TNCC NOTES FOR WRITTEN EXAM LATEST 2024
VERIFIED QUESTIONS WITH COMPLETE EXPERT
ANSWERS (GUARANTEED PASS) | RATED A+
I Wish You the Best in Your Studies and Exam Revision.
You are blessed!
, What are the nursing interventions for a patient with a maxillofacial or neck injury? -
Answer>>>- Administer oxygen
- For facial trauma, place pt in high-fowler's position if no spinal injury is present.
- Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected
- Monitor for progressive airway assessment
- Prepare for intubation, PRN.
- Cannulate 2 large IV's, initiate isotonic crystalloid IV solution
- Control external bleeding w/direct pressure
- Monitor for continued bleeding + expanding hematomas
- Apply cold compresses to face to minimize edema
- Assist w/repair of oral lac's, PRN
- Admin antibiotics
- Stabilize impaled objects
- Admin analgesic meds
What is the DOPE mnemonic? - Answer>>>D - Displaced tube
- O - Obstruction: Check secretions or pt biting tube
-
- P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator
-
- E - Equipment failure: pt may have become detached from equipment or there's a kink in the
tubing
With any eye injury, what should the evaluation and ongoing assessments be? - Answer>>>-
Reassessing visual acuity at reasonable intervals
- Reassessing pain, including response to nonpharmacologic + pharmacologic interventions
- Monitoring appearance, position, movements of globe and pupillary responses
- Monitoring airway patency, respiratory effort and ABG's
,What are the most common type of injury associated with chest trauma? - Answer>>>blunt;
MVC's. Penetrating; firarm injuries or stabbings
What are the interventions for Disability? - Answer>>>- If assessment indicates a decreased
LOC, conduct further investigation during secondary focused assessments
- If pt is not alert or verbal, continue to monitor for any compromise to ABC's
- If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation.
What are S/S of a rib fracture? - Answer>>>- Dyspnea
- Localized pain on movement, palpation, or inspiration
- Pt assumes position intended to splint chest wall to reduce pain
- Chest wall ecchymosis or sternal contusion
- Bony crepitus or deformity
What is a flail chest? - Answer>>>A fracture of two or more sites on two or more adjacent ribs,
or when rib fractures produce a free-floating sternum.
Flail segments may not be clinically evident in the first several hours after injury b/c of muscle
spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement
ceases.
What could a flail chest be associated with? - Answer>>>- Ineffective ventilation
- Pulmonary contusion
- Lacerated lung parenchyma
What are the S/S of flail chest? - Answer>>>- Dyspnea
- Chest wall pain
- Paradoxical chest wall movement - the flail segment moves in during inspiration and out
during expiration.
Define Pneumothorax. - Answer>>>Results when an injury to lung leads to accumulation of air
in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of
lung may ensue.
, An open pneumothorax results from wound through chest wall. Air enters pleural space both
through the wound and trachea.
What are the S/S of a pneumothorax? - Answer>>>- Dyspnea, tachypnea
- Tachycardia
- Hyerresonance (increased echo produced by percussion over the lung field) on the injured side
- Decreased or absent breath sounds on the injured side
- Chest pain
- Open, sucking wound on inspiration (open pneumothorax)
Define tension pneumothorax. - Answer>>>Life-threatening injury. Air enters pleural space on
inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on
side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and
uninjured lung. Venous return impeded, cardiac output falls, hypotension results.
Immediate decompression should be performed. Treatment should not be delayed.
What are the S/S of a tension pneumothorax? - Answer>>>- Severe respiratory distress
- Markedly diminished or absent breath sounds on affected side
- hypotension
- Distended neck, head and upper extremity veins-may not be clinically appreciated if
significant blood loss present
- Tracheal deviation - shift toward uninjured side (LATE sign)
- Cyanosis (LATE sign)
Define Hemothorax. - Answer>>>Accumulation of blood in the pleural space.
What are the S/S of Hemothorax? - Answer>>>- Dyspnea, tachypnea
- Chest pain
- Signs of shock
- Decreased breath sounds on injured side
VERIFIED QUESTIONS WITH COMPLETE EXPERT
ANSWERS (GUARANTEED PASS) | RATED A+
I Wish You the Best in Your Studies and Exam Revision.
You are blessed!
, What are the nursing interventions for a patient with a maxillofacial or neck injury? -
Answer>>>- Administer oxygen
- For facial trauma, place pt in high-fowler's position if no spinal injury is present.
- Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected
- Monitor for progressive airway assessment
- Prepare for intubation, PRN.
- Cannulate 2 large IV's, initiate isotonic crystalloid IV solution
- Control external bleeding w/direct pressure
- Monitor for continued bleeding + expanding hematomas
- Apply cold compresses to face to minimize edema
- Assist w/repair of oral lac's, PRN
- Admin antibiotics
- Stabilize impaled objects
- Admin analgesic meds
What is the DOPE mnemonic? - Answer>>>D - Displaced tube
- O - Obstruction: Check secretions or pt biting tube
-
- P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator
-
- E - Equipment failure: pt may have become detached from equipment or there's a kink in the
tubing
With any eye injury, what should the evaluation and ongoing assessments be? - Answer>>>-
Reassessing visual acuity at reasonable intervals
- Reassessing pain, including response to nonpharmacologic + pharmacologic interventions
- Monitoring appearance, position, movements of globe and pupillary responses
- Monitoring airway patency, respiratory effort and ABG's
,What are the most common type of injury associated with chest trauma? - Answer>>>blunt;
MVC's. Penetrating; firarm injuries or stabbings
What are the interventions for Disability? - Answer>>>- If assessment indicates a decreased
LOC, conduct further investigation during secondary focused assessments
- If pt is not alert or verbal, continue to monitor for any compromise to ABC's
- If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation.
What are S/S of a rib fracture? - Answer>>>- Dyspnea
- Localized pain on movement, palpation, or inspiration
- Pt assumes position intended to splint chest wall to reduce pain
- Chest wall ecchymosis or sternal contusion
- Bony crepitus or deformity
What is a flail chest? - Answer>>>A fracture of two or more sites on two or more adjacent ribs,
or when rib fractures produce a free-floating sternum.
Flail segments may not be clinically evident in the first several hours after injury b/c of muscle
spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement
ceases.
What could a flail chest be associated with? - Answer>>>- Ineffective ventilation
- Pulmonary contusion
- Lacerated lung parenchyma
What are the S/S of flail chest? - Answer>>>- Dyspnea
- Chest wall pain
- Paradoxical chest wall movement - the flail segment moves in during inspiration and out
during expiration.
Define Pneumothorax. - Answer>>>Results when an injury to lung leads to accumulation of air
in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of
lung may ensue.
, An open pneumothorax results from wound through chest wall. Air enters pleural space both
through the wound and trachea.
What are the S/S of a pneumothorax? - Answer>>>- Dyspnea, tachypnea
- Tachycardia
- Hyerresonance (increased echo produced by percussion over the lung field) on the injured side
- Decreased or absent breath sounds on the injured side
- Chest pain
- Open, sucking wound on inspiration (open pneumothorax)
Define tension pneumothorax. - Answer>>>Life-threatening injury. Air enters pleural space on
inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on
side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and
uninjured lung. Venous return impeded, cardiac output falls, hypotension results.
Immediate decompression should be performed. Treatment should not be delayed.
What are the S/S of a tension pneumothorax? - Answer>>>- Severe respiratory distress
- Markedly diminished or absent breath sounds on affected side
- hypotension
- Distended neck, head and upper extremity veins-may not be clinically appreciated if
significant blood loss present
- Tracheal deviation - shift toward uninjured side (LATE sign)
- Cyanosis (LATE sign)
Define Hemothorax. - Answer>>>Accumulation of blood in the pleural space.
What are the S/S of Hemothorax? - Answer>>>- Dyspnea, tachypnea
- Chest pain
- Signs of shock
- Decreased breath sounds on injured side
