TNCC 20TH EDITION EXAM 5 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE
"
D.Quaternary
C.Use a jaw thrust to open the airway and look for signs of obstruction. - ansAn adult patient
was brought to the emergency department following a motorcycle crash. On arrival, the
patient is only responsive to pain, has bleeding from the nose, and multiple abrasions and
contusions to the face. What is the priority intervention?
A.Use a bulb syringe to suction out secretions from the mouth.
B.Insert a nasopharyngeal airway to maintain an open airway.
C.Use a jaw thrust to open the airway and look for signs of obstruction.
D.Ask the patient to open their mouth to inspect the airway.
cardiac monitor - ansWhat can be applied in step 12 of "Circulation and Control of
Hemorrhage" for which credit is given in the LMNOP section?
D.Assist ventilation with a bag-mask device - ansFollowing a gun shot wound, pre-hospital
providers report diminished breath sounds bilaterally. Upon emergency department arrival, the
patient is unresponsive with shallow respirations and an O2 sat of 88%. What is the priority
intervention for this patient?
A.Administer 15 L oxygen via nonrebreather mask
B.Attach patient to a CO2 detector
C.Prepare for a definitive airway
D.Assist ventilation with a bag-mask device
D.Coagulopathy - ansA patient who sustained severe injuries was brought to the emergency
department following a high-speed motor vehicle collision. Interventions for hypovolemic
shock have been initiated. What component of the trauma triad of death is most likely to have
begun at the time of injury?
A.Acidosis
B.Hypothermia
C.Hypocalcemia
D.Coagulopathy
D.Gently rewarm over 15 to 30 minutes - ansA patient arrives following prolonged exposure of
their left hand to the cold. The patient is awake and alert and complains of a tingling
sensation to the fingers. Assessment reveals swelling and bright red skin to the left hand and
a 1-inch round clear blister to the dorsum of that hand. Which of the following nursing
interventions is most appropriate for this patient?
A.Massage the injured areas to promote circulation
B.Drain and debride the blister on the hand
C.Immerse in water between 37.5oC and 39.5oC (99.5oF to 103.1oF).
D.Gently rewarm over 15 to 30 minutes
D.Insert an oropharyngeal airway if there is no gag reflex - ansDuring the primary survey of an
unconscious patient with multi-system trauma, the nurse notes snoring respirations. Which
priority nursing intervention should be performed next?
,TNCC 20TH EDITION EXAM 5 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE
A.Open the airway with the head-tilt/chin-lift maneuver
B.Auscultate bilateral breath sounds
C.Assist respirations using a bag-mask device
D.Insert an oropharyngeal airway if there is no gag reflex
D.Moral injury - ansA nurse verbalizes guilt and remorse after caring for multiple severely
injured patients during a staffing crisis. The nurse expresses anger stating that the patients
did not receive quality care and begins exhibiting aggression toward colleagues. This is most
consistent with which condition?
A.Compassion fatigue
B.Vicarious trauma
C.Secondary traumatic stress
D.Moral injury
D.Prepare the patient for surgery to remove the rod. - ansA patient arrives with a large metal
rod embedded in their left thigh and no active bleeding. Which intervention is most appropriate
for this patient?
A.Remove the rod immediately to facilitate cleansing.
B.Apply a tourniquet to the leg above the metal rod.
C.Hold antibiotics until after the rod is removed.
D.Prepare the patient for surgery to remove the rod.
D.Widening pulse pressure - ansA patient with a traumatic brain injury has a mean arterial
pressure (MAP) of 65 mm Hg (8.66 kPa) and an intracranial pressure (ICP) of 22 mm Hg (2.93
kPa). Which finding is most likely an indication of the body's response to these findings?
A.Reflex hypotension
B.Increased respiratory effort
C.Reflex tachycardia
D.Widening pulse pressure
Distraction, family presence, padding bony prominences, repositioning, splinting, verbal
reassurance - ansWhat are examples of nonpharmacologic measures? (must identify at least
one during testing)
During "Circulation" assessment - ansWhen should 2 IV sites be established?
EKG - ansIn step M of "Get Adjuncts", what else might be indicated besides cardiac monitor?
fat embolism - ansA patient has been in the emergency department for several hours waiting
to be admitted. They sustained multiple rib fractures and a femur fracture after a fall. The
patient has been awake, alert, and complaining of leg pain. Their spouse reported that the
patient suddenly became anxious and confused. Upon reassessment, the patient is restless,
with respiratory distress and petechiae to his neck. The patient is exhibiting signs and
symptoms most commonly associated with which of the following conditions?
A.Acute lung injury
,TNCC 20TH EDITION EXAM 5 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE
B.Fat embolism
C.Pneumothorax
D.Pulmonary contusion
flank - ansDuring the head-to-toe, where would you find Grey-Turner's sign?
Globe rupture - ansA 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?
A.Oculomotor nerve palsy
B.Globe rupture
C.Retrobulbar hematoma
D.Retinal detachment
glucose - ansIn Step 13 of "Disability", what is assessed if pt is altered?
Immediately initiate isolation precautions - ansThree adults present at different times during a
one-hour period with a high fever, fatigue, and headache. All three patients have a rash which
started on their mouth, face, and arms with progression to the chest and abdomen. They all
visited the same grocery store within the last week. What is the most appropriate intervention
from triage for these patients?
A.Move them to a decontamination area
B.Mask the patients and send them to the waiting room
C.Immediately initiate isolation precautions
D.Send them to the waiting room without a mask
In Step 15 of "Exposure and Environment" - ansAt what point PRIOR TO the head-to-toe is the
patient inspected for obvious injuries?
Initiate two large-caliber intravenous lines for isotonic crystalloid administration. - ansA
patient is thrown against a car during a tornado and presents with obvious bilateral femur
fractures. The patient is pale, alert, disoriented, and has delayed capillary refill. Which of the
following interventions would be most appropriate for this patient based on the disaster triage
principles?
A.Initiate two large-caliber intravenous lines for isotonic crystalloid administration.
B.Administer intravenous medications for pain.
C.Place the patient in an observation area for care within the next few hours.
D.Contact the command center for personnel to notify next of kin.
inspecting posterior - ansWhat is sometimes deferred at the end of the head-to-toe?
intervene as appropriate and reassess - ansWhat do you do when alterations are identified in
any of the steps in the primary survery?
It should be avoided with a suspected spine injury prior to imaging - ansWhich of the following
is true about the log-roll maneuver?
A.It causes less spinal motion than the lift-and-slide maneuver
, TNCC 20TH EDITION EXAM 5 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE
B.It is recommended for patients with unstable pelvic fractures
C.It should be avoided with a suspected spine injury prior to imaging
D.It decreases the risk of hemorrhage from unstable pelvic injuries
just keep evaluating - vipp - ansWhat does the J stand for at the end of the secondary survery?
Medical records, prehospital report, SAMPLE - ansWhat three items are obtained during the
pertinent history assessment?
moving patient from assisted ventilation to mechanical - ansWhat should you verbalize after
completing all ETT assessments?
post-concussive syndrome - ansAn older adult presents to the emergency department with
complaints of dizziness, headache, and nausea. The patient was involved in a motor vehicle
collision 10 days ago. There was no loss of consciousness and a hematoma is noted to the
forehead. The patient is currently on anticoagulant therapy. What is most likely the cause of
their symptoms?
A.Intracerebral hemorrhage
B.Epidural hematoma
C.Diffuse axonal injury
D.Post-concussive syndrome
the need for a second person to provide manual c-spine stabilization - ansIf c-spine
stabilization is necessary, what need should be stated?
umbilicus - ansDuring the head-to-toe, where would you find Cullen's sign?
urinary incontinence - ansWhile caring for a trauma patient in the emergency department,
what finding raises suspicion of a complete spinal cord injury?
A.Weakness in the lower extremities
B.Urinary incontinence
C.Sacral sparing
D.Spastic paralysis of the legs
vital signs, injuries/interventions, primary survey, pain - ansWhat does VIPP stand for?
Voluntary anal sphincter tone - ansA patient has been diagnosed with an incomplete spinal
cord injury at L1. Which finding would indicate sacral sparing?
A.Involuntary flexion of the great toe
B.Priapism
C.Voluntary anal sphincter tone
D.Numbness to the perianal area
"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?
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE
"
D.Quaternary
C.Use a jaw thrust to open the airway and look for signs of obstruction. - ansAn adult patient
was brought to the emergency department following a motorcycle crash. On arrival, the
patient is only responsive to pain, has bleeding from the nose, and multiple abrasions and
contusions to the face. What is the priority intervention?
A.Use a bulb syringe to suction out secretions from the mouth.
B.Insert a nasopharyngeal airway to maintain an open airway.
C.Use a jaw thrust to open the airway and look for signs of obstruction.
D.Ask the patient to open their mouth to inspect the airway.
cardiac monitor - ansWhat can be applied in step 12 of "Circulation and Control of
Hemorrhage" for which credit is given in the LMNOP section?
D.Assist ventilation with a bag-mask device - ansFollowing a gun shot wound, pre-hospital
providers report diminished breath sounds bilaterally. Upon emergency department arrival, the
patient is unresponsive with shallow respirations and an O2 sat of 88%. What is the priority
intervention for this patient?
A.Administer 15 L oxygen via nonrebreather mask
B.Attach patient to a CO2 detector
C.Prepare for a definitive airway
D.Assist ventilation with a bag-mask device
D.Coagulopathy - ansA patient who sustained severe injuries was brought to the emergency
department following a high-speed motor vehicle collision. Interventions for hypovolemic
shock have been initiated. What component of the trauma triad of death is most likely to have
begun at the time of injury?
A.Acidosis
B.Hypothermia
C.Hypocalcemia
D.Coagulopathy
D.Gently rewarm over 15 to 30 minutes - ansA patient arrives following prolonged exposure of
their left hand to the cold. The patient is awake and alert and complains of a tingling
sensation to the fingers. Assessment reveals swelling and bright red skin to the left hand and
a 1-inch round clear blister to the dorsum of that hand. Which of the following nursing
interventions is most appropriate for this patient?
A.Massage the injured areas to promote circulation
B.Drain and debride the blister on the hand
C.Immerse in water between 37.5oC and 39.5oC (99.5oF to 103.1oF).
D.Gently rewarm over 15 to 30 minutes
D.Insert an oropharyngeal airway if there is no gag reflex - ansDuring the primary survey of an
unconscious patient with multi-system trauma, the nurse notes snoring respirations. Which
priority nursing intervention should be performed next?
,TNCC 20TH EDITION EXAM 5 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE
A.Open the airway with the head-tilt/chin-lift maneuver
B.Auscultate bilateral breath sounds
C.Assist respirations using a bag-mask device
D.Insert an oropharyngeal airway if there is no gag reflex
D.Moral injury - ansA nurse verbalizes guilt and remorse after caring for multiple severely
injured patients during a staffing crisis. The nurse expresses anger stating that the patients
did not receive quality care and begins exhibiting aggression toward colleagues. This is most
consistent with which condition?
A.Compassion fatigue
B.Vicarious trauma
C.Secondary traumatic stress
D.Moral injury
D.Prepare the patient for surgery to remove the rod. - ansA patient arrives with a large metal
rod embedded in their left thigh and no active bleeding. Which intervention is most appropriate
for this patient?
A.Remove the rod immediately to facilitate cleansing.
B.Apply a tourniquet to the leg above the metal rod.
C.Hold antibiotics until after the rod is removed.
D.Prepare the patient for surgery to remove the rod.
D.Widening pulse pressure - ansA patient with a traumatic brain injury has a mean arterial
pressure (MAP) of 65 mm Hg (8.66 kPa) and an intracranial pressure (ICP) of 22 mm Hg (2.93
kPa). Which finding is most likely an indication of the body's response to these findings?
A.Reflex hypotension
B.Increased respiratory effort
C.Reflex tachycardia
D.Widening pulse pressure
Distraction, family presence, padding bony prominences, repositioning, splinting, verbal
reassurance - ansWhat are examples of nonpharmacologic measures? (must identify at least
one during testing)
During "Circulation" assessment - ansWhen should 2 IV sites be established?
EKG - ansIn step M of "Get Adjuncts", what else might be indicated besides cardiac monitor?
fat embolism - ansA patient has been in the emergency department for several hours waiting
to be admitted. They sustained multiple rib fractures and a femur fracture after a fall. The
patient has been awake, alert, and complaining of leg pain. Their spouse reported that the
patient suddenly became anxious and confused. Upon reassessment, the patient is restless,
with respiratory distress and petechiae to his neck. The patient is exhibiting signs and
symptoms most commonly associated with which of the following conditions?
A.Acute lung injury
,TNCC 20TH EDITION EXAM 5 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE
B.Fat embolism
C.Pneumothorax
D.Pulmonary contusion
flank - ansDuring the head-to-toe, where would you find Grey-Turner's sign?
Globe rupture - ansA 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?
A.Oculomotor nerve palsy
B.Globe rupture
C.Retrobulbar hematoma
D.Retinal detachment
glucose - ansIn Step 13 of "Disability", what is assessed if pt is altered?
Immediately initiate isolation precautions - ansThree adults present at different times during a
one-hour period with a high fever, fatigue, and headache. All three patients have a rash which
started on their mouth, face, and arms with progression to the chest and abdomen. They all
visited the same grocery store within the last week. What is the most appropriate intervention
from triage for these patients?
A.Move them to a decontamination area
B.Mask the patients and send them to the waiting room
C.Immediately initiate isolation precautions
D.Send them to the waiting room without a mask
In Step 15 of "Exposure and Environment" - ansAt what point PRIOR TO the head-to-toe is the
patient inspected for obvious injuries?
Initiate two large-caliber intravenous lines for isotonic crystalloid administration. - ansA
patient is thrown against a car during a tornado and presents with obvious bilateral femur
fractures. The patient is pale, alert, disoriented, and has delayed capillary refill. Which of the
following interventions would be most appropriate for this patient based on the disaster triage
principles?
A.Initiate two large-caliber intravenous lines for isotonic crystalloid administration.
B.Administer intravenous medications for pain.
C.Place the patient in an observation area for care within the next few hours.
D.Contact the command center for personnel to notify next of kin.
inspecting posterior - ansWhat is sometimes deferred at the end of the head-to-toe?
intervene as appropriate and reassess - ansWhat do you do when alterations are identified in
any of the steps in the primary survery?
It should be avoided with a suspected spine injury prior to imaging - ansWhich of the following
is true about the log-roll maneuver?
A.It causes less spinal motion than the lift-and-slide maneuver
, TNCC 20TH EDITION EXAM 5 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE
B.It is recommended for patients with unstable pelvic fractures
C.It should be avoided with a suspected spine injury prior to imaging
D.It decreases the risk of hemorrhage from unstable pelvic injuries
just keep evaluating - vipp - ansWhat does the J stand for at the end of the secondary survery?
Medical records, prehospital report, SAMPLE - ansWhat three items are obtained during the
pertinent history assessment?
moving patient from assisted ventilation to mechanical - ansWhat should you verbalize after
completing all ETT assessments?
post-concussive syndrome - ansAn older adult presents to the emergency department with
complaints of dizziness, headache, and nausea. The patient was involved in a motor vehicle
collision 10 days ago. There was no loss of consciousness and a hematoma is noted to the
forehead. The patient is currently on anticoagulant therapy. What is most likely the cause of
their symptoms?
A.Intracerebral hemorrhage
B.Epidural hematoma
C.Diffuse axonal injury
D.Post-concussive syndrome
the need for a second person to provide manual c-spine stabilization - ansIf c-spine
stabilization is necessary, what need should be stated?
umbilicus - ansDuring the head-to-toe, where would you find Cullen's sign?
urinary incontinence - ansWhile caring for a trauma patient in the emergency department,
what finding raises suspicion of a complete spinal cord injury?
A.Weakness in the lower extremities
B.Urinary incontinence
C.Sacral sparing
D.Spastic paralysis of the legs
vital signs, injuries/interventions, primary survey, pain - ansWhat does VIPP stand for?
Voluntary anal sphincter tone - ansA patient has been diagnosed with an incomplete spinal
cord injury at L1. Which finding would indicate sacral sparing?
A.Involuntary flexion of the great toe
B.Priapism
C.Voluntary anal sphincter tone
D.Numbness to the perianal area
"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?
