bag-mask device without difficulty and the patient's oxygen saturations are above 92% indicates that this is a lower priority than the low blood pressure. The dilated, non-reactive pupil indicates significant elevated intracranial pressure, which must be treated, but this will occur after the blood pressure is stabilized Family presence in the trauma room should be facilitated: - CORRECT ANSWER Ideally, family resuscitation should be facilitated as soon as possible as this will likely benefit both the patient and family. Education about what will be experienced and the role of the family when they are in the room, should however be reviewed with the family before entering the room. Ushering the family into the trauma room does not need to occur during any specific portion of the resuscitation (e.g. after the secondary survey or between obtaining vital signs and laboratory tests). Family presence in the resuscitation room does not require consent forms

During resuscitation of a traumatically injured unconscious pregnant patient, who is at 38 weeks gestation, the trauma nurse pulls back the sheet covering the patient and notes that the child's head has delivered vaginally. The nurse assures that there is no cord around the child's neck. The next step in the process is to push the head gently towards the: - CORRECT ANSWER Ideally, the anterior shoulder should be delivered first. This may be facilitated by gently pushing the child's head downward towards the stretcher. Once the anterior shoulder is delivered, delivery of the posterior shoulder may be facilitated by gently pushing the child's head up towards the mother's perineum The trauma nurse knows that reduction for which of the following injuries is most time-sensitive? - CORRECT ANSWER If a dislocated hip is not reduced in a timely manner (six hours), femoral head necrosis may occur. This may result in the need for a hip replacement; therefore, reduction of this injury is time sensitive. A scaphoid fracture is not reduced and the treatment for this injury is not as time sensitive as a hip dislocation. Similarly, fractures of the calcaneus are not time sensitive. Repair of this injury may be delayed for days to allow edema to reduce. Although a dislocated patella can be easily reduced and is often done in a timely manner, reduction of this injury is not as time sensitive as a hip dislocation A tourniquet, applied tightly just above the source of bleeding on a mangled limb, does not effectively control bleeding. What is the next most appropriate step? - CORRECT ANSWER If a tourniquet, applied correctly, does not control bleeding, a second tourniquet should be applied two inches above the first tourniquet. The original tourniquet should never be released and there is no advantage in applying it several inches higher. It is preferable to apply a second tourniquet to control bleeding from a mangled limb rather than giving large volumes of crystalloids. While some crystalloids may need to be given, large volumes may induce coagulopathies. A second tourniquet is more likely to control bleeding in a mangled limb than applying ice to the bleeding area. Because there is a tourniquet in place, the bleeding area is already hypoxic and ice may cause secondary tissue damage During secondary review of a patient's chart, it is noted that a patient had a urethral disruption that was not noted until the patient had been in the trauma intensive care unit for five days, resulting in secondary complications. This injury

can be defined as: - CORRECT ANSWER In performance improvement, injuries found after admission but prior to discharge are defined as "delayed injuries." A "missed injury" is an injury which is not found until after the patient is discharged. Injuries that are missed initially are not defined as "secondary" or "consequential." A patient has a complete spinal cord injury at the level of C7. Which of the following statements about this injury is accurate? The patient will: - CORRECT ANSWER Injuries above T7 lose the ability to cough and are unable to clear their own airways, therefore suctioning and other airway assistance should be anticipated. Generally, patients with injuries below C4 can breathe unassisted although respirations will be less effective if the injury is in the high thoracic or lower cervical nerves. An injury at C7 is likely to cause neurogenic shock, which will cause slow, rather than rapid respirations. The ability to shrug the shoulders without arm movement is more consistent with an injury at C5. Patients with injuries at C7 have arm movement but are unable to use their hands A patient's intraabdominal pressures are obtained. Based on the results obtained, the only intervention was the administration of a bolus of intravenous fluid. What was the patient's intrabdominal pressure before the bolus? - CORRECT ANSWER Intraabdominal pressures above 12 mm Hg are considered elevated and often result in a decrease in blood pressure (due to compression of the vena cava and decreased preload). In pressures between 12 and 15 mm Hg, the goal is to maintain euvolemia. When pressures are between 16 and 20 mm Hg, intravenous fluid boluses are often given to maintain an adequate blood pressure and therefore maintain abdominal perfusion pressure. When pressures exceed 20 mm Hg in the abdomen, further action will be required to reduce intraabdominal pressure (such as insertion of a percutaneous drain into the abdomen, surgical opening of the peritoneum or another means of decompression). If the pressures were 2 or 9 mm Hg, there would be no need to administer a fluid bolus. If the pressures were 30 mm Hg, a fluid bolus may have been considered as needed to maintain the blood pressure but this would not have been the only intervention. Other interventions, such as insertion of a percutaneous drain or abdominal decompression would also have been done The trauma nurse expects diuretics may be used as part of the treatment plan for a patient with: - CORRECT ANSWER Intrarenal kidney injury leaves a patient with

insufficient glomerular function and may result in azotemia (elevated BUN and creatinine). This may be treated with diuretics which will maximize functioning of uninjured glomerular units in an effort to make up for the insufficient functioning of injured glomerular units. The only effective treatment for obstructive shock is to relieve the obstruction, which is not accomplished with diuretics. Pancreatic trauma is more likely to be treated with insulin and blood products and there is no therapeutic reason to give diuretics to someone with pancreatic trauma. Although a patient with a bladder rupture may not make urine, the problem is not because of lack of urine production but rather because of leakage of urine into the tissue from the bladder trauma or from blockage of the bladder outlet from blood and clots. Neither of these conditions will be effectively treated with diuretics Left-sided facial weakness is noted on a patient with a suspected left-sided epidural bleed. This would be documented as: - CORRECT ANSWER Ipsilateral means "same side as", so if the weakness is on the same side of the body as the injury it is "ipsilateral". If the weakness were on the opposite side of the body, it would be described as "contralateral". The suffix "-plegia" refers to weakness and the suffix "-paresis" refers to paralysis. So weakness to one side of the face would be referred to as "hemiplegia" Which of the following parameters should be most closely monitored in a patient receiving mannitol? - CORRECT ANSWER Mannitol, an osmotic diuretic, is known to alter serum electrolytes, especially sodium, which may be lost during the diuresis process. Mannitol does not alter liver enzymes, serum troponin or the white blood cell count in the same way it effects serum sodium The trauma nurse expects a metal eye shield will be used in the treatment of: - CORRECT ANSWER Metal shields may be used to protect a ruptured globe from further damage. The shield should be taped to the bony surfaces around the eye to ensure that no pressure is applied directly to the globe. In a globe luxation as well as an object protruding from the eye, a raised object (such as a paper cup) should be placed over the object or injury since it protrudes beyond the bony socket. Applying a metal shield over these types of injuries could exacerbate the injury. Eye coverings, including metal shields, are not recommended for corneal abrasions. These can alter the patient's vision, increase the risk for further injury and may encourage the growth of bacteria under the shield

Which of the following factors has the greatest likelihood of exerting a negative impact on the rehabilitation stage of trauma care? - CORRECT ANSWER Motivation in the rehabilitative stage of trauma is partially driven by having realistic goals for rehabilitation. If the patient does not know what the final rehabilitation potential is, they may not work towards that goal. But if the patient has goals for rehabilitation in mind that exceed what is possible, they may lose motivation because of constant failure to achieve desired goals. Younger patients often have a greater capacity to learn and may do better in rehabilitation than older patients. Involvement of the family in rehabilitation may increase a patient's motivation to rehabilitate and will also allow the family to learn the skills necessary to assist the patient after discharge. Delays between injury and rehabilitation are more likely to result in poorer outcomes than being involved in rehabilitation shortly after the injury (e.g. seven days) N-acetylcysteine via the inhalation route is prescribed for a patient. What is the most likely reason for the patient's admission? - CORRECT ANSWER N- Acetylcysteine is used as a mucolytic agent in lung disorders and may be prescribed along with inhaled heparin to decrease clot and cast formation in the lungs following a smoke inhalation injury to facilitate the removal of secretions in the lungs. This drug will have no therapeutic effect when delivered via inhalation for liver failure, increased intracranial pressure or acute respiratory distress syndrome Two nurses verify a patient's identify and the compatibility of blood products before initiating blood transfusions. This action exemplifies the ethical concept of:

• CORRECT ANSWER Non-maleficence is an ethical concept that means "do no harm." Providing incompatible blood products could harm a patient so double checking the patient's identify and compatibility of blood products reduces the potential of harming the patient by providing incompatible blood products. This example does not embody the ethical concept of justice (equally distributing healthcare good across society), veracity (being honest and sharing information freely with a patient) or beneficence (ensuring actions carried out benefit a patient) When caring for the patient with liver trauma, the trauma nurse knows that liver enzymes: - CORRECT ANSWER Normally, liver enzymes elevate following liver

trauma and the degree of elevation is usually associated with the severity of the liver injury. They do not decrease either initially or permanently The trauma nurse knows that the eye of a patient with ocular entrapment secondary to an orbital fracture will nearly always deviate: - CORRECT ANSWER Ocular entrapment, associated with an orbital fracture, nearly almost always causes the eye to deviate downwards with pain on upward gaze. It is unlikely that ocular deviation goes toward the midline, up towards the forehead or externally towards the ear on the same side as the fracture Deficiencies in trauma care are discussed during a pre-hospital trauma performance review meeting. All parties present at the meeting decide to alter the trauma alert process. What is the next step after the new process has been implemented? - CORRECT ANSWER Once a modification or action has been undertaken in the performance review process, data should be collected to ensure that the actions have created the desired improvements. This is known as "loop closure." If the actions taken do not result in the changes desired (as evidenced by further data collection) then true performance improvement has not taken place. A quaternary review is reserved for cases that need additional review. In this case, an action has been decided upon, so a quaternary review is unnecessary. A morbidity/mortality review is used to review a patient death. Individual employee counseling may have been chosen as an action or modification but since a different action was chosen, further data collection, rather than individual employee counseling is the best choice Which of the following activities best exemplifies the maintenance of chain of evidence? - CORRECT ANSWER One component of maintaining the chain of evidence is ensuring that a careful record of everyone who handles evidence is maintained. This would include the law enforcement officer who collects the evidence. Recording the name, badge number and agency of that officer helps to maintain the chain of evidence so it can be reconstructed, if necessary, at a later time. Although applying paper bags over the hands of a patient with a gunshot wound, utilizing body diagrams in the recording process and cutting away from evidence on clothing are all appropriate principals of collecting forensic evidence, they do not necessarily assist in the maintenance of the chain of evidence

One goal of an effective public trauma education program is to: - CORRECT ANSWER One goal of a public trauma education program is to teach participants when and how to access the trauma system. For example, a first aid class, stop the bleed class or basic life support class should clearly indicate when a patient should be referred to healthcare and the best way to accomplish that. An effective trauma education program should decrease both direct and indirect costs by reducing injuries or reducing the severity of injuries. The public does not get directly involved in a performance improvement program, therefore it is not a goal for a trauma education program. The goal of an educational program is not necessarily to reach the greatest number of people, but rather to reach a particular audience. For example, if the purpose of the program is to reduce falls, then the elderly would be targeted but the goal would not be to focus on the younger population The trauma nurse knows that one goal of treatment for a patient with a pulmonary contusion has been met if: - CORRECT ANSWER One goal of care for patient's with pulmonary contusions is to control their pain. This will facilitate coughing to clear secretions, increased mobility and increased tolerance for chest physiotherapy. Peak inspiratory pressures on a ventilator above 40 mm Hg are considered elevated and may be associated with barotrauma to the lungs. This would not be desirable. The peak of the capnography waveform indicates the patient's carbon dioxide level which should be maintained below 45 mm Hg, not above it. Chest tubes are not effective for treating a pulmonary contusion as chest tubes are placed in the pleural space and blood and other contaminants associated with a pulmonary contusion collect in the alveoli. In addition, bubbling may be noted on inspiration, not exhalation in a patent chest drainage set Which of the following findings indicates that treatment for abdominal compartment syndrome has been effective? - CORRECT ANSWER One of the earliest indications of abdominal compartment syndrome is a decrease in urinary output due to the pressure that is put on the kidneys by the enlarging peritoneal cavity as well as hypotension from pressure exerted on the vena cava (reducing preload). Effective treatment of abdominal compartment syndrome should relieve pressure on the kidneys and elevate the blood pressure, both of which should increase urinary output. Although patients with abdominal compartment syndrome may experience pain, this is not always the case, therefore, this is not a goal of treatment. Reducing pressure on the vena cava by reducing pressure in

the peritoneum should reduce rather than increase systemic vascular resistance. Treating abdominal compartment syndrome should increase, rather than decrease abdominal perfusion pressure An early finding associated with fat embolism syndrome (FES) is: - CORRECT ANSWER One of the early findings often noted in patients who develop fat embolism syndrome is a change in neurological status (e.g. restlessness, agitation, disorientation, etc.) Reduction in blood flow through the pulmonary circulation related to fat globules in the capillaries of the lungs means less blood return to the left ventricle and the blood pressure tends to decrease rather than increase. A reduction in blood flow around the alveoli causes PaO2 to decrease and PaCO2 to increase (rather than decrease). Fat emboli affect the circulation in the lung as opposed to ventilation, so lung sounds will tend to be unaffected, especially early in the syndrome The trauma nurse knows that a goal of treatment for rhabdomyolysis has been met if the: - CORRECT ANSWER One of the main goals in treating rhabdomyolysis is to ensure adequate urinary output which indicates that kidneys are functioning and increases clearance of myoglobin through the kidneys. A goal of treatment should be 200 - 300 mL per hour. A goal of care in treatment rhabdomyolysis is not pain control. Although pain should be treated appropriately, it is generally not associated with rhabdomyolysis and is not a treatment goal for this condition. One treatment for rhabdomyolysis is alkalization of the urine with sodium bicarbonate. The ideal urine pH would be above 8.0 rather than below 6.0. Rhabdomyolysis does not affect level of consciousness and increasing level of consciousness is not a goal of treatment Which of the following performance improvement measures would be appropriate to track to reduce catheter associated urinary tract infections (CAUTI) in traumatically injured patients? - CORRECT ANSWER One of the recognized risk factors for catheter associated urinary tract infections (CAUTI) is the length of time that a urinary catheter is in place and the sooner the catheter is removed, the less likely the patient is to develop CAUTI. (The risk of CAUTI increases 3 - 7% each day the catheter is in place). Therefore tracking the number of days a catheter is in place to determine if it is longer than the national average may help determine the core of the problem so it can be addressed. It is unlikely that tracking the number of days after catheter placement an infection develops, the