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TNCC Written Exam – Exam Questions With 100%
Correct Answers (Distinction)
What are the late signs of breathing compromise? Correct ans - - Tracheal deviation
What are signs of ineffective breathing? Correct ans - - AMS
- Cyanosis, especially around the mouth
- Asymmetric expansion of chest wall
- Paradoxical movement of the chest wall during inspiration and expiration
- Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
- Sucking chest wounds
- Absent or diminished breath sounds
- Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
- Anticipate definitive airway management to support ventilation.
Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? Correct ans - A tight-fitting nonrebreather mask at 12-15 lpm.
What intervention should be done if a pt presents with effective circulation? Correct ans - - Insert 2 large caliber IV's
- Administer warmed isotonic crystalloid solution at an appropriate rate
What are signs of ineffective circulation? Correct ans - - 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? Correct ans - - 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)
What are factors that contribute to ineffective ventilation? Correct ans
- 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? Correct ans - LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents
What are the Rapid Sequence Intubation Steps? Correct ans - PREPARATION:
- gather equipment, staffing, etc. PREOXYGENATION:
- Use 100% O2 (prevent risk of aspiration). PRETREATMENT:
- D ecrea se S/ E 's o f intub ati o n 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
How do you inspect the chest for adequate ventilation? Correct ans - Observe:
- mental status
- RR and pattern
- chest wall symmetry
- any injuries
- patient's skin color (cyanosis?)
- J V D o r tr achea l devi ati o n? (Tens i o n pne umo thor ax)
What are you looking for when auscultating lung sounds? Correct ans - 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? Correct ans - Dullness:
- hemothorax Hyperresonance
- Pneumothorax
What are you looking for when palpating the chest wall, clavicles and neck? Correct ans - - 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? Correct ans - 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. Correct ans - 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:
Explain Cardiogenic Shock. Correct ans - Syndrome that results from ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes: MI, Blunt cardiac injury, Mitral valve insufficiency, dysrhythmias, Cardiac Failure
Explain Obstructive Shock. Correct ans - 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. Correct ans - 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? Correct ans - 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? Correct ans - Renal ischemia activates release of renin.
Explain Pulmonary Response. Correct ans - Tachypnea happens for 2 reasons:
- Maintain acid-base balance
- Maintain increased supply of oxygen
- Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli.
Explain Irreversible Shock. Correct ans - Shock uncompensated or irreversible stages will cause compromises to most body systems.
- Inadequate venous return
- inadequate cardiac filling
- decreased coronary artery perfusion
- Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage.
How would you assess a pt in hypovolemic shock? Correct ans - (Use Initial Assessment) and then: 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? Correct ans - 1. Brain
- CSF
- 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.
Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP.
What are the early signs and symptoms of increased ICP? Correct ans -
- Headache
- N/V
- Amnesia regarding events around the injury
- Altered LOC
- Restlessness, drowsiness, changes in speech, or loss of judgement
What are the late observable signs of symptoms of increased ICP? Correct ans - - Dilated, nonreactive pupil
- Unresponsiveness to verbal or painful stimuli
- Abnormal motor posturing patterns
- Widening pulse pressure
- Increased systolic blood pressure
- Changes in RR and pattern
- Bradycardia
What is Cushing's phenomenon or Cushing's Reflex? Correct ans - Triad of progressive HTN, bradycardia and diminished respiratory effort.
What are the two types of herniation that occurs with ICP? Correct ans
- Central or transtentorial herniation
What are the signs and symptoms of postconcussive syndrome? Correct ans - - Persistent H/A
- Dizziness
- Nausea
- Memory impairment
- Attention deficit
- Irritability
- Insomnia
- Impaired judgement
- Loss of libido
- Anxiety
- Depression
What is diffuse axonal injury and its signs and symptoms? Correct ans
- (DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. S/ S :
- Immediate unconsciousness
- mild DAI, coma = 6-24 hrs
- se vere DAI, co ma = we ek s / months o r per s i s te nt veg e tati ve sta te
- Elevated ICP
- Abnormal posturing
- HTN
- Hyperthermia
- Excessive sweating because of autonomic dysfunction
- Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits
What i s a ce rebra l contus i o n a nd i ts S/ S? C orrect ans - A co mmon focal brain injury in which brain tissue is bruised and damaged in a local area. Mainly located in frontal and temporal lobes. May cause hemorrhage, infarction, necrosis and edema. Max effects of bleeding & edema peak 18- post injury. S/ S :
- Alteration in LOC
- Behavior, motor or speech deficits
- Abnormal motor posturing
- Signs of increased ICP
What i s an epid ur al he ma to ma and i ts S/ S? C o rrect ans - Re sul ts whe n a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly:
- Compression of underlying brain
- rapid increase in ICP
- Decreased CBF
- Secondary brain injury
- Usually requires surgical intervention S/ S :
- Transient LOC
- Lucid period lasting a few minutes to several hours
- Rapid deterioration in neurologic status
- Severe H/A
- Sleepiness
- Dizziness
- N/V
- Hemiparesis or hemiplegia on opposite side of hematoma
- Unilateral fixed and dilated pupil on same side of hematoma
What i s a s ubd ura l he ma to ma a nd i ts S/ S? C orrect ans - A f oca l brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic.
Acute pt's hematoma manifest 48 hrs post injury S/ S :
- Altered LOC or steady decline in LOC
- S/ S o f i ncreas ed I CP
- Hemiparesis or hemiplegia on opposite side of hematoma
- Unilateral fixed and dilated pupil on same side of hematoma
Chronic pt's " " up to 2 wks post injury
- H/A
- Progressive decrease in LOC
- Ataxia
- Incontinence
- Sz's
What are i ntr a cereb ra l he ma to ma 's a nd i ts S/ S? C orrect ans - Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/ S :
- Progressive and often rapid decline in LOC
- H/A
- Signs of increasing ICP
- Pupil abnormalities
- Contralateral hemiplegia
- Point tenderness
- Depressions or deformities
- Hematomas
- Assess all 4 extremities for:
- Motor function, muscle strength and abnormal motor posturing
- Sensory function DIAGNOSTIC PROCEDURES
- Lab Studies PLANNING AND IMPLEMENTATION
- (Initial assessment)
- Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration.
- Administer O2 via NRB
- Assist with early ET intubation
- Admi ni s ter s ed ati ve/ ne uro mus cul ar b l ocking ag e nt
- Consider hyperventilation
- PaCO2 above 45 mm Hg may cause increased cerebral vasodilation, increased CBF, increased ICP.
- Prolonged hyperventilation NOT RECOMMENDED.
- Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction.
- Hyperoxygenate pt with 100% O2 via bag-mask
- Apply direct pressure to bleeding sites except depressed skull fractures
- Cannulate 2 large IV's
- Hypotension doubles pt's death rate (w/severe head trauma)
- Vasopressors used to maintain CPP.
- Insert OG or NGT. OG should be used with severe facial trauma.
- Position pt, elevate head to decrease ICP (but may also reduce CPP).
- Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain
- Prepare for ICP monitoring device
- Administer mannitol as prescribed.
- Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys.
- Administer anticonvulsant
- Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis:
- Depressed skull fx
- Sz at time of injury
- Sz on arrival to ED
- Hx of sz's
- Penetrating brain injury
- Acute s ubd ura l/ epi d ura l hema to ma
- Administer antipyretic med/Cooling blanket
- Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP
- D o not pack e a rs/ n o se i f CSF le a k sus pecte d
- Admin tetanus prophylaxis
- Wo und repa ir f o r faci al/ sca l p La c' s
- Admin other meds
- Analgesics, sedatives, narcan, romazicon, etc.
- Admin antibiotics
- Pt's w/basilar skull fx need prophylaxis against meningitis
- Prepare pt for OR, hospital admin or transfer.
What are signs of a serious eye injury? Correct ans - - Visual disturbances
- Pain
- Redness and ecchymosis of the eye
- Periorbital ecchymosis
- Increased intraocular pressure
What i s hyp he ma and i ts S/ S? C orrect ans - Accumul ati o n o f bl ood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/ S :
- Blood in anterior chamber
- Deep, aching pain
- Mild to severe diminished visual acuity
- Increased intraocular pressure
What are s / s o f chemica l b urns to the eye? C orrect ans - Chemica l injuries require immediate intervention if it is to be preserved. S/ S :
- Pain
- Corneal Opacification
- Coexisting chemical burn and swelling of lids
What are S/ S o f penetr ating trauma/ ope n o r r up tured g l obe? C orrect ans
- Marked visual impairments
- Extrusion of intraocular contents
- Flattened or shallow anterior chamber
- Subconjunctival hemorrhage, hyphema
- Decreased intraocular pressure
- Restriction of extraocular movements
- Edema or hematoma formation at the fracture site
- Blood behind, ruptured, tympanic membrane
- Anesthesia of the lower lip
What are neck inj ury S/ S? C orrect ans - - Dyspnea
- Hemoptysis (coughing up blood)
- Subcutaneous emphysema in neck, face, or suprasternal area
- Decreased or absent breath sounds
- Penetrating wounds or impaled objects
- Pulsatile or expanding hematoma
- Loss of normal anatomic prominence of the laryngeal region
- Bruits
- Active external bleeding
- Neurologic deficit, such as aphasia or hemiplegia
- Cranial nerve deficits
- Facial sensory or motor nerve deficits
- Dysphonia (hoarseness)
- Dysphagia (difficulty swallowing)
How would you assess a patient with ocular, maxillofacial and neck trauma? Correct ans - (Initial assessment) HISTORY
- MOI?
- Acceleration/Deceleration?
- What was it caused by?
- Pt restrained? Airbags deployed? Etc.
- What are the pt's complaints?
- Pt normally wear glasses or contacts?
- Pt have hx of eye problems?
- Pt ever have eye surgery?
- Pt have visual or ocular changes associated with chronic illness? PHYSICAL INSPECTION:
- Inspect eye, orbits, face and neck
- Check for symmetry, edema, ecchymosis, ptosis, lacerations and hematomas
- Inspect globe for lacerations, large corneal abrasions, hyphema, and extrusion or prolapse of intraocular contents
- Determine whether lid lac's
- Assess pupil's (PERRL)
- Unilateral fixed and dilated pupil may indicate oculomotor nerve compression as a result of ICP + herniation syndrome
- Bilateral fixed and pinpoint pupils = pontine lesion or drugs
- Mildly dilated pupil w/sluggish response may early sign of herniation syndrome
- Widely dilated pupil occasionally occurs w/direct trauma to globe of eye
- Assess for consensual response
- Assess redness, eye watering, blepharospasm
- Assess extraocular movement, except when an open globe injury is known or suspected.
- Limitation range of ocular motion may indicate orbital rim fx w/entrapment or paralysis of cranial nerve or ocular muscle
- Perform visual acuity exam
- Use Snellen or handheld chart. Check uninjured eye first
- Assess for blurred or double vision with injured eye and then with both eyes open
- Inspect for rhinorrhea or otorrhea
- If drng present, may indicate CSF leak
- Observe for impaled objects
- Assess occlusion of mandible and maxilla
- Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx
- Observe for uncontrolled bleeding PALPATION
- Palpate periorbital area, face and neck for:
- Tenderness
- Edema
- Step-off defects or depressions
- Subcutaneous emphysema (esophageal or tracheal tear)
- Palpate trachea above suprasternal notch
- Trach deviation = late indication of tension pneumothorax or massive hemothorax
- Assess sensory fx of perioribital areas, face and neck
- Facial fx's can impinge on infraorbital nerve, causing numbness of inferior eyelid, lateral nose, cheek, or upper lip on affected side.
- Check position of trachea DIAGNOSTIC STUDIES:
- Xrays, CT scans, MRI's
- Fluorescein staining
- Slit-lamp exam
- tonometry (measures intraocular pressure)
- Bronchoscopy or esophagoscopy
What are the nursing interventions for a pt with an ocular injury? Correct ans - - Assess visual acuity & reassess
- Elevate HOB to minimize intraocular pressure
- Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure
- Assist w/removal of foreign bodies as indicated; stabilize impaled objects
- Apply cool packs to decrease pain + periorbital swelling
- Admin medications
- Instill prescribed topical anesthetic drops for pain
What are S/ S o f a r ib fr acture? C orrect a ns - - Dyspne a
- Localized pain on movement, palpation, or inspiration
- Pt assumes position intended to splint chest wall to reduce pain
- Chest wall ecchymosis or sternal contusion
- Bony crepitus or deformity
What is a flail chest? Correct ans - A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum.
Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases.
What could a flail chest be associated with? Correct ans - - Ineffective ventilation
- Pulmonary contusion
- Lacerated lung parenchyma
What are the S/ S o f flai l ches t? C orrect ans - - Dyspne a
- Chest wall pain
- Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration.
Define Pneumothorax. Correct ans - Results when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue.
An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea.
What are the S/ S o f a pne umo thor ax? C orrect ans - - D yspnea, tachypnea
- Tachycardia
- Hyerresonance (increased echo produced by percussion over the lung field) on the injured side
- Decreased or absent breath sounds on the injured side
- Chest pain
- Open, sucking wound on inspiration (open pneumothorax)
Define tension pneumothorax. Correct ans - Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and
uninjured lung. Venous return impeded, cardiac output falls, hypotension results.
Immediate decompression should be performed. Treatment should not be delayed.
What are the S/ S o f a t ens i o n pne umo th o r ax? C orrect ans - - Severe respiratory distress
- Markedly diminished or absent breath sounds on affected side
- hypotension
- Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present
- Tracheal deviation - shift toward uninjured side (LATE sign)
- Cyanosis (LATE sign)
Define Hemothorax. Correct ans - Accumulation of blood in the pleural space.
What are the S/ S o f He mo thor ax? C orrect ans - - Dyspnea , tachyp nea
- Chest pain
- Signs of shock
- Decreased breath sounds on injured side
- Dullness to percussion on the injured side
What is a pulmonary contusion? Correct ans - They occur as a result of direct impact, deceleration or high-velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately.
What are the S/ S o f pul mona ry co ntus i o n? C orrect ans - - Dyspnea
- Ineffective cough
- Hemoptysis
- Hypoxia
- Chest pain
- Chest wall contusion or abrasions
What happens to a ruptured diaphragm? Correct ans - Potentially life- threatening, results from forces that penetrate the body. Left hemidiaphragm is more susceptible to injury because the right side is protected by the liver.
- Herniation of abdominal contents
- Respiratory compromise b/c impaired lung capacity + displacement of normal tissue.
- Mediastinal structures may shift to opposite side of injury
What are S/ S o f a r up tured di ap hr ag m? C orrect a ns - ( A nythi ng bel o w the nipple line and should be evaluated for potential diaphragmatic injury).
