TRAUMA NURSING ACTUAL TEST PAPER
ACCURATE QUESTIONS AND CORRECT
ANSWERS GRADED APLUS
●● What is the Mnemonic for the Initial Assessment?
Answer: A = Airway with simultaneous cervical spine protection
B = Breathing
C = Circulation
D = Disability (neurologic status)
E = Expose/Environmental controls (remove clothing and keep the
patient warm)
●● What is the Mnemonic for the Secondary Assessment?
Answer: F = Full set of VS/Focused adjuncts (includes cardiac monitor,
urinary catheter, and gastric tube)/Family presence
G = Give comfort measures (verbal reassurance, touch, and
pharmacologic and nonpharmacologic management of pain).
H = Hx and Head-to-toe assessment
I = Inspect posterior surfaces
●● Where do you listen to auscultate breath sounds?
,Answer: Auscultate the lungs bilaterally at the second intercostal space
midclavicular line and at the fifth intercostal space at the anterior
axillary line.
●● What are the late signs of breathing compromise?
Answer: - Tracheal deviation
- JVD
●● What are signs of ineffective breathing?
Answer: - 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?
,Answer: A tight-fitting nonrebreather mask at 12-15 lpm.
●● What intervention should be done if a pt presents with effective
circulation?
Answer: - Insert 2 large caliber IV's
- Administer warmed isotonic crystalloid solution at an appropriate rate
●● What are signs of ineffective circulation?
Answer: - 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?
Answer: - 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"?
Answer: DISABILITY
A = Alert
V = Verbal
P = Pain
U = Unresponsive
- GCS
- 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
ACCURATE QUESTIONS AND CORRECT
ANSWERS GRADED APLUS
●● What is the Mnemonic for the Initial Assessment?
Answer: A = Airway with simultaneous cervical spine protection
B = Breathing
C = Circulation
D = Disability (neurologic status)
E = Expose/Environmental controls (remove clothing and keep the
patient warm)
●● What is the Mnemonic for the Secondary Assessment?
Answer: F = Full set of VS/Focused adjuncts (includes cardiac monitor,
urinary catheter, and gastric tube)/Family presence
G = Give comfort measures (verbal reassurance, touch, and
pharmacologic and nonpharmacologic management of pain).
H = Hx and Head-to-toe assessment
I = Inspect posterior surfaces
●● Where do you listen to auscultate breath sounds?
,Answer: Auscultate the lungs bilaterally at the second intercostal space
midclavicular line and at the fifth intercostal space at the anterior
axillary line.
●● What are the late signs of breathing compromise?
Answer: - Tracheal deviation
- JVD
●● What are signs of ineffective breathing?
Answer: - 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?
,Answer: A tight-fitting nonrebreather mask at 12-15 lpm.
●● What intervention should be done if a pt presents with effective
circulation?
Answer: - Insert 2 large caliber IV's
- Administer warmed isotonic crystalloid solution at an appropriate rate
●● What are signs of ineffective circulation?
Answer: - 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?
Answer: - 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"?
Answer: DISABILITY
A = Alert
V = Verbal
P = Pain
U = Unresponsive
- GCS
- 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
