TNCC 20TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE verified pass
"
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
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 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE verified pass
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?
1. attach CO2 detector and assess for evidence of exhaled CO2; 2. observe for rise and fall of the chest w/
assisted ventilations; 3. auscultate over epigastrium for gurgling AND lungs for bilateral breath sounds -
ansWhat three assessments must be done if the patient is intubated?
1. inspect AND palpate skin color, temp, moisture and 2. palpate a pulse - ansTo assess circulation, you
must do these two main tasks:
,TNCC 20TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE verified pass
A.Alert with no neurologic deficits - ansUsing the American College of Surgeons screening guidelines,
what assessment finding would prompt the nurse to prepare a patient for cervical spine imaging?
A.Alert with no neurologic deficits
B.Multiple abrasions to the extremities
C.Ecchymosis to the flank
D.Responds to verbal stimulation
A.Cardiogenic - ansA patient is brought to the emergency department with chest pain and shortness of
breath following a high-speed motor vehicle collision in which they were the unrestrained driver. There is
crepitus to the left chest with clear and equal breath sounds. The vital signs are BP 80/40 mmHg, HR 140
beats/minute, and RR 40 breaths/minute. Cardiac monitor shows sinus tachycardia with premature
ventricular contractions. These findings are most consistent with which type of shock?
A.Cardiogenic
B.Neurogenic
C.Hypovolemic
D.Obstructive
A.Decrease the rate of manual ventilation. - ansAn adult patient who sustained a severe head trauma has
been intubated and is being manually ventilated via a bag-mask device at a rate of 18 breaths/minute. The
patient has received one intravenous fluid bolus of 500 mL of warmed isotonic crystalloid solution. The
PaCO2 is 30 mm Hg (4.0 kPa), and the pulse oximetry is 92%. BP is 142/70 mm Hg. What is the most
important intervention to manage the cerebral blood flow?
A.Decrease the rate of manual ventilation.
B.Initiate another fluid bolus.
C.Recheck endotracheal tube placement.
D.Increase the amount of oxygen delivered.
A.Initiate warming measures - ansA patient is brought to the emergency department following a
snowmobile crash with prolonged exposure time prior to transport. The patient is confused. Vital signs are
BP 96/54 mm Hg, HR 114 beats/minute, RR 24 breaths/minute, T 34.6oC (94.2oF) and an SpO2 of 90% on
oxygen at 15L per non-rebreather mask. Other findings include ETCO2 24, serum lactate of 6 mmol/L, and
a pH of 6.8. Based on these findings, what is the most appropriate intervention?
A.Initiate warming measures
B.Titrate oxygen to 6 L per nasal cannula
C.Bolus with 500 mL isotonic crystalloids
D.Vigorously massage the extremities
A.Report your suspicion of maltreatment in accordance with local regulations - ansA 5-year-old child
presents to the emergency department 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?
A.Report your suspicion of maltreatment in accordance with local regulations
B.Apply ice to the bruises and provide wound care
C.Engage in therapeutic communication to determine the mechanism of injury
D.Provide the family with injury prevention resources
A.Reverse Trendelenburg - ansWhat position optimizes ventilation in the obese patient with a lumbar
fracture?
A.Reverse Trendelenburg
B.Supine
, TNCC 20TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE verified pass
C.Prone
D.Fowler's
AFTER head-to-toe, BEFORE J (VIPP) - ansAntibiotics, consults, head CT, imaging, law enforcement,
mandatory reporting, psychosocial support, social services, splinting, tetanus, and wound care are all
interventions that you do AFTER and before WHAT?
all patients - ansFor whom is capnography highly recommended?
Apply a pelvic binder - ansAn adult pedestrian was struck on the right side by a sport utility vehicle
traveling at 40 mph. The patient is awake and alert and the right leg is shortened. Following initial
resuscitation with fluids, the patient remains hypotensive. What would be the priority intervention?
A.Send blood for type and crossmatch
B.Apply a pelvic binder
C.Prepare the patient for surgery
D.Insert a urinary catheter
assess ETT position by noting the number at teeth/gums AND secure ETT - ansIf the patient is intubated
and you've already assessed ETT placement, what else needs to be done with the ETT? (step 10)
Assessing patency and protection of the airway, Step 7 of
"Alertness and Airway with Simultaneous Cervical Spinal Stabilization" - ansDuring which part of the
primary survey would there be anticipation for intubation, insertion of OPA/NPA, removal of any loose
teeth or foreign objects, or suctioning?
B. Rising diastolic - ansWhich blood pressure finding is associated with early or compensated hypovolemic
shock?
A.Rising systolic
B.Rising diastolic
C.Decreasing diastolic
D.Decreasing systolic
B.A 2-year-old lands on grass from a second-story balcony - ansBased on fall mechanism, which patient
warrants prehospital transfer to a trauma center?
A.A 35-year-old lands on a wooden porch from an 8-foot ladder
B.A 2-year-old lands on grass from a second-story balcony
C.A 14-year-old forcefully pushed onto cement from standing
D.A 50-year-old lands on a carpeted floor after tripping
B.Amputation of a limb - ansWhich of the following situations could cause functional grief?
A.Inability to live at home
B.Amputation of a limb
C.Loss of one's self-image
D.Destruction of the patient's car
B.Control the bleeding - ansAn unconscious patient arrives following a motor vehicle collision. The patient
is on a backboard with a cervical collar in place and one intravenous line running. Respirations are
shallow and there is active brisk bleeding from a large leg wound. What is the priority intervention for this
patient?
A.Check for a patent airway
B.Control the bleeding
C.Start a second intravenous line
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE verified pass
"
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
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 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE verified pass
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?
1. attach CO2 detector and assess for evidence of exhaled CO2; 2. observe for rise and fall of the chest w/
assisted ventilations; 3. auscultate over epigastrium for gurgling AND lungs for bilateral breath sounds -
ansWhat three assessments must be done if the patient is intubated?
1. inspect AND palpate skin color, temp, moisture and 2. palpate a pulse - ansTo assess circulation, you
must do these two main tasks:
,TNCC 20TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE verified pass
A.Alert with no neurologic deficits - ansUsing the American College of Surgeons screening guidelines,
what assessment finding would prompt the nurse to prepare a patient for cervical spine imaging?
A.Alert with no neurologic deficits
B.Multiple abrasions to the extremities
C.Ecchymosis to the flank
D.Responds to verbal stimulation
A.Cardiogenic - ansA patient is brought to the emergency department with chest pain and shortness of
breath following a high-speed motor vehicle collision in which they were the unrestrained driver. There is
crepitus to the left chest with clear and equal breath sounds. The vital signs are BP 80/40 mmHg, HR 140
beats/minute, and RR 40 breaths/minute. Cardiac monitor shows sinus tachycardia with premature
ventricular contractions. These findings are most consistent with which type of shock?
A.Cardiogenic
B.Neurogenic
C.Hypovolemic
D.Obstructive
A.Decrease the rate of manual ventilation. - ansAn adult patient who sustained a severe head trauma has
been intubated and is being manually ventilated via a bag-mask device at a rate of 18 breaths/minute. The
patient has received one intravenous fluid bolus of 500 mL of warmed isotonic crystalloid solution. The
PaCO2 is 30 mm Hg (4.0 kPa), and the pulse oximetry is 92%. BP is 142/70 mm Hg. What is the most
important intervention to manage the cerebral blood flow?
A.Decrease the rate of manual ventilation.
B.Initiate another fluid bolus.
C.Recheck endotracheal tube placement.
D.Increase the amount of oxygen delivered.
A.Initiate warming measures - ansA patient is brought to the emergency department following a
snowmobile crash with prolonged exposure time prior to transport. The patient is confused. Vital signs are
BP 96/54 mm Hg, HR 114 beats/minute, RR 24 breaths/minute, T 34.6oC (94.2oF) and an SpO2 of 90% on
oxygen at 15L per non-rebreather mask. Other findings include ETCO2 24, serum lactate of 6 mmol/L, and
a pH of 6.8. Based on these findings, what is the most appropriate intervention?
A.Initiate warming measures
B.Titrate oxygen to 6 L per nasal cannula
C.Bolus with 500 mL isotonic crystalloids
D.Vigorously massage the extremities
A.Report your suspicion of maltreatment in accordance with local regulations - ansA 5-year-old child
presents to the emergency department 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?
A.Report your suspicion of maltreatment in accordance with local regulations
B.Apply ice to the bruises and provide wound care
C.Engage in therapeutic communication to determine the mechanism of injury
D.Provide the family with injury prevention resources
A.Reverse Trendelenburg - ansWhat position optimizes ventilation in the obese patient with a lumbar
fracture?
A.Reverse Trendelenburg
B.Supine
, TNCC 20TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+|100 % COMPLETE verified pass
C.Prone
D.Fowler's
AFTER head-to-toe, BEFORE J (VIPP) - ansAntibiotics, consults, head CT, imaging, law enforcement,
mandatory reporting, psychosocial support, social services, splinting, tetanus, and wound care are all
interventions that you do AFTER and before WHAT?
all patients - ansFor whom is capnography highly recommended?
Apply a pelvic binder - ansAn adult pedestrian was struck on the right side by a sport utility vehicle
traveling at 40 mph. The patient is awake and alert and the right leg is shortened. Following initial
resuscitation with fluids, the patient remains hypotensive. What would be the priority intervention?
A.Send blood for type and crossmatch
B.Apply a pelvic binder
C.Prepare the patient for surgery
D.Insert a urinary catheter
assess ETT position by noting the number at teeth/gums AND secure ETT - ansIf the patient is intubated
and you've already assessed ETT placement, what else needs to be done with the ETT? (step 10)
Assessing patency and protection of the airway, Step 7 of
"Alertness and Airway with Simultaneous Cervical Spinal Stabilization" - ansDuring which part of the
primary survey would there be anticipation for intubation, insertion of OPA/NPA, removal of any loose
teeth or foreign objects, or suctioning?
B. Rising diastolic - ansWhich blood pressure finding is associated with early or compensated hypovolemic
shock?
A.Rising systolic
B.Rising diastolic
C.Decreasing diastolic
D.Decreasing systolic
B.A 2-year-old lands on grass from a second-story balcony - ansBased on fall mechanism, which patient
warrants prehospital transfer to a trauma center?
A.A 35-year-old lands on a wooden porch from an 8-foot ladder
B.A 2-year-old lands on grass from a second-story balcony
C.A 14-year-old forcefully pushed onto cement from standing
D.A 50-year-old lands on a carpeted floor after tripping
B.Amputation of a limb - ansWhich of the following situations could cause functional grief?
A.Inability to live at home
B.Amputation of a limb
C.Loss of one's self-image
D.Destruction of the patient's car
B.Control the bleeding - ansAn unconscious patient arrives following a motor vehicle collision. The patient
is on a backboard with a cervical collar in place and one intravenous line running. Respirations are
shallow and there is active brisk bleeding from a large leg wound. What is the priority intervention for this
patient?
A.Check for a patent airway
B.Control the bleeding
C.Start a second intravenous line
