TNCC Exam 8th edition study updated 2024

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? - ANSWER-Globe rupture A teardrop-shaped pupil suggests a globe rupture. A patient with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? - ANSWER-Bradycardia and absent motor function below the level of injury Patients with a complete spinal cord injury will have absent motor function below the level of the lesion. They become hypotensive and bradycardic due to loss of autonomic nervous system function. During the primary survey of an unconscious patient with multi-system trauma, the nurse notes snoring respirations. What priority nursing intervention should be performed next? - ANSWER-Insert an oropharyngeal airway if there is no gag reflex Snoring respirations may indicate airway obstruction from the tongue. Insert an airway adjunct to alleviate obstruction by the tongue. Oropharyngeal airways can be used in patients without a gag reflex. 1.What is the effect of hypothermia on the oxyhemoglobin dissociation curve - ANSWERHaemoglobin does not readily release oxygen for use by the tissues A shift to the left occurs in an environment of low metabolic demand (hypothermia, hypocapnia, alkalosis), increasing hemoglobin's affinity for oxygen. 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? - ANSWER-Straight catheter for urine sample Insertion of a urinary catheter is contraindicated if urethral transection is suspected. Signs and symptoms of urethral injury include blood at the meatus, perineal ecchymosis, scrotal ecchymosis, and a high-riding or non-palpable prostate. 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? - ANSWER-Apply a splint and elevate the extremity above the level of the heart Splinting the injured extremity stabilizes the extremity and reduces further injury. Elevation above the level of the heart promotes venous return and may reduce swelling. A 49-year-old restrained driver involved in a motor vehicle collision presents to the trauma center complaining of abdominal, pelvic, 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? - ANSWERDiagnostic peritoneal lavage Diagnostic peritoneal lavage is indicated for hemodynamically unstable patients or if FAST and CT are not available. 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? - ANSWER-Report your suspicion of maltreatment in accordance with local regulations Nurses are mandated reporters in most jurisdictions. With no alterations in the primary survey, this is the priority intervention.