TNCC 9TH EDITION TNP 120 QUESTIONS AND CORRECT ANSWERS (GRADED A+), Exams of Nursing

Download TNCC 9TH EDITION TNP 120 QUESTIONS AND CORRECT ANSWERS (GRADED A+) and more Exams Nursing in PDF only on Docsity! TNCC 9TH EDITION TNP 120 QUESTIONS AND CORRECT ANSWERS (GRADED A+) You are caring for a patient who was thrown from a bike and was not wearing a helmet. While performing the head-to-toe assessment, you note clear drainage from the right ear. Which of the following is the most appropriate next step? A. Clean the ear with a cotton-tipped applicator. B. Pack the ear with gauze. C. Notify the physician D. Document and continue the exam. - ANSWER C. Notify the physician A patient is brought to the emergency department of a rural hospital following a high- speed motor vehicle collision. When significant abdominal and pelvic injuries are noted in the primary survey, what is the priority intervention? A. Initiate transfer to a trauma center B. Attempt family notification C. Obtain additional imaging studies D. Place an indwelling urinary catheter - ANSWER A. Initiate transfer to a trauma center An adult who fell from a second story roof is brought to the emergency department by private vehicle. The patient is confused with unlabored respirations and has strong, palpable radial pulses. There is an open wound in proximity to an obvious deformity of the left lower extremity. What is the priority intervention? A. Initiate cervical spine stabilization B. Apply a splint to the lower extremity C. Put the patient on portable oxygen. D. Log roll the patient onto a spine board - ANSWER A. Initiate cervical spine stabilization An adult patient who sustained a severe head trauma has been intubated and is being manually ventilated via a bag-mask device at a rate of 18 breaths/minute. The patient has received one intravenous fluid bolus of 500 mL of warmed isotonic crystalloid solution. The PaCO2 is 30 mm Hg (4.0 kPa), and the pulse oximetry is 92%. BP is 142/70 mm Hg. What is the most important intervention to manage the cerebral blood flow? A. Decrease the rate of manual ventilation. B. Initiate another fluid bolus. C. Recheck endotracheal tube placement. D. Increase the amount of oxygen delivered. - ANSWER A. Decrease the rate of manual ventilation. An adult patient is brought to the emergency department following a vehicle "roll-over" with prolonged extrication. Assessment reveals swelling and bruising to the right proximal thigh and a weak pedal pulse. Skin is pale, cool, and moist. What is the most appropriate initial intervention? A. Application of a tourniquet to the affected extremity B. Application of a pelvic binder A patient presents to the emergency department with a degloving injury involving the entire forearm. What should the nurse consider when planning care for a patient with this injury? A.Wound edges can be easily approximated for suturing. B.Surgical intervention will be needed C.Extent of tissue damage does not affect potential limb salvage D.Only soft tissue has been damaged - ANSWER A 35-year-old male 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? A.Oculomotor nerve palsy B.Globe rupture C.Retrobulbar hematoma D.Retinal detachment - ANSWER A driver involved in a high-speed motor vehicle collision arrives in the emergency department. The vehicle's air-bag failed to deploy. The patient is drowsy but arousable and complaining of chest pain with ecchymosis noted to the chest. The patient is tachycardic and hypotensive with no evidence of uncontrolled bleeding. Cardiac monitor shows premature ventricular contractions. Which of the following is the most appropriate intervention for this patient? A.Rapid fluid boluses B.Tranexamic acid administration C.Inotropic support D.Epinephrine administration - ANSWER A trauma patient who is 30-weeks pregnant arrives at the emergency department following a motor vehicle collision. Which normal physiologic change should be considered when assessing ventilatory status? A.Increased functional reserve capacity B.Increased oxygen consumption C.Decreased minute ventilation D.Slower desaturation rates with apnea - ANSWER A trauma patient is being resuscitated in the emergency department when the radiology staff notifies the charge nurse that the computed tomography (CT) scanner will be out of service for several hours. The team gathers to plan accordingly. Which of the following terms best describes this trauma team's communication? A.Brief B.Closed-loop C.Debrief D.Huddle - ANSWER An adult pedestrian was struck on the right side by a sport utility vehicle traveling at 40 mph. The patient is awake and alert and the right leg is shortened. Following initial resuscitation with fluids, the patient remains hypotensive. What would be the priority intervention? A.Send blood for type and crossmatch B.Apply a pelvic binder C.Prepare the patient for surgery D.Insert a urinary catheter - ANSWER A patient with a traumatic brain injury has a mean arterial pressure (MAP) of 65 mm Hg (8.66 kPa) and an intracranial pressure (ICP) of 22 mm Hg (2.93 kPa). Which finding is most likely an indication of the body's response to these findings? A.Increased respiratory effort B.Reflex tachycardia C.Widening pulse pressure D.Reflex hypotension - ANSWER While caring for a child who has been injured, what nursing intervention is consistent with a family-center approach? A.Identifying a single family member to speak with B.Having the family make all the care decisions C.Allowing family to participate in the care of the patient D.Limiting dissemination of complex information - ANSWER SpO2 of 90% on oxygen at 15L per non-rebreather mask. Other findings include ETCO2 24, serum lactate of 6 mmol/L, and a pH of 6.8. Based on these findings, what is the most appropriate intervention? A.Initiate warming measures B.Titrate oxygen to 6 L per nasal cannula C.Bolus with 500 mL isotonic crystalloids D.Vigorously massage the extremities - ANSWER A patient presents with chest pain and shortness of breath following a motor vehicle collision. An electrocardiogram shows sinus tachycardia and ischemic changes with an elevated troponin. The nurse should be highly suspicious for which injury? A.Cardiac tamponade B.Blunt cardiac injury C.Aortic disruption D.Pulmonary contusion - ANSWER What intravascular solution is most commonly used for patients who have sustained burns? A.Lactated Ringer's B.Normal saline C.D5 / normal saline D.Hypertonic saline - ANSWER A patient has been diagnosed with an incomplete spinal cord injury at L1. Which finding would indicate sacral sparing? A.Involuntary flexion of the great toe B.Priapism C.Voluntary anal sphincter tone D.Numbness to the perianal area - ANSWER A patient arrives with a large metal rod embedded in their left thigh and no active bleeding. Which intervention is most appropriate for this patient? A.Remove the rod immediately to facilitate cleansing. B.Apply a tourniquet to the leg above the metal rod. C.Hold antibiotics until after the rod is removed. D.Prepare the patient for surgery to remove the rod. - ANSWER A patient has received multiple transfusions of banked blood in the past two hours. The patient has now developed muscle tremors and short runs of ventricular tachycardia. Which of the following medications does the nurse anticipate administering? A.Hypertonic saline B.Calcitonin C.Insulin and glucose D.Calcium gluconate - ANSWER Which of the following is true regarding cavitation? A.Energy causes the tissues to accelerate and displace outward B.Once a bullet passes, the tissue always returns to its normal location C.Damage occurs only to internal organs and blood vessels D.Hollow organs do not tolerate high-velocity cavitation - ANSWER A patient arrives with a 3-inch laceration to their forearm from a tree branch. Which of the following methods will the nurse use to remove small pieces of bark and debris from the wound? A.Low-pressure irrigation B.High-pressure irrigation C.Scrubbing with normal saline D.Scrubbing with tap water - ANSWER An adult patient was a restrained passenger involved in a high-speed motor vehicle collision. The patient complained of generalized abdominal and left leg pain. A FAST exam was negative for fluid in the abdominal cavity. While awaiting inpatient bed placement, the patient develops increased abdominal pain with rebound tenderness, fever, and an elevated white blood cell count. These findings are most consistent with an injury to which organ? A.Spleen B.Kidney C.Small bowel What are examples of nonpharmacologic measures? (must identify at least one during testing) - ANSWER Distraction, family presence, padding bony prominences, repositioning, splinting, verbal reassurance For whom is capnography highly recommended? - ANSWER all patients In step M of "Get Adjuncts", what else might be indicated besides cardiac monitor? - ANSWER EKG In Step 16 of "Exposure and Environment", you must name at least one of these interventions: - ANSWER blankets, room temp increase, warmed fluids, warming lights At what point PRIOR TO the head-to-toe is the patient inspected for obvious injuries? - ANSWER In Step 15 of "Exposure and Environment" In Step 13 of "Disability", what is assessed if pt is altered? - ANSWER glucose To assess circulation, you must do these two main tasks: - ANSWER 1. inspect AND palpate skin color, temp, moisture and 2. palpate a pulse What do you do when alterations are identified in any of the steps in the primary survery? - ANSWER intervene as appropriate and reassess What three assessments must be done if the patient is intubated? - ANSWER 1. attach CO2 detector and assess for evidence of exhaled CO2; 2. observe for rise and fall of the chest w/ assisted ventilations; 3. auscultate over epigastrium for gurgling AND lungs for bilateral breath sounds Four of these must be identified to assess breathing effectiveness: - ANSWER Breath sounds, depth/pattern/rate, spontaneous breathing, subcutaneous emphysema, increased work of breathing, symmetrical chest rise and fall, tracheal deviation/JVD, open wounds/deformities, skin color What can be applied in step 12 of "Circulation and Control of Hemorrhage" for which credit is given in the LMNOP section? - ANSWER cardiac monitor When should 2 IV sites be established? - ANSWER During "Circulation" assessment If the patient is intubated and you've already assessed ETT placement, what else needs to be done with the ETT? (step 10) - ANSWER assess ETT position by noting the number at teeth/gums AND secure ETT What should you verbalize after completing all ETT assessments? - ANSWER moving patient from assisted ventilation to mechanical During which part of the primary survey would you anticipate the need for a chest tube, intubation, decompression of pneumothorax, oxygen, or BVMs? - ANSWER "Breathing and Ventilation" Four of these must be identified to assess patency and protection of the airway: - ANSWER bony deformity, loose teeth, edema, inhalation injury, sounds, tongue obstruction, burns, fluids, foreign objects, vocalization During which part of the primary survey would there be anticipation for intubation, insertion of OPA/NPA, removal of any loose teeth or foreign objects, or suctioning? - ANSWER Assessing patency and protection of the airway, Step 7 of "Alertness and Airway with Simultaneous Cervical Spinal Stabilization" If c-spine stabilization is necessary, what need should be stated? - ANSWER the need for a second person to provide manual c-spine stabilization An adult patient who sustained a severe head trauma has been intubated and is being manually ventilated via a bag-mask device at a rate of 18 breaths/minute. The patient has received one intravenous fluid bolus of 500 mL of warmed isotonic crystalloid solution. The PaCO2 is 30 mm Hg (4.0 kPa), and the pulse oximetry is 92%. BP is 142/70 mm Hg. What is the most important intervention to manage the cerebral blood flow? A.Decrease the rate of manual ventilation. B.Initiate another fluid bolus. C.Re - ANSWER A.Decrease the rate of manual ventilation. An older adult presents to the emergency department with complaints of dizziness, headache, and nausea. The patient was involved in a motor vehicle collision 10 days ago. There was no loss of consciousness and a hematoma is noted to the forehead. The patient is currently on anticoagulant therapy. What is most likely the cause of their symptoms? A.Intracerebral hemorrhage B.Epidural hematoma C.Diffuse axonal injury D.Post-concussive syndrome - ANSWER post-concussive syndrome A patient with a lower extremity fracture complains of severe pain and tightness in his calf, minimally relieved by pain medications. Which of the following is the priority nursing intervention? A.Elevating the leg above the level of the heart B.Repositioning the leg and applying ice C.Elevating the leg to the level of the heart A.Weakness in the lower extremities B.Urinary incontinence C.Sacral sparing D.Spastic paralysis of the legs - ANSWER urinary incontinence Which blood pressure finding is associated with early or compensated hypovolemic shock? A.Rising systolic B.Rising diastolic C.Decreasing diastolic D.Decreasing systolic - ANSWER B. Rising diastolic Which of the following is true about the log-roll maneuver? A.It causes less spinal motion than the lift-and-slide maneuver B.It is recommended for patients with unstable pelvic fractures C.It should be avoided with a suspected spine injury prior to imaging D.It decreases the risk of hemorrhage from unstable pelvic injuries - ANSWER It should be avoided with a suspected spine injury prior to imaging A patient has uncontrolled bleeding from a wound to his right upper extremity. What is the priority intervention? A.Initiate two intravenous access sites B.Place the patient on supplemental oxygen C.Apply direct pressure to the wound D.Use a tourniquet to control the bleeding - ANSWER C.Apply direct pressure to the wound Which of the following situations could cause functional grief? A.Inability to live at home B.Amputation of a limb C.Loss of one's self-image D.Destruction of the patient's car - ANSWER B.Amputation of a limb Using the American College of Surgeons screening guidelines, what assessment finding would prompt the nurse to prepare a patient for cervical spine imaging? A.Alert with no neurologic deficits B.Multiple abrasions to the extremities C.Ecchymosis to the flank D.Responds to verbal stimulation - ANSWER A.Alert with no neurologic deficits An adult was thrown against a concrete wall during a factory explosion and sustained a femur fracture, liver laceration, and a small subdural hematoma. These injuries most likely occurred during what level of blast trauma? A.Primary B.Secondary C.Tertiary D.Quaternary - ANSWER C.Tertiary An adult patient was brought to the emergency department following a motorcycle crash. On arrival, the patient is only responsive to pain, has bleeding from the nose, and multiple abrasions and contusions to the face. What is the priority intervention? A.Use a bulb syringe to suction out secretions from the mouth. B.Insert a nasopharyngeal airway to maintain an open airway. C.Use a jaw thrust to open the airway and look for signs of obstruction. D.Ask the patient to open their mouth to inspect - ANSWER C.Use a jaw thrust to open the airway and look for signs of obstruction. An adult pedestrian was struck on the right side by a sport utility vehicle traveling at 40 mph. The patient is awake and alert and the right leg is shortened. Following initial resuscitation with fluids, the patient remains hypotensive. What would be the priority intervention? A.Send blood for type and crossmatch B.Apply a pelvic binder C.Prepare the patient for surgery D.Insert a urinary catheter - ANSWER Apply a pelvic binder A severely injured patient has been intubated and is being mechanically ventilated. The patient has received a balanced resuscitation including multiple blood products. Under which circumstance will it be harder for the hemoglobin to release oxygen to the tissues? D.Widening pulse pressure - ANSWER D.Widening pulse pressure An unconscious patient arrives following a motor vehicle collision. The patient is on a backboard with a cervical collar in place and one intravenous line running. Respirations are shallow and there is active brisk bleeding from a large leg wound. What is the priority intervention for this patient? A.Check for a patent airway B.Control the bleeding C.Start a second intravenous line D.Ventilate with a bag-mask device - ANSWER B.Control the bleeding An obese trauma patient requires intubation. Assuming there are no contraindications, which position will provide the best visualization for insertion of the endotracheal tube? A.Reverse Trendelenburg B.Lying on side C.Ramped D.Supine - ANSWER C.Ramped Your patient is a pedestrian struck by a car and thrown 35 feet. They were unconscious at the scene but became responsive with initial and subsequent Glasgow Coma Scale (GCS) scores of 13 (E-3, V-4, M-6). The patient has bilateral subdural hematomas and is awaiting transfer to the ICU. Your next assessment reveals a GCS of 9 (E-2, V-2, M- 5). What is the priority nursing intervention? A.Hold all pain medications B.Notify the provider of the change C.Repeat the GCS in 30 minutes D.Place the patie - ANSWER B.Notify the provider of the change A patient arrives following prolonged exposure of their left hand to the cold. The patient is awake and alert and complains of a tingling sensation to the fingers. Assessment reveals swelling and bright red skin to the left hand and a 1-inch round clear blister to the dorsum of that hand. Which of the following nursing interventions is most appropriate for this patient? A.Massage the injured areas to promote circulation B.Drain and debride the blister on the hand C.Immerse in water between 37.5 - ANSWER D.Gently rewarm over 15 to 30 minutes A nurse verbalizes guilt and remorse after caring for multiple severely injured patients during a staffing crisis. The nurse expresses anger stating that the patients did not receive quality care and begins exhibiting aggression toward colleagues. This is most consistent with which condition? A.Compassion fatigue B.Vicarious trauma C.Secondary traumatic stress D.Moral injury - ANSWER D.Moral injury What is the rationale for obtaining a serum lactate level during the initial assessment of a trauma patient? A.Measures oxygenation and ventilation B.Assesses the degree of alkalosis and base deficit C.Gauges end-organ perfusion and tissue hypoxia D.Determines the underlying cause of shock - ANSWER C.Gauges end-organ perfusion and tissue hypoxia What is the most important consideration during the initial assessment when caring for an older adult who has sustained serious injuries? A.They are likely to be fearful in the emergency department B.Medical history including current medications C.Availability of support systems after discharge D.Accessibility to a primary care physician - ANSWER B.Medical history including current medications Following a gun shot wound, pre-hospital providers report diminished breath sounds bilaterally. Upon emergency department arrival, the patient is unresponsive with shallow respirations and an O2 sat of 88%. What is the priority intervention for this patient? A.Administer 15 L oxygen via nonrebreather mask B.Attach patient to a CO2 detector C.Prepare for a definitive airway A.Initiating a second large caliber intravenous line B.Maintaining spinal motion restriction C.Placing the patient on pulse oximetry D.Turning the patient to remove the backboard - ANSWER B.Maintaining spinal motion restriction What position optimizes ventilation in the obese patient with a lumbar fracture? A.Reverse Trendelenburg B.Supine C.Prone D.Fowler's - ANSWER A.Reverse Trendelenburg During the primary survey of an unconscious patient with multi-system trauma, the nurse notes snoring respirations. Which priority nursing intervention should be performed next? A.Open the airway with the head-tilt/chin-lift maneuver B.Auscultate bilateral breath sounds C.Assist respirations using a bag-mask device D.Insert an oropharyngeal airway if there is no gag reflex - ANSWER D.Insert an oropharyngeal airway if there is no gag reflex A trauma patient is being held in the emergency department because there are no available inpatient beds. The patient sustained a femur fracture and required multiple blood products. The patient now has blood oozing from abrasions, IV sites, the nose, and gums. What condition is most consistent with these findings? A.Rhabdomyolysis B.Fat embolism C.Disseminated intravascular coagulopathy D.Multiple organ dysfunctions syndrome - ANSWER C.Disseminated intravascular coagulopathy A patient is brought to the emergency department following a snowmobile crash with prolonged exposure time prior to transport. The patient is confused. Vital signs are BP 96/54 mm Hg, HR 114 beats/minute, RR 24 breaths/minute, T 34.6oC (94.2oF) and an SpO2 of 90% on oxygen at 15L per non-rebreather mask. Other findings include ETCO2 24, serum lactate of 6 mmol/L, and a pH of 6.8. Based on these findings, what is the most appropriate intervention? A.Initiate warming measures B.Titrate oxygen to - ANSWER A.Initiate warming measures Which of the following is a late sign of increased intracranial pressure? A.Restlessness B.Vomiting C.Decreased respiratory effort D.Narrowing pulse pressure - ANSWER C.Decreased respiratory effort Based on fall mechanism, which patient warrants prehospital transfer to a trauma center? A.A 35-year-old lands on a wooden porch from an 8-foot ladder B.A 2-year-old lands on grass from a second-story balcony C.A 14-year-old forcefully pushed onto cement from standing D.A 50-year-old lands on a carpeted floor after tripping - ANSWER B.A 2-year-old lands on grass from a second-story balcony The trauma nurse is caring for an unrestrained driver who struck their head on the windshield following a high-speed MVC. The patient has been diagnosed with an anterior spinal cord injury at the level of C6. Which assessment finding would be most concerning? A.Distension of the bladder B.Incontinence of stool C.Increasing work of breathing D.Inability to move the legs - ANSWER C.Increasing work of breathing While caring for a child who has been injured, what nursing intervention is consistent with a family-center approach? A.Identifying a single family member to speak with B.Having the family make all the care decisions C.Allowing family to participate in the care of the patient