TNCC 8th Edition
A 5-year-old child presents to the ED 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? -
Report your suspicion of maltreatment in accordance with local
regulations A 20-year-old male presents to the ED complaining of
severe lower abdominal pain after landing hard on the bicycle cross
bars while performing an aerial BMX maneuver. Secondary
assessment reveals lower abdominal tenderness and scrotal
ecchymosis. Which of the following orders would the nurse question?
- Straight catheter for urine sample 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? - globe rupture A 36-year old female has a deformity
of the left wrist after a fall. She is reluctant to move her hand due
to pain. Which of the following is the most appropriate intervention?
- Apply a splint and elevate the extremity ABOVE the level of the
heart A 49-year-old restrained driver involved in a motor vehicle
collision present to the trauma center complaining of abdominal,
pelvis, and bilateral lower extremity pain. Vital signs are stable. The
nurse can anticipate all of these after a negative FAST exam
EXCEPT which of the following? - diagnostic peritoneal lavage A
56-year-old male patient involved in a motor vehicle crash is
brought to the emergency department of a rural critical assess
facility. He complaints of neck pain, shortness of breath, and diffuse
abdominal pain. His Glasgow Coma Score is 15. His vital signs are
as follows: BP 98/71 mm Hg, HR 125 beats/minute, RR 26
breaths/minute, SpO2 94% on high-flow oxygen via non-
, rebreather mask. Which of the follow is the priority intervention
for this patient? - Expedite transfer to the closest trauma center 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 distressed,
cyanosis and decreasing blood pressure. Which of the following is
the MOST appropriate immediate intervention? - dressing removal
A patient has been in the emergency department for several hours
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 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 follow conditions? - fat embolism 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, which of the following is
the priority intervention? - Initiate transfer to a trauma center A
patient is found lying on the floor after falling 13 hours ago. Which
of the following laboratory values is expected with a musculoskeletal
complication associated with this presentation? - Elevated creatine
kinase A patient is thrown against a car during a tornado and
presents with obvious bilateral femoral 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? - Initiate two large-caliber
intravenous lines for Ringer's lactate solution administration A
patient with a complete spinal cord injury in neurogenic shock will
demonstrate hypotension and which other clinical signs? -
Bradycardia and absent motor function below the level of injury A
A 5-year-old child presents to the ED 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? -
Report your suspicion of maltreatment in accordance with local
regulations A 20-year-old male presents to the ED complaining of
severe lower abdominal pain after landing hard on the bicycle cross
bars while performing an aerial BMX maneuver. Secondary
assessment reveals lower abdominal tenderness and scrotal
ecchymosis. Which of the following orders would the nurse question?
- Straight catheter for urine sample 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? - globe rupture A 36-year old female has a deformity
of the left wrist after a fall. She is reluctant to move her hand due
to pain. Which of the following is the most appropriate intervention?
- Apply a splint and elevate the extremity ABOVE the level of the
heart A 49-year-old restrained driver involved in a motor vehicle
collision present to the trauma center complaining of abdominal,
pelvis, and bilateral lower extremity pain. Vital signs are stable. The
nurse can anticipate all of these after a negative FAST exam
EXCEPT which of the following? - diagnostic peritoneal lavage A
56-year-old male patient involved in a motor vehicle crash is
brought to the emergency department of a rural critical assess
facility. He complaints of neck pain, shortness of breath, and diffuse
abdominal pain. His Glasgow Coma Score is 15. His vital signs are
as follows: BP 98/71 mm Hg, HR 125 beats/minute, RR 26
breaths/minute, SpO2 94% on high-flow oxygen via non-
, rebreather mask. Which of the follow is the priority intervention
for this patient? - Expedite transfer to the closest trauma center 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 distressed,
cyanosis and decreasing blood pressure. Which of the following is
the MOST appropriate immediate intervention? - dressing removal
A patient has been in the emergency department for several hours
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 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 follow conditions? - fat embolism 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, which of the following is
the priority intervention? - Initiate transfer to a trauma center A
patient is found lying on the floor after falling 13 hours ago. Which
of the following laboratory values is expected with a musculoskeletal
complication associated with this presentation? - Elevated creatine
kinase A patient is thrown against a car during a tornado and
presents with obvious bilateral femoral 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? - Initiate two large-caliber
intravenous lines for Ringer's lactate solution administration A
patient with a complete spinal cord injury in neurogenic shock will
demonstrate hypotension and which other clinical signs? -
Bradycardia and absent motor function below the level of injury A
