TESTBANK FOR TNCC 10TH EDITION EXAM 3 LATEST VERSIONS

"Breathing and Ventilation" - ansDuring which part of the primary survey would you anticipate the need for a chest tube, intubation, decompression of pneumothorax, oxygen, or BVMs? 1. attach CO2 detector and assess for evidence of exhaled CO2; 2. observe for rise and fall of the chest w/ assisted ventilations; 3. auscultate over epigastrium for gurgling AND lungs for bilateral breath sounds - ansWhat three assessments must be done if the patient is intubated? 1. inspect AND palpate skin color, temp, moisture and 2. palpate a pulse - ansTo assess circulation, you must do these two main tasks: A.Alert with no neurologic deficits - ansUsing 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 A.Cardiogenic - ansA 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.Decrease the rate of manual ventilation. - ansAn 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. A.Initiate warming measures - ansA 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 nonrebreather 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 A.Report your suspicion of maltreatment in accordance with local regulations - ansA 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.Reverse Trendelenburg - ansWhat position optimizes ventilation in the obese patient with a lumbar fracture? A.Reverse Trendelenburg B.Supine C.Prone D.Fowler's AFTER head-to-toe, BEFORE J (VIPP) - ansAntibiotics, consults, head CT, imaging, law enforcement, mandatory reporting, psychosocial support, social services, splinting, tetanus, and wound care are all interventions that you do AFTER and before WHAT? all patients - ansFor whom is capnography highly recommended? Apply a pelvic binder - ansAn 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 assess ETT position by noting the number at teeth/gums AND secure ETT - ansIf the patient is intubated and you've already assessed ETT placement, what else needs to be done with the ETT? (step 10) Assessing patency and protection of the airway, Step 7 of "Alertness and Airway with Simultaneous Cervical Spinal Stabilization" - ansDuring which part of the primary survey would there be anticipation for intubation, insertion of OPA/NPA, removal of any loose teeth or foreign objects, or suctioning? B. Rising diastolic - ansWhich blood pressure finding is associated with early or compensated hypovolemic shock? A.Rising systolic B.Rising diastolic C.Decreasing diastolic D.Decreasing systolic B.A 2-year-old lands on grass from a second-story balcony - ansBased 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 B.Amputation of a limb - ansWhich 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 B.Control the bleeding - ansAn 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 B.During the secondary surveyt - ansWhen 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 B.Increased oxygen consumption - ansA 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 B.It can be used in hypotensive patients too unstable for computed tomography scan - ansWhich 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 B.Loss of reflexes - ansA 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 B.Maintaining spinal motion restriction - ansWhat 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 B.Medical history including current medications - ansWhat 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 B.Notify the provider of the change - ansYour 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 blankets, room temp increase, warmed fluids, warming lights - ansIn Step 16 of "Exposure and Environment", you must name at least one of these interventions: bony deformity, loose teeth, edema, inhalation injury, sounds, tongue obstruction, burns, fluids, foreign objects, vocalization - ansFour of these must be identified to assess patency and protection of the airway: Bowel sounds heard in the left lower chest - ansA 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 Breath sounds, depth/pattern/rate, spontaneous breathing, subcutaneous emphysema, increased work of breathing, symmetrical chest rise and fall, tracheal deviation/JVD, open wounds/deformities, skin color - ansFour of these must be identified to assess breathing effectiveness: C.3240 mL - ansA 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 C.Allowing family to participate in the care of the patient - ansWhile 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 C.Apply direct pressure to the wound - ansA 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 C.Decreased body temperature - ansA 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 C.Decreased respiratory effort - ansWhich of the following is a late sign of increased intracranial pressure? A.Restlessness B.Vomiting C.Decreased respiratory effort D.Narrowing pulse pressure C.Disseminated intravascular coagulopathy - ansA 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