TNCC Test Prep A Nursing Process| Already
Graded A+
500 mL/hr - ANSYou are treating a 27 y/o M in respiratory distress who was involved in
a house fire. Calculating TBSA burned is deferred due to the need for emergent
intubation. At what rate should you begin fluid resuscitation?
a 52 y/o diabetic male with a partial thickness burn to the left lower leg - ANSWhich of
the following patients warrants referral to a burn center?
a pertinent medical hx is crucial - ANSWhich of the following considerations is the most
important when caring for a geriatric trauma pt?
acidosis - ANSWhich of the following is a component of the trauma triad of death?
advanced age - ANSWhich of the following is most likely to contribute to inadequate
oxygenation and ventilation?
after a physical examination if the pt has no radiologic abnormalities on CT - ANSEMS
arrives with the intoxicated driver of a car involved in a MVC. EMS reports significant
damage to the drivers side of the car. The pt is asking to have the cervical collar
removed. When it is appropriate to remove the cervical collar?
apply splint and elevate above the level of the heart - ANSa 37 y/o F has a deformity of
the L wrist after a fall. She is reluctant to move her hand due to pain. Which of the
following is the most appropriate intervention?
bardycardia and absent motor function below the level of injury - ANSA pt with a
complete spinal cord injury in neurogenic shock will demonstrate hypotension and which
other clinical signs?
bowel - ANSWhich of the following injuries is LEAST likely to be promptly identified?
calcium - ANSif a pt has received multiple transfusions of banked blood preserved with
citrate, which electrolyte is most likely to drop and require supplementation?
compensated - ANSA trauma pt is restless and repeatedly asking "where am i?" VS
upon arrival: BP 110/60, HR96, RR 24. Her skin is cool and dry. Current VS are BP
104/84, HR 108, RR 28. The pt is demonstrating s/sx of which stage of shock?
Complete - ANSEMS brings a pt from MVC. VS: BP 90/49, HR 48, RR 12, temp 97.2F
(36.2 C). The pt exhibits urinary incontinence and priapism. These assessment findings
are most consistent with which of the following types of spinal cord injury?
, TNCC Test Prep A Nursing Process| Already
Graded A+
defusings - ANSAll of these are considered a critical communication point in trauma
care EXCEPT which of the following?
dressing removal - ANSA 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 distress, cyanosis and decreasing blood pressure.
Which of the following is the MOST appropriate immediate intervention?
dysrhythmias - ANSPatients with a crush injury should be monitored for which of the
following conditions?
elevating the extremity to the level of the heart - ANSA pt with a lower extremity fracture
complains of severe pain and tightness in his calf, minimally by pain medications. Which
of the following is the priority nursing intervention?
endotracheal tube - ANSThe trauma nurse knows that placing a bariatric patient in a
ramped position providers better visualization during the insertion of which device?
Expedite transfer to the closest trauma center - ANSA 56 y/o M pt involved in a motor
vehicle crash is brought to the ED of a rural critical access facility. He complains of neck
pain, SOB, and diffuse abd pain. His GCS is 15. His VS: BP 98/71, HR 125, RR 26,
SpO2 94% on high-flow O2 via NRB mask. Which of the following is the priority
intervention for this patient?
fat embolism - ANSa pt has been in the ED for several hrs 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 pt is restless with respiratory distress and
petechiae to his neck. The pt is exhibiting s/sx most commonly associated with which of
the following conditions?
flucuation in the water seal chamber - ANSWhich of the following is an expected finding
in a pt with a tube thoracstomy connected to a chest drainage system?
globe rupture - ANSA 35 y/o M 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?
hemoglobin does not readily release O2 for use by the tissues - ANSWhat is the effect
of hypothermia on the oxyhemoglobin dissociation curve?
Graded A+
500 mL/hr - ANSYou are treating a 27 y/o M in respiratory distress who was involved in
a house fire. Calculating TBSA burned is deferred due to the need for emergent
intubation. At what rate should you begin fluid resuscitation?
a 52 y/o diabetic male with a partial thickness burn to the left lower leg - ANSWhich of
the following patients warrants referral to a burn center?
a pertinent medical hx is crucial - ANSWhich of the following considerations is the most
important when caring for a geriatric trauma pt?
acidosis - ANSWhich of the following is a component of the trauma triad of death?
advanced age - ANSWhich of the following is most likely to contribute to inadequate
oxygenation and ventilation?
after a physical examination if the pt has no radiologic abnormalities on CT - ANSEMS
arrives with the intoxicated driver of a car involved in a MVC. EMS reports significant
damage to the drivers side of the car. The pt is asking to have the cervical collar
removed. When it is appropriate to remove the cervical collar?
apply splint and elevate above the level of the heart - ANSa 37 y/o F has a deformity of
the L wrist after a fall. She is reluctant to move her hand due to pain. Which of the
following is the most appropriate intervention?
bardycardia and absent motor function below the level of injury - ANSA pt with a
complete spinal cord injury in neurogenic shock will demonstrate hypotension and which
other clinical signs?
bowel - ANSWhich of the following injuries is LEAST likely to be promptly identified?
calcium - ANSif a pt has received multiple transfusions of banked blood preserved with
citrate, which electrolyte is most likely to drop and require supplementation?
compensated - ANSA trauma pt is restless and repeatedly asking "where am i?" VS
upon arrival: BP 110/60, HR96, RR 24. Her skin is cool and dry. Current VS are BP
104/84, HR 108, RR 28. The pt is demonstrating s/sx of which stage of shock?
Complete - ANSEMS brings a pt from MVC. VS: BP 90/49, HR 48, RR 12, temp 97.2F
(36.2 C). The pt exhibits urinary incontinence and priapism. These assessment findings
are most consistent with which of the following types of spinal cord injury?
, TNCC Test Prep A Nursing Process| Already
Graded A+
defusings - ANSAll of these are considered a critical communication point in trauma
care EXCEPT which of the following?
dressing removal - ANSA 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 distress, cyanosis and decreasing blood pressure.
Which of the following is the MOST appropriate immediate intervention?
dysrhythmias - ANSPatients with a crush injury should be monitored for which of the
following conditions?
elevating the extremity to the level of the heart - ANSA pt with a lower extremity fracture
complains of severe pain and tightness in his calf, minimally by pain medications. Which
of the following is the priority nursing intervention?
endotracheal tube - ANSThe trauma nurse knows that placing a bariatric patient in a
ramped position providers better visualization during the insertion of which device?
Expedite transfer to the closest trauma center - ANSA 56 y/o M pt involved in a motor
vehicle crash is brought to the ED of a rural critical access facility. He complains of neck
pain, SOB, and diffuse abd pain. His GCS is 15. His VS: BP 98/71, HR 125, RR 26,
SpO2 94% on high-flow O2 via NRB mask. Which of the following is the priority
intervention for this patient?
fat embolism - ANSa pt has been in the ED for several hrs 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 pt is restless with respiratory distress and
petechiae to his neck. The pt is exhibiting s/sx most commonly associated with which of
the following conditions?
flucuation in the water seal chamber - ANSWhich of the following is an expected finding
in a pt with a tube thoracstomy connected to a chest drainage system?
globe rupture - ANSA 35 y/o M 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?
hemoglobin does not readily release O2 for use by the tissues - ANSWhat is the effect
of hypothermia on the oxyhemoglobin dissociation curve?
