TESTBANK FOR TNCC FINAL EXAM LATEST VERSIONS

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: A - ansA) report your suspicion of the maltreatment in accordance with local regulations *** B) apply ice to the bruises and consult wound care C) engage in therapeutic communication to determine the MOI D) provide the family with injury prevention resourse A 20-year old male presents to the ED c/o severe lower abd pain after landing hard on the bicycle cross bars which performing an aerial BMX maneuver. Secondary assessment reveals lower abd tenderness and scrotal ecchymosis. Which of the following orders would the nurse questions? Answer: C - ansA) Fast exam B) CT scan C) straight cath for urine sample *** D) ice and elevation of the scrotum A 35-year old male presents with facial trauma after bring struck inthe face with a baseball. a tear-drop shaped left pupil is noted on exam. What type of injury is suspected? Answer: B - ansA) oculomotor nerve palsy B) globe rupture *** C) uncal herniation D) retinal detachment 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: B - ansA) apply a sling and elevate the extremity to the level of the heart. B) apply a splint and ELEVATE ABOVE THE LEVEL OF THE HEART *** C) Apply a sling and elevate the extremity above the level of the heart D) apply a splint and elevate the extremity to the level of the heart. A 49-year old restrained driver involved in a MVC presents to the trauma center c/o abd, pelvic, and bil lower extremity pain Vitals signs are stable. The nurse can anticipate all of these negative fast exam except which of the following? Answer: A The FAST exam is done at the bedside to identify pathological fluid in the abdominal and pelvic cavities. FAST exams reduce the use of more invasive diagnostic peritoneal lavage and can be repeated if clinical changes or hemodynamic changes occur. A negative FAST study does not rule out injury and may warrant a follow-up computed tomography scan. Serial FAST exams can identify increasing abdominal fluid collections from hemorrhage. Diagnostic peritoneal lavage/diagnostic peritoneal aspiration is performed by the surgical team to rapidly identify the presence of hemorrhage in patients who are hemodynamically unstable after trauma. - ansA) diagnostic peritoneal lavage *** B) serial fast exams C) abdominal and pelvic CT scans D) serial abdominal assessments A 56-year- male patient involved in a MVC is brought to the ED of a rural critical access facility. He c/o neck pain, SOB, and diffuse abd pain. His GCS is 15. His vitals are as follows: BP 98/71 HR 125 beats/min RR 26 breaths/min SpO2 94% on high flow O2 via NRB mask which of the following is the priority intervention for this patient? Answer: C - ansA) Expedite transport to the CT scanner B) prepare the patient for spinal radiographs C) expedite transfer to the closest trauma center *** D) notify the patients family A passenger is brought to the emergency department of a rural hospital following a high-speed MVC. When significant abdominal and pelvic injuries are noted in the primary survey, which of the following is the priority interventions? Answer: A - ansA) initiate transfer to a trauma center ** B) provide report to the operating room nurse C) Obtained imaging studies D) Place a gastric tube A patient arrives with a large open chest wound after being assault ed with a machete, Prehospital providers placed a nonporous dressing over the chest wound and tapes it on 3 sides. He is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis, and decreasing blood pressure. Which of the following is the MOST appropriate interventions? Answer: C - ansA) needle decompression B) tube thoracostomy C) dressing removal **