TNCC 9th Edition FINAL TEST QUESTIONS AND ANSWERS. GRADED A+, Exams of Nursing

TNCC 9th Edition FINAL TEST QUESTIONS AND ANSWERS. GRADED A+, Exams of Nursing 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 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 A patient is thrown against a car during a tornado and presents with obvious bilateral femur fractures. The patient is pale, alert, disoriented, and has delayed capillary refill. Which of the following interventions would be most appropriate for this patient based on the disaster triage principles? A.Initiate two large-caliber intravenous lines for isotonic crystalloid administration. B.Administer intravenous medications for pain. C.Place the patient in an observation area for care within the next few hours. D.Contact the command center for personnel to notify next of kin. 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. The patient 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? A.Needle decompression B.Tube thoracostomy C.Dressing removal D.Surgical repair 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.Hemostatic resuscitation A patient is diagnosed with a T12 spinal cord injury following a 20- foot fall. Which finding is consistent with spinal shock? 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. 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 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 D.Preparing the patient for ultrasound of the leg A patient involved in a high-speed rollover is complaining of increased difficulty breathing. There is a small penetrating wound to the sixth intercostal space in the left lateral chest. Which finding is most consistent with an injury to the diaphragm? A.Severe left-sided abdominal pain B.Bowel sounds heard in the left lower chest C.Pain radiating to the left shoulder. D.Decreased breath sounds on the left side A patient has been in the emergency department for several hours waiting to be admitted. They sustained multiple rib fractures and a femur fracture after a fall. The patient has been awake, alert, and complaining of leg pain. Their spouse reported that the patient suddenly became anxious and confused. Upon reassessment, the patient is restless, with respiratory distress and petechiae to his neck. The patient is exhibiting signs and symptoms most commonly associated with which of the following conditions? A.Acute lung injury B.Fat embolism C.Pneumothorax D.Pulmonary contusion 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 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 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 the airway. 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 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? A.Decreased pH B.Elevated carbon dioxide level C.Decreased body temperature D.Increased metabolic demand A patient is thrown against a car during a tornado and presents with obvious bilateral femur fractures. The patient is pale, alert, disoriented, and has delayed capillary refill. Which of the following interventions would be most appropriate for this patient based on the disaster triage principles? A.Initiate two large-caliber intravenous lines for isotonic crystalloid administration. B.Administer intravenous medications for pain. C.Place the patient in an observation area for care within the next few hours. D.Contact the command center for personnel to notify next of kin. 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. The patient 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? A.Needle decompression B.Tube thoracostomy C.Dressing removal D.Surgical repair 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.Hemostatic resuscitation A patient is diagnosed with a T12 spinal cord injury following a 20- foot fall. Which finding is consistent with spinal shock? A.Bradycardia B.Loss of reflexes C.Widened pulse pressure D.Warm skin D.Widening pulse pressure 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.Reflex hypotension B.Increased respiratory effort C.Reflex tachycardia D.Widening pulse pressure 23) 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 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 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 patient in Trendelenburg position 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 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 37.5oC and 39.5oC (99.5oF to 103.1oF). 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 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 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 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 D.Assist ventilation with a bag-mask device Your patient was the unrestrained driver involved in a moderate speed motor vehicle collision. Assessment reveals tenderness in the upper right quadrant, crepitus in the lower right ribs, and ecchymosis around the umbilicus. The nurse is concerned about injury to which organ? A.Transverse colon B.Pancreas C.Liver D.Spleen 33) What position optimizes ventilation in the obese patient with a lumbar fracture? A.Reverse Trendelenburg B.Supine C.Prone D.Fowler's 34) A 5-year-old child presents to the emergency department with bruises to the upper arms 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 nursing intervention? A.Report your suspicion of maltreatment in accordance with local regulations B.Apply ice to the bruises and provide wound care C.Engage in therapeutic communication to determine the mechanism of injury D.Provide the family with injury prevention resources 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 A patient is brought to the emergency department with chest pain and shortness of breath following a high-speed motor vehicle collision in which they were the unrestrained driver. There is crepitus to the left chest with clear and equal breath sounds. The vital signs are BP 80/40 mmHg, HR 140 beats/minute, and RR 40 breaths/minute. Cardiac monitor shows sinus tachycardia with premature ventricular contractions. These findings are most consistent with which type of shock? A.Cardiogenic B.Neurogenic C.Hypovolemic D.Obstructive 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. When should the definitive calculation for intravenous fluid resuscitation rate be performed for a patient with burns? A.As soon as the patient arrives B.During the secondary survey C.Should only be done at a burn center D.During the primary survey Which of the following is true about use of the focused assessment sonography for trauma exam for a patient with abdominal trauma? A.It has a higher sensitivity than diagnostic peritoneal lavage for fluid detection B.It can be used in hypotensive patients too unstable for computed tomography scan C.It can detect as little as 30 mL of fluid in the abdominal cavity D.It has high sensitivity in pediatric patients for identifying fluid in the peritoneum What is the priority intervention for a child who has been diagnosed with an atlanto-occipital dislocation following a high-speed motor vehicle collision? 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 During the primary survey of an unconscious patient with multisystem 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 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 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 6 L per nasal cannula C.Bolus with 500 mL isotonic crystalloids D.Vigorously massage the extremities Which of the following is a late sign of increased intracranial pressure? A.Restlessness B.Vomiting C.Decreased respiratory effort D.Narrowing pulse pressure 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 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 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 A patient who sustained severe injuries was brought to the emergency department following a high-speed motor vehicle collision. Interventions for hypovolemic shock have been initiated. What component of the trauma triad of death is most likely to have begun at the time of injury? A.Acidosis B.Hypothermia C.Hypocalcemia D.Coagulopathy An adult patient involved in a motor vehicle collision is brought to the emergency department of a rural critical access facility. They complain of neck pain, shortness of breath, and diffuse abdominal pain. The Glasgow Coma Score is 15. Vital signs are: BP 98/71 mm Hg, HR 125 beats/minute, RR 26 breaths/minute, and SpO2 94% on high-flow oxygen via non-rebreather mask. Which of the following is the priority intervention for this patient? A.Expedite transport to the CT scanner B.Prepare the patient for spinal radiographs C.Expedite transfer to the closest trauma center D.Notify the patient's family A patient who weighs 120 kg is brought to the emergency department after sustaining partial thickness burns to both upper extremities and chest with a total body surface area burned of 27%. How much intravenous fluid should be administered in the first 8 hours? A.1620 mL B.2160 mL C.3240 mL D.6480 mL A patient with complete spinal cord injury who is in neurogenic shock will demonstrate hypotension and which other clinical signs? A. Bradycardia and ipsilateral a sense of motor function. B. Tachycardia and respiratory depression. C. Tachycardia and piokilothermia. D. Bradycardia and absent motor function below the level of injury. You are caring for a patient who was shot multiple times in the chest and abdomen. The patient is unresponsive with snoring, shallow respirations. Assessment reveals absent radial pulses, weak and rapid carotid pulse, and cool, diaphoretic skin. Which management strategy should the nurse anticipate? A. Autotransfusion B. Massive transfusion C. Controlled fluid boluses D. Inotropic medications Which of the following characteristics is found in high performing teams? A. Interdisciplinary collaboration B. Provide on-the-job training C. Work individually D. Minimal feedback to decrease confusion An adult patient weighing 75 kg sustained partial and full thickness burns to 32% of their body 2 hours prior to arrival. Intravenous fluid resuscitation was calculated to be 400 mL/hr. The urine output over the last hour was 15mL. What intervention should the nurse anticipate? A. Add blood products to the resuscitation B. Increase isotonic crystalloid infusion rate C. Administer an intravenous diuretic D. Switch to a hypertonic saline solution You are speaking with the family of a critically injured patient. The spouse is crying loudly and the daughter is angry and yelling at staff. Which of the following nursing interventions is most appropriate? A. Have the family escorted out of the department B. Ask if the family would like spiritual support C. Allow only the spouse to see the patient D. Do not include the family in decision-making at this time An unresponsive trauma patient has an oropharyngeal airway in place, shallow and labored respirations, and dusky skin. Medications for drug-assisted intubation have been administered but intubation was unsuccessful. What is the most appropriate next step? A. Ventilate with a bag-mask device B. Prepare for a cricothyroidotomy C. Administer reversal medications D. Contact anesthesia for assistance A restrained driver involved in a motor vehicle collision is brought to the emergency department with abdominal, pelvic, and bilateral lower extremity pain. Vital signs are BP 114/78 mm Hg, HR 98 beats/minute, RR 22 breaths/minute. A FAST exam is negative for fluid in the abdominal and peritoneal cavities. Which of the following should the nurse anticipate? A. Diagnostic peritoneal lavage B. Angiography C. Non-contrast abdominal CT scan D. Serial abdominal assessments Which of the following is true of cavitation? A. Energy cause the tissues to accelerate and displace outward B. Once a bullet passes, the tissues always return to its normal location C. Damage occurs only to internal organs and blood vessels D. Hollow organs do not tolerate high-velocity cavitation An adult patient involved in an assault presents with shortness of breath, BP 88/50 mmHg, heart rate 130 beats/minute. The patient has muffled heart sounds and is cyanotic. What is the priority intervention? A. Needle thoracostomy B. Chest tube insertion C. Pericardiocentesis D. Tracheal intubation A patient with a chest tube is being transported to the intensive care unit and fluctuation is noted in the water seal chamber during inspiration and expiration. What is the best action for the nurse to take? A. Clamp the chest tube B. Return to the emergency department C. Assist ventilation with bag-mask device D. Continue to intensive care unit In a motor vehicle collision, which injury pathway is most likely to increase the patients morbidity and mortality? A. Rotational B. Ejection C. Lateral D. Rollover Which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax? A. Increased work of breathing B. Unilaterally diminished breath sounds C. Tachycardia D. Hypotension An 85 year old is brought to the emergency department by a family member for fever and cough. There are multiple bruises in various stages of healing on the upper extremities and the back. Based on these findings what is the most appropriate initial question to facilitate screening for abuse? A. How did you get these bruises? B. How long have you had these bruises? C. Did someone hurt you? D. Who takes care of you? Caregivers carry a 2 year old into the emergency department who fell out of a second story window. The patient is awake and crying with increased work of breathing and pale skin. Which intervention has the highest priority? A. Stabilizing the cervical spine B. Applying a nonrebreather mask C. Establishing intravenous access D. Preparing for drug-assisted intubation A patient arrives at the emergency department following a motor vehicle collision. Prehospital personnel report significant damage to the vehicle. The patient is alert and agitated with a strong odor of alcohol and appears intoxicated. After physician evaluation, under what circumstances can an order to remove the rigid cervical collar be anticipated? A. No imaging abnormalities of the neck B. No neurological abnormalities on examination C. No point tenderness to cervical spine D. Absence of neck pain with movement 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 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 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 D. Liver A patient involved in a fall from 25 feet has a traumatic brain injury, three anterior rib fractures on the right, and a grade III liver injury. The patient was intubated and placed on a ventilator with PEEP. Chest tube was deferred at this time. Upon reassessment, which finding is most concerning? A. Severely diminished breath sounds on the right B. Guarding in the right upper quadrant C. Ecchymosis in the right upper quadrant D. Crepitus to the right chest A patient presents, after a 25 foot fall, with paradoxical chest wall movement to the right lower chest and complaints of shortness of breath. What is the priority intervention? A. Surgical intervention B. Chest tube insertion C. Needle decompression D. Airway and ventilation support An adult presents to the emergency department after sustaining severe facial injuries during an altercation. The patient is awake, confused, and smells heavily of alcohol. Pulse oximetry is 94% on room air. Immediate intubation should be anticipated based on which clinical indicator? A. Confusion B. Pulse oximetry reading C. Severe facial injuries D. Smell of alcohol on breath 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 A trauma patient is en route to a rural emergency department Radiology 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 A seriously injured patient is noted to have weak, thready pulse and cool, clammy skin. There is instability of the pelvis on palpating and blood on the urinary meatus. A pelvic binder is appropriately applied and balanced fluid resuscitation is being managed by the team. What is most likely to be ordered next? A. Insert a urinary catheter B. Bolus with 2L isotonic crystalloid solution C. Diagnostic peritoneal lavage D. Insertion of a Supra public catheter Patients with a crush injury should be monitored for which of the following conditions? A. Hypermatremia B. Hypercalcemia C. Dysrhythmias D. Polyuria Which commonly prescribed medication may worsen a complication that is associated with massive transfusion? A. Lisinopril B. Metformin C. Metoprolol D. Diltiazem A 36-year-old patient has a deformity of the left wrist after a fall. The patient is reluctant to move their hand due to pain. Which of the following is the most appropriate intervention? A. Apply a sling and elevate the extremity to the level of the heart B. Apply a splint and elevate the extremity above the level of the heart C. Apply a sling and elevate the extremity above the level of the heart D. Apply a splint and elevate the extremity to the level of the heart 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 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? A. Mitigation B. Preparedness C. Response D. Recovery A trauma patient is restless and repeatedly asking "Where am I?" Vital signs upon arrival were BP 110/60 mm Hg, HR 96 beats/minute, and RR 24 breaths/minute. Skin is cool and moist. Current vital signs are BP 86/68 mm Hg, HR 118 beats/minute, and RR 28 breaths/minute. The patient is demonstrating signs and symptoms of which stage of shock? A. Compensated B. Refractory C. Irreversible D. Decompensated When should the definitive calculation for intravenous fluid resuscitation rate be performed for a patient with burns? A. As soon as the patient arrives B. After removal of clothing C. Only at a burn center D. During the circulation assessment 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 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 traction splint to the affected extremity 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) 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 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 Three adults present at different times during a one-hour period with a high fever, fatigue, and headache. All three patients have a rash which started on their mouth, face, and arms with progression to the chest and abdomen. They all visited the same grocery store within the last week. What is the most appropriate intervention from triage for these patients? A.Move them to a decontamination area B.Mask the patients and send them to the waiting room C.Immediately initiate isolation precautions D.Send them to the waiting room without a mask 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 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 While caring for a trauma patient in the emergency department, what finding raises suspicion of a complete spinal cord injury? A.Weakness in the lower extremities B.Urinary incontinence C.Sacral sparing D.Spastic paralysis of the legs Which blood pressure finding is associated with early or compensated hypovolemic shock? A.Rising systolic B.Rising diastolic C.Decreasing diastolic D.Decreasing systolic