TNCC 9th Edition Test e xam 2024 You are caring for a patient who was thrown from a bike and was not wearing a helmet. While performing the head -to-toe assessment, you note clear drainage from the right ear. Which of the following is the most appropriate next step? A. Clean the ear with a cotton -tipped applicator. B. Pack the ear with gauze. C. Notify the physician D. Document and continue the exam. - CORRECT ANSWER -C. Notify the physician 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 - CORRECT ANSWER -A. Initiate transfer to a trauma center 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 - CORRECT ANSWER -A. Initiate cervical spine stabilization 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. - CORRECT ANSWER -A. Decrease the rate of manual ventilation. 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 pelvic binder 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) - CORRECT ANSWER -B. Application of a pelvic binder 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 - CORRECT ANSWER - Using the American College of Surgeons Guidelines for Screening Patients with Suspected Spine Injury, what assessment finding would prompt the nurse to prepare a patient for cervical spine imaging? A. Alert with no neurologic deficits or neck pain B. Multiple abrasions to the extremities C. Ecchymosis to the flank D. Responds to verbal stimulation using AVPU - CORRECT ANSWER - 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 prena tal 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 - CORRECT ANSWER - During the primary survey of an unconscious patient with multi -system trauma, the nurse notes snoring respirations. Which priority nursing intervention should be performed next?
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 - CORRECT ANSWER -A. Initiate transfer to a trauma center 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 - CORRECT ANSWER -A. Initiate cervical spine stabilization 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. - CORRECT ANSWER -A. Decrease the rate of manual ventilation. 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 pelvic binder 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) - CORRECT ANSWER -B. Application of a pelvic binder 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 - CORRECT ANSWER - Using the American College of Surgeons Guidelines for Screening Patients with Suspected Spine Injury, what assessment finding would prompt the nurse to prepare a patient for cervical spine imaging? A. Alert with no neurologic deficits or neck pain B. Multiple abrasions to the extremities C. Ecchymosis to the flank D. Responds to verbal stimulation using AVPU - CORRECT ANSWER - 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 prena tal 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 - CORRECT ANSWER - During the primary survey of an unconscious patient with multi -system trauma, the nurse notes snoring respirations. Which priority nursing intervention should be performed next?
