TNCC NOTES FOR WRITTEN EXAM LATEST 2025 |TEST
BANK|100% COMPLETE Pass A+
What are s/s of chemical burns to the eye? - ansChemical injuries require immediate intervention if it is to
be preserved.
S/S:
- Pain
- Corneal Opacification
- Coexisting chemical burn and swelling of lids
What are S/S of penetrating trauma/open or ruptured globe? - ans- Marked visual impairments
- Extrusion of intraocular contents
- Flattened or shallow anterior chamber
- Subconjunctival hemorrhage, hyphema
- Decreased intraocular pressure
- Restriction of extraocular movements
What are S/S with blunt cardiac injury? - ans"Cardiac contusion" or "concussion." Common with MVC or
falls from heights.
- ECG (sinus tach, PVC's, AV blocks)
- Chest pain
- Chest wall ecchymosis
What are S/S with tracheobronchial injury? - ansBlunt trauma. "Clothesline-type" injuries.
- Dyspnea, tachypnea
- Hoarseness
- Hemoptysis
- Subcutaneous emphysema in neck, face, or suprasternal area
- Decreased or absent breath sounds
- S/S of airway obstruction
What are signs of a serious eye injury? - ans- Visual disturbances
- Pain
- Redness and ecchymosis of the eye
- Periorbital ecchymosis
- Increased intraocular pressure
What are signs of ineffective breathing? - ans- AMS
- Cyanosis, especially around the mouth
- Asymmetric expansion of chest wall
- Paradoxical movement of the chest wall during inspiration and expiration
- Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
- Sucking chest wounds
- Absent or diminished breath sounds
- Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
- Anticipate definitive airway management to support ventilation.
What are signs of ineffective circulation? - ans- Tachycardia
- AMS
- Uncontrolled external bleeding
- Pale, cool, moist skin
- Distended or abnormally flattened external jugular veins
- Distant heart sounds
,TNCC NOTES FOR WRITTEN EXAM LATEST 2025 |TEST
BANK|100% COMPLETE Pass A+
What are the early signs and symptoms of increased ICP? - ans- Headache
- N/V
- Amnesia regarding events around the injury
- Altered LOC
- Restlessness, drowsiness, changes in speech, or loss of judgement
What are the interventions for Disability? - ans- 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 the interventions for Effective/Ineffective Circulation? - ans- Control any uncontrolled external
bleeding by:
- Applying direct pressure over bleeding site
- Elevating bleeding extremity
- Applying pressure over arterial pressure points
- Using tourniquet (last resort).
- Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution
- Use warmed solution
- Use pressure bags to increase speed of IVF infusion
- Use blood administration tubing for possible administration of blood
- Use rapid infusion device based on protocol
- Use NS 0.9% in same tubing as blood product
- IV = surgical cut-down, central line, or both.
- Blood sample to determine ABO and Rh group
- IO in sternum, legs, arms or pelvis
- Administer blood products
- PASG (without interfering with fluid resuscitation)
What are the late observable signs of symptoms of increased ICP? - ans- Dilated, nonreactive pupil
- Unresponsiveness to verbal or painful stimuli
- Abnormal motor posturing patterns
- Widening pulse pressure
- Increased systolic blood pressure
- Changes in RR and pattern
- Bradycardia
What are the late signs of breathing compromise? - ans- Tracheal deviation
- JVD
What are the mandibular fracture S/S? - ans- Malocclusion
- Inability to open the mouth (trismus)
- Pain, especially on movement
- Facial asymmetry and a palpable step-off deformity
- Edema or hematoma formation at the fracture site
- Blood behind, ruptured, tympanic membrane
- Anesthesia of the lower lip
What are the most common type of injury associated with chest trauma? - ansblunt; MVC's. Penetrating;
firarm injuries or stabbings
What are the nursing interventions for a patient with a maxillofacial or neck injury? - ans- Administer
oxygen
, TNCC NOTES FOR WRITTEN EXAM LATEST 2025 |TEST
BANK|100% COMPLETE Pass A+
- 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 are the nursing interventions for a pt with an ocular injury? - ans- Assess visual acuity & reassess
- Elevate HOB to minimize intraocular pressure
- Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise
intraocular pressure
- Assist w/removal of foreign bodies as indicated; stabilize impaled objects
- Apply cool packs to decrease pain + periorbital swelling
- Admin medications
- Instill prescribed topical anesthetic drops for pain
- Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to
prevent drying and ulceration
- Antibiotics topically or systemically
- Admin tetanus prophylactically
- Use an eye patch to affected eye
- Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries
- Patch, shield or cover w/cool pack
- Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected
eye. Use metal or plastic and do not put pressure on the globe.
- Provide psychosocial support
- Obtain an ophthalmology consultation
- Provide d/c instructions:
- Importance of protective eyewear
- No driving w/eye patch on
- Wear sunglasses to prevent tearing, aid photophobia
- Prepare for admission, OR or transfer
What are the Rapid Sequence Intubation Steps? - ansPREPARATION:
- gather equipment, staffing, etc.
PREOXYGENATION:
- Use 100% O2 (prevent risk of aspiration).
PRETREATMENT:
- Decrease S/E's of intubation
PARALYSIS WITH INDUCTION:
- Pt has LOC, then administer neuromuscular blocking agent
PROTECTION AND POSITIONING:
- Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration
PLACEMENT WITH PROOF
- Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between
attempts.
- After intubation, inflate the cuff
- Confirm tube placement w/exhaled CO2 detector.
BANK|100% COMPLETE Pass A+
What are s/s of chemical burns to the eye? - ansChemical injuries require immediate intervention if it is to
be preserved.
S/S:
- Pain
- Corneal Opacification
- Coexisting chemical burn and swelling of lids
What are S/S of penetrating trauma/open or ruptured globe? - ans- Marked visual impairments
- Extrusion of intraocular contents
- Flattened or shallow anterior chamber
- Subconjunctival hemorrhage, hyphema
- Decreased intraocular pressure
- Restriction of extraocular movements
What are S/S with blunt cardiac injury? - ans"Cardiac contusion" or "concussion." Common with MVC or
falls from heights.
- ECG (sinus tach, PVC's, AV blocks)
- Chest pain
- Chest wall ecchymosis
What are S/S with tracheobronchial injury? - ansBlunt trauma. "Clothesline-type" injuries.
- Dyspnea, tachypnea
- Hoarseness
- Hemoptysis
- Subcutaneous emphysema in neck, face, or suprasternal area
- Decreased or absent breath sounds
- S/S of airway obstruction
What are signs of a serious eye injury? - ans- Visual disturbances
- Pain
- Redness and ecchymosis of the eye
- Periorbital ecchymosis
- Increased intraocular pressure
What are signs of ineffective breathing? - ans- AMS
- Cyanosis, especially around the mouth
- Asymmetric expansion of chest wall
- Paradoxical movement of the chest wall during inspiration and expiration
- Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
- Sucking chest wounds
- Absent or diminished breath sounds
- Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
- Anticipate definitive airway management to support ventilation.
What are signs of ineffective circulation? - ans- Tachycardia
- AMS
- Uncontrolled external bleeding
- Pale, cool, moist skin
- Distended or abnormally flattened external jugular veins
- Distant heart sounds
,TNCC NOTES FOR WRITTEN EXAM LATEST 2025 |TEST
BANK|100% COMPLETE Pass A+
What are the early signs and symptoms of increased ICP? - ans- Headache
- N/V
- Amnesia regarding events around the injury
- Altered LOC
- Restlessness, drowsiness, changes in speech, or loss of judgement
What are the interventions for Disability? - ans- 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 the interventions for Effective/Ineffective Circulation? - ans- Control any uncontrolled external
bleeding by:
- Applying direct pressure over bleeding site
- Elevating bleeding extremity
- Applying pressure over arterial pressure points
- Using tourniquet (last resort).
- Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution
- Use warmed solution
- Use pressure bags to increase speed of IVF infusion
- Use blood administration tubing for possible administration of blood
- Use rapid infusion device based on protocol
- Use NS 0.9% in same tubing as blood product
- IV = surgical cut-down, central line, or both.
- Blood sample to determine ABO and Rh group
- IO in sternum, legs, arms or pelvis
- Administer blood products
- PASG (without interfering with fluid resuscitation)
What are the late observable signs of symptoms of increased ICP? - ans- Dilated, nonreactive pupil
- Unresponsiveness to verbal or painful stimuli
- Abnormal motor posturing patterns
- Widening pulse pressure
- Increased systolic blood pressure
- Changes in RR and pattern
- Bradycardia
What are the late signs of breathing compromise? - ans- Tracheal deviation
- JVD
What are the mandibular fracture S/S? - ans- Malocclusion
- Inability to open the mouth (trismus)
- Pain, especially on movement
- Facial asymmetry and a palpable step-off deformity
- Edema or hematoma formation at the fracture site
- Blood behind, ruptured, tympanic membrane
- Anesthesia of the lower lip
What are the most common type of injury associated with chest trauma? - ansblunt; MVC's. Penetrating;
firarm injuries or stabbings
What are the nursing interventions for a patient with a maxillofacial or neck injury? - ans- Administer
oxygen
, TNCC NOTES FOR WRITTEN EXAM LATEST 2025 |TEST
BANK|100% COMPLETE Pass A+
- 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 are the nursing interventions for a pt with an ocular injury? - ans- Assess visual acuity & reassess
- Elevate HOB to minimize intraocular pressure
- Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise
intraocular pressure
- Assist w/removal of foreign bodies as indicated; stabilize impaled objects
- Apply cool packs to decrease pain + periorbital swelling
- Admin medications
- Instill prescribed topical anesthetic drops for pain
- Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to
prevent drying and ulceration
- Antibiotics topically or systemically
- Admin tetanus prophylactically
- Use an eye patch to affected eye
- Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries
- Patch, shield or cover w/cool pack
- Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected
eye. Use metal or plastic and do not put pressure on the globe.
- Provide psychosocial support
- Obtain an ophthalmology consultation
- Provide d/c instructions:
- Importance of protective eyewear
- No driving w/eye patch on
- Wear sunglasses to prevent tearing, aid photophobia
- Prepare for admission, OR or transfer
What are the Rapid Sequence Intubation Steps? - ansPREPARATION:
- gather equipment, staffing, etc.
PREOXYGENATION:
- Use 100% O2 (prevent risk of aspiration).
PRETREATMENT:
- Decrease S/E's of intubation
PARALYSIS WITH INDUCTION:
- Pt has LOC, then administer neuromuscular blocking agent
PROTECTION AND POSITIONING:
- Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration
PLACEMENT WITH PROOF
- Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between
attempts.
- After intubation, inflate the cuff
- Confirm tube placement w/exhaled CO2 detector.
