COMPLETE TNCC 2025/2026 100
QUESTIONS AND CORRECT
DETAILED ANSWERS .
EXAM
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 -ANSWERA. 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 -ANSWERA.
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
C. Fluid resuscitation to maintain a urine output of 0.5 mL/kg/hour
D. Oxygen to maintain the ETCO2 between 30-35 mm Hg (3.9-
4.6 kPa) -ANSWERB. Application of a pelvic binder
An adult arrives at the emergency department with superficial
burns to the extremities following a house fire. The patient is
reporting a headache with nausea and is drowsy and confused.
What is the most likely cause of these symptoms?
A. Capillary leak syndrome
B. Rhabdomyolysis
C. Carbon monoxide poisoning
D. Hypothermia -ANSWERC. Carbon monoxide poisoning
Using the American College of Surgeons Guidelines for
Screening Patients with Suspected Spine Injury, what
assessment finding would prompt the nurse to prepare a patient
for cervical spine imaging?
A. Alert with no neurologic deficits or neck pain
B. Multiple abrasions to the extremities
C. Ecchymosis to the flank
D. Responds to verbal stimulation using AVPU -ANSWERD.
Responds to verbal stimulation using AVPU
, A 5-month pregnant patient arrives in the emergency department
stating she tripped and fell, landing on her abdomen. Assessment
reveals bruising to the abdomen, both arms, and her neck. She
states she does not take any medications and has not had any
prenatal care. The nurse suspects the findings are most likely
related to which of the following?
A.Intentional violence
B.Pregnancy-related changes
C.Undiagnosed embolus
D.Iron deficiency -ANSWERA. Intentional violence
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 -
ANSWERD. Insert an oropharyngeal airway if there is no gag
reflex
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 -ANSWERC.Tertiary
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?
QUESTIONS AND CORRECT
DETAILED ANSWERS .
EXAM
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 -ANSWERA. 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 -ANSWERA.
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
C. Fluid resuscitation to maintain a urine output of 0.5 mL/kg/hour
D. Oxygen to maintain the ETCO2 between 30-35 mm Hg (3.9-
4.6 kPa) -ANSWERB. Application of a pelvic binder
An adult arrives at the emergency department with superficial
burns to the extremities following a house fire. The patient is
reporting a headache with nausea and is drowsy and confused.
What is the most likely cause of these symptoms?
A. Capillary leak syndrome
B. Rhabdomyolysis
C. Carbon monoxide poisoning
D. Hypothermia -ANSWERC. Carbon monoxide poisoning
Using the American College of Surgeons Guidelines for
Screening Patients with Suspected Spine Injury, what
assessment finding would prompt the nurse to prepare a patient
for cervical spine imaging?
A. Alert with no neurologic deficits or neck pain
B. Multiple abrasions to the extremities
C. Ecchymosis to the flank
D. Responds to verbal stimulation using AVPU -ANSWERD.
Responds to verbal stimulation using AVPU
, A 5-month pregnant patient arrives in the emergency department
stating she tripped and fell, landing on her abdomen. Assessment
reveals bruising to the abdomen, both arms, and her neck. She
states she does not take any medications and has not had any
prenatal care. The nurse suspects the findings are most likely
related to which of the following?
A.Intentional violence
B.Pregnancy-related changes
C.Undiagnosed embolus
D.Iron deficiency -ANSWERA. Intentional violence
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 -
ANSWERD. Insert an oropharyngeal airway if there is no gag
reflex
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 -ANSWERC.Tertiary
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?
