TNCC FULL SOLUTION PACK(ALL TNCC EXAMSAND STUDY QUESTIONS ARE HERE ,ALL ANSWERED CORRECTLY, Exams of Nursing

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TNCC FULL SOLUTION PACK(ALL TNCC EXAMSAND STUDY QUESTIONS ARE HERE ,ALL ANSWERED CORRECTLY LATEST 2023-2024)

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Expedite transfer to the closest trauma center - A 56 y/o M pt involved in a motor vehicle crash is brought to the ED of a rural critical access facility. He complains of neck pain, SOB, and diffuse abd pain. His GCS is 15. His VS: BP 98/71, HR 125, RR 26, SpO2 94% on high-flow O2 via NRB mask. Which of the following is the priority intervention for this patient? a pertinent medical hx is crucial - Which of the following considerations is the most important when caring for a geriatric trauma pt? Mitigation - Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of a future disaster. Which phase of the disaster life cycle does this describe? Multiple requests for water - EMS brings a pt who fell while riding his bicycle. Using the American College of Surgeobs screening guidelines, which assessment finding would prompt the RN to prepare the pt for a radiologic spine clearance? hemoglobin does not readily release O2 for use by the tissues - What is the effect of hypothermia on the oxyhemoglobin dissociation curve? acidosis - Which of the following is a component of the trauma triad of death? Complete - EMS brings a pt from MVC. VS: BP 90/49, HR 48, RR 12, temp 97.2F (36. C). The pt exhibits urinary incontinence and priapism. These assessment findings are most consistent with which of the following types of spinal cord injury? flucuation in the water seal chamber - Which of the following is an expected finding in a pt with a tube thoracstomy connected to a chest drainage system? insert an oropharyngeal airway if there is no gag reflex - During the primary survey of an unconscious pt with multi-system trauma, the nurse notes snoring respirations. What priority nursing interventions should be preformed next? globe rupture - A 35 y/o M presents with facial trauma after being struck in the face with a baseball. A teardrop-shaped left pupil is noted on exam. What type of injury is suspected?

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pulse oximetry and capnography - What bedside monitoring parameters are used to assess for adequacy of O2 and effectiveness of ventilation? padding the upper back while stabilizing the cervical spine - Caregivers carry in a 2 y/o into the ED who fell out of a second-story window. The pt is awake and crying with increased work of breathing and pale skin. Which of the following interventions has the highest priority? bowel - Which of the following injuries is LEAST likely to be promptly identified? Initiate transfer to a trauma center - A pt is brought to the ED of a rural hospital following a high-speed MVC. When significant abd and pelvic injuries are noted in the primary survey, which of the following is the priority interventions? bardycardia and absent motor function below the level of injury - A pt with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? apply splint and elevate above the level of the heart - a 37 y/o F has a deformity of the L wrist after a fall. She is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention? the aorta is torn at its attachment with the ligamentum arteriosum - which of the following occurs during the third impact of a motor vehicle crash? Report your suspicion of maltreatment in accordance with local regulations - a 5 y/o child presents to the ED with bruises to the upper arm and buttocks in various stages of healing and multiple small, clean, round burns to the back. There are no abnormalities found based on the pediatric assessment triangle or primary survey. Which of the following is the priority survey. Which of the following is the priority nursing intervention? to guage end-organ perfusion and tissue hypoxia - Why is a measure of serum lactate obtained in the initial assessment of a trauma patient? elevating the extremity to the level of the heart - A pt with a lower extremity fracture complains of severe pain and tightness in his calf, minimally by pain medications. Which of the following is the priority nursing intervention? velocity - What factor contributes most to the kinetic energy of a body in motion? subdural hematoma - An elderly patient with a history of anticoagulant use presents after a fall at home today. She denies any loss of consciousness. She has a hematoma to her forehead and complains of headache, dizziness, and nausea. What is the most likely cause of her symptoms?

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fat embolism - a pt has been in the ED for several hrs waiting to be admitted. He sustained multiple rib fractures and a femur fracture after a fall. He has been awake, alert, and complaining of leg pain. His wife reported that he suddenly became anxious and confused. Upon reassessment, the pt is restless with respiratory distress and petechiae to his neck. The pt is exhibiting s/sx most commonly associated with which of the following conditions? nausea and vomiting - Which of the following is a late sign of increased intracranial pressure? serial FAST exams - a 49 y/o restrained driver involved in a MVC presents to the trauma center complaining of abd, pelvic, and bilateral lower extremity pain. VS are stable. The nurse can anticipate all of these after a negative FAST exam EXCEPT which of the following? pericardiocentesis - Which of the following is NOT considered goal-directed therapy for cardiogenic shock? endotracheal tube - The trauma nurse knows that placing a bariatric patient in a ramped position providers better visualization during the insertion of which device? increased work of breathing? - which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax? calcium - if a pt has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation? identifying individuals who made mistakes during the traumatic event - Which of the following is NOT considered a benefit of debriefings? 500 mL/hr - You are treating a 27 y/o M in respiratory distress who was involved in a house fire. Calculating TBSA burned is deferred due to the need for emergent intubation. At what rate should you begin fluid resuscitation? advanced age - Which of the following is most likely to contribute to inadequate oxygenation and ventilation? a 52 y/o diabetic male with a partial thickness burn to the left lower leg - Which of the following patients warrants referral to a burn center? dressing removal - A patient arrives with a large open chest wound after being assaulted with a machete. Prehospital providers placed a nonporous dressing over the chest wound and taped it on three sides. he is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis and decreasing blood pressure. Which of the following is the MOST appropriate immediate intervention?

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• Cyanosis, especially around the mouth

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• Asymmetric expansion of chest wall
• Paradoxical movement of the chest wall during inspiration and expiration
• Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
• Sucking chest wounds
• Absent or diminished breath sounds
• Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
• Anticipate definitive airway management to support ventilation. Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - A tight-fitting nonrebreather mask at 12 - 15 lpm. What intervention should be done if a pt presents with effective circulation? - - Insert 2 large caliber IV's
• Administer warmed isotonic crystalloid solution at an appropriate rate What are signs of ineffective circulation? - - Tachycardia
• AMS
• Uncontrolled external bleeding
• Pale, cool, moist skin
• Distended or abnormally flattened external jugular veins
• Distant heart sounds What are the interventions for Effective/Ineffective Circulation? - - Control any uncontrolled external bleeding by:
• Applying direct pressure over bleeding site
• Elevating bleeding extremity
• Applying pressure over arterial pressure points
• Using tourniquet (last resort).
• Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution
• Use warmed solution
• Use pressure bags to increase speed of IVF infusion
• Use blood administration tubing for possible administration of blood
• Use rapid infusion device based on protocol
• Use NS 0.9% in same tubing as blood product
• IV = surgical cut-down, central line, or both.
• Blood sample to determine ABO and Rh group
• IO in sternum, legs, arms or pelvis
• Administer blood products
• PASG (without interfering with fluid resuscitation) How do you assess Mnemonic "D"? - DISABILITY A = Alert V = Verbal P = Pain U = Unresponsive

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- PERRL?

• Determine presence of lateralizing signs including:
• Unilateral deterioration in motor movements or unequal pupils
• Symptoms that help to locate area of injury in brain What are the interventions for Disability? - - If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments
• If pt is not alert or verbal, continue to monitor for any compromise to ABC's
• If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation. What is assessed and intervened for Expose/Environmental Controls? - - Remove clothing
• Ensure appropriate decontamination if exposed to hazardous material
• Keep pt warm
• Keep clothing for evidence What is the first thing assessed under the Secondary Assessment? - FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE
• ABCDE should be completed
• Labs, X-rays, CT, Foley,
• Family Presence What is the second thing assessed under the Secondary Assessment? - GIVE COMFORT MEASURES
• Talking to pt
• Pharmacologic/Nonpharmacologic pain management
• Observe for physical signs of pain What is assessed under the Mnemonic "H"? - HISTORY / HEAD-TO-TOE ASSESSMENT
• MIVT
• M = Mechanism of injury
• I = Injuries sustained
• V = Vital Signs
• T = Treatment
• Pt generated information
• PMH
• Head-to-toe assessment What is assessed under the Mnemonic "I"? - INSPECT POSTERIOR SURFACES
• While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs.
• Palpate vertebral column for deformity and areas of tenderness
• Assess rectum for presence/absence of tone, presence of blood

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What she be done after the Secondary Assessment? - Reassess:

• Primary survey,
• VS
• Pain
• Any injuries What are factors that contribute to ineffective ventilation? - - AMS
• LOC
• Neurologic injury
• Spinal Cord Injury
• Intracranial Injury
• Blunt trauma
• Pain caused by rib fractures
• Penetrating Trauma
• Preexisting hx of respiratory diseases
• Increased age What medications are used during intubation? - LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? - PREPARATION:
• gather equipment, staffing, etc. PREOXYGENATION:
• Use 100% O2 (prevent risk of aspiration). PRETREATMENT:
• Decrease S/E's of intubation PARALYSIS WITH INDUCTION:
• Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING:
• Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF
• Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30- 60 seconds between attempts.
• After intubation, inflate the cuff
• Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT:
• Secure ET tube
• Set ventilator settings
• Obtain Chest x-ray
• Continue to medicate
• Recheck VS and pulse oxtimetry

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• patient's skin color (cyanosis?)

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• JVD or tracheal deviation? (Tension pneumothorax) What are you looking for when auscultating lung sounds? - Absence of BS:
• Pneumothorax
• Hemothorax
• Airway Obstruction Diminished BS:
• Splinting or shallow BS may be a result of pain What are you looking for when percussing the chest? - Dullness:
• hemothorax Hyperresonance
• Pneumothorax What are you looking for when palpating the chest wall, clavicles and neck? - - Tenderness
• Swelling
• subcutaneous emphysema
• step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax. What is the DOPE mnemonic? - D - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing Explain Hypovolemic Shock. - Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn). Some causes:
• Blood loss
• Burns, etc. Explain Cardiogenic Shock. - Syndrome that results from ineffective perfusion caused by ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes:
• MI

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

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hormone)

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then:

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Inspect:

• LOC
• Rate and quality of respirations
• External bleeding?
• Skin color and moisture
• Assess jugular veins and peripheral veins Auscultate:
• BP
• Pulse pressure
• Breath sounds
• Heart sounds
• Bowel sounds Percuss:
• Chest and abdomen Palpate:
• Central pulse (carotid or femoral)
• Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse
• Palpate peripheral pulses
• Palpate skin temp and moisture Diagnostic Procedures:
• Xrays and other studies
• Labs Planning and Implementation
• Oxygen
• IV's with warmed replacement fluids
• Control external bleeding with direct pressure
• Elevate LE's
• NGT
• Foley
• Monitor and pulse oximeter
• Monitor for development of coagulopathies
• Surgery? ICP is a reflection of what three volumes? What happens when one increases? - 1. Brain

2. CSF
3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful.