NCLEX RN Trauma Nursing Practice
Exam 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A client arrives in the emergency department after a motor vehicle
collision. Which assessment finding requires immediate intervention?
A. Closed fracture of the radius
B. Respiratory rate of 24/min
C. Tracheal deviation with absent breath sounds on one side
D. Bruising over the abdomen
Answer: Tracheal deviation with absent breath sounds on one side
Rationale: These findings are highly suggestive of tension pneumothorax,
which can rapidly compromise ventilation and circulation. Immediate
decompression is required.
2. A trauma client has severe bleeding from a leg wound. What is the
nurse's priority intervention?
A. Apply a warm blanket
B. Elevate the injured extremity
C. Apply direct pressure to the wound
D. Obtain a detailed medical history
Answer: Apply direct pressure to the wound
Rationale: Controlling external hemorrhage is an immediate priority in
trauma care. Direct pressure is the first-line intervention for most severe
external bleeding.
3. A client with suspected cervical spine injury arrives after a diving
accident. Which action should the nurse take first?
,A. Flex the client's neck to assess movement
B. Maintain cervical spine stabilization
C. Place the client in high-Fowler position
D. Ask the client to walk to assess gait
Answer: Maintain cervical spine stabilization
Rationale: Spinal motion can worsen an unstable cervical injury and cause
permanent neurologic damage. Manual stabilization and appropriate
immobilization are priorities.
4. A trauma client is unconscious and has blood and secretions obstructing
the airway. Which intervention is most appropriate?
A. Perform a head-tilt/chin-lift maneuver
B. Perform a jaw-thrust maneuver while maintaining spinal alignment
C. Place the client prone
D. Give oral fluids
Answer: Perform a jaw-thrust maneuver while maintaining spinal alignment
Rationale: The jaw-thrust maneuver opens the airway while minimizing
movement of the cervical spine in a client with possible spinal injury.
5. A client with blunt abdominal trauma develops tachycardia, hypotension,
and cool clammy skin. What should the nurse suspect?
A. Neurogenic shock
B. Hypovolemic shock
C. Cardiogenic shock
D. Septic shock
Answer: Hypovolemic shock
Rationale: Trauma-related blood loss can cause decreased circulating volume,
producing tachycardia, hypotension, cool skin, and poor tissue perfusion.
6. Which finding is most concerning in a client with a suspected pelvic
fracture?
A. Mild bruising of the thigh
B. Hematuria
,C. Severe pelvic pain
D. Hypotension and increasing heart rate
Answer: Hypotension and increasing heart rate
Rationale: Pelvic fractures can cause massive internal hemorrhage.
Hemodynamic instability suggests significant blood loss and requires
immediate intervention.
7. A client has a penetrating chest wound with air moving through the
wound. Which intervention should the nurse anticipate?
A. Application of an occlusive dressing secured on all four sides
B. Application of a vented or three-sided occlusive dressing
C. Removal of the penetrating object
D. Immediate oral feeding
Answer: Application of a vented or three-sided occlusive dressing
Rationale: An open chest wound can allow air into the pleural space. A
dressing that permits air to escape helps reduce the risk of developing tension
pneumothorax.
8. A client with a suspected spinal cord injury has hypotension, warm dry
skin, and bradycardia. Which condition does the nurse suspect?
A. Hypovolemic shock
B. Neurogenic shock
C. Septic shock
D. Cardiogenic shock
Answer: Neurogenic shock
Rationale: Neurogenic shock results from loss of sympathetic vascular tone,
causing vasodilation, hypotension, and often bradycardia with warm, dry
skin.
9. A client with a traumatic brain injury becomes increasingly restless and
confused. What should the nurse do first?
A. Assume the client is anxious
B. Assess oxygenation and neurologic status
, C. Administer a sedative immediately
D. Encourage ambulation
Answer: Assess oxygenation and neurologic status
Rationale: New restlessness and confusion can indicate worsening cerebral
hypoxia or increased intracranial pressure. Prompt assessment is essential.
10.Which finding is characteristic of increased intracranial pressure?
A. Hypotension and tachycardia
B. Bradycardia with widening pulse pressure
C. Tachycardia with narrow pulse pressure
D. Hyperactive bowel sounds
Answer: Bradycardia with widening pulse pressure
Rationale: Bradycardia, widened pulse pressure, and irregular respirations
constitute Cushing's response, a late sign of increased intracranial pressure.
11.A trauma client has a Glasgow Coma Scale score of 7. How should the
nurse interpret this finding?
A. Mild neurologic impairment
B. Moderate neurologic impairment
C. Severe neurologic impairment
D. Normal neurologic function
Answer: Severe neurologic impairment
Rationale: A Glasgow Coma Scale score of 8 or less indicates severe brain
injury and raises concern for inability to protect the airway.
12.A client with a head injury has clear drainage from the nose. What
should the nurse suspect?
A. Allergic rhinitis
B. Cerebrospinal fluid leakage
C. Sinus infection
D. Dehydration
Answer: Cerebrospinal fluid leakage
Exam 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A client arrives in the emergency department after a motor vehicle
collision. Which assessment finding requires immediate intervention?
A. Closed fracture of the radius
B. Respiratory rate of 24/min
C. Tracheal deviation with absent breath sounds on one side
D. Bruising over the abdomen
Answer: Tracheal deviation with absent breath sounds on one side
Rationale: These findings are highly suggestive of tension pneumothorax,
which can rapidly compromise ventilation and circulation. Immediate
decompression is required.
2. A trauma client has severe bleeding from a leg wound. What is the
nurse's priority intervention?
A. Apply a warm blanket
B. Elevate the injured extremity
C. Apply direct pressure to the wound
D. Obtain a detailed medical history
Answer: Apply direct pressure to the wound
Rationale: Controlling external hemorrhage is an immediate priority in
trauma care. Direct pressure is the first-line intervention for most severe
external bleeding.
3. A client with suspected cervical spine injury arrives after a diving
accident. Which action should the nurse take first?
,A. Flex the client's neck to assess movement
B. Maintain cervical spine stabilization
C. Place the client in high-Fowler position
D. Ask the client to walk to assess gait
Answer: Maintain cervical spine stabilization
Rationale: Spinal motion can worsen an unstable cervical injury and cause
permanent neurologic damage. Manual stabilization and appropriate
immobilization are priorities.
4. A trauma client is unconscious and has blood and secretions obstructing
the airway. Which intervention is most appropriate?
A. Perform a head-tilt/chin-lift maneuver
B. Perform a jaw-thrust maneuver while maintaining spinal alignment
C. Place the client prone
D. Give oral fluids
Answer: Perform a jaw-thrust maneuver while maintaining spinal alignment
Rationale: The jaw-thrust maneuver opens the airway while minimizing
movement of the cervical spine in a client with possible spinal injury.
5. A client with blunt abdominal trauma develops tachycardia, hypotension,
and cool clammy skin. What should the nurse suspect?
A. Neurogenic shock
B. Hypovolemic shock
C. Cardiogenic shock
D. Septic shock
Answer: Hypovolemic shock
Rationale: Trauma-related blood loss can cause decreased circulating volume,
producing tachycardia, hypotension, cool skin, and poor tissue perfusion.
6. Which finding is most concerning in a client with a suspected pelvic
fracture?
A. Mild bruising of the thigh
B. Hematuria
,C. Severe pelvic pain
D. Hypotension and increasing heart rate
Answer: Hypotension and increasing heart rate
Rationale: Pelvic fractures can cause massive internal hemorrhage.
Hemodynamic instability suggests significant blood loss and requires
immediate intervention.
7. A client has a penetrating chest wound with air moving through the
wound. Which intervention should the nurse anticipate?
A. Application of an occlusive dressing secured on all four sides
B. Application of a vented or three-sided occlusive dressing
C. Removal of the penetrating object
D. Immediate oral feeding
Answer: Application of a vented or three-sided occlusive dressing
Rationale: An open chest wound can allow air into the pleural space. A
dressing that permits air to escape helps reduce the risk of developing tension
pneumothorax.
8. A client with a suspected spinal cord injury has hypotension, warm dry
skin, and bradycardia. Which condition does the nurse suspect?
A. Hypovolemic shock
B. Neurogenic shock
C. Septic shock
D. Cardiogenic shock
Answer: Neurogenic shock
Rationale: Neurogenic shock results from loss of sympathetic vascular tone,
causing vasodilation, hypotension, and often bradycardia with warm, dry
skin.
9. A client with a traumatic brain injury becomes increasingly restless and
confused. What should the nurse do first?
A. Assume the client is anxious
B. Assess oxygenation and neurologic status
, C. Administer a sedative immediately
D. Encourage ambulation
Answer: Assess oxygenation and neurologic status
Rationale: New restlessness and confusion can indicate worsening cerebral
hypoxia or increased intracranial pressure. Prompt assessment is essential.
10.Which finding is characteristic of increased intracranial pressure?
A. Hypotension and tachycardia
B. Bradycardia with widening pulse pressure
C. Tachycardia with narrow pulse pressure
D. Hyperactive bowel sounds
Answer: Bradycardia with widening pulse pressure
Rationale: Bradycardia, widened pulse pressure, and irregular respirations
constitute Cushing's response, a late sign of increased intracranial pressure.
11.A trauma client has a Glasgow Coma Scale score of 7. How should the
nurse interpret this finding?
A. Mild neurologic impairment
B. Moderate neurologic impairment
C. Severe neurologic impairment
D. Normal neurologic function
Answer: Severe neurologic impairment
Rationale: A Glasgow Coma Scale score of 8 or less indicates severe brain
injury and raises concern for inability to protect the airway.
12.A client with a head injury has clear drainage from the nose. What
should the nurse suspect?
A. Allergic rhinitis
B. Cerebrospinal fluid leakage
C. Sinus infection
D. Dehydration
Answer: Cerebrospinal fluid leakage
