TNCC FINAL EXAM UPDATED AND VERIFIED
SOLUTIONS (GRADED A+) 2025/2026
Why is a measure of serum lactate obtained in the initial assessment of the trauma patient?
Answer: c - ANS-a) to measure oxygenation and ventilation
b) to quantify the base deficit for the adequacy of cellular perfusion
c) *to gauge end-organ perfusion and tissue hypoxia **
d) to determine the underlying cause of shock
A trauma patient is restless and repeatedly asking "where am I?" vital signs upon arrival were BP
100/60 mm Hg, HR 96 beats/min, and RR 24 breaths/min. Her skin is cool and dry. Current vital
signs are BP 104/84mm Hg, HR 108, RR 28 breaths/min. The patient is demonstrating signs and
symptoms of which stage of shock?
Answer: A - ANS-A) compensated **
B) Progressive
C) irreversible
D) decompensated
An elderly patient with a history of anticoagulant use presents after a fall at home that day. she
denies any loss of consciousness. She has a hematoma to her forehead and complains of
headache, dizziness, and nausea. Which is a most likely cause of her symptoms?
Answer: D - ANS-A) epidural hematoma
B) diffuse axonal injury
C) post-concussive syndrome
,D) subdural hematoma ***
EMS brings a patient who fell riding his bicycle. Using the American College of Surgeons
screening guidelines, which assessment finding would prompt the nurse to prepare the patient for
radiologic spine clearance?
Answer: D - ANS-A) Alert with no neurologic deficits
B) Multiple abrasions to the extremities
C) Multiple requests of water
D) Smell of alcohol on breath ***
Which of the following occurs during the third impact of a motor vehicle crash?
Answer: C - ANS-A) The driver of the vehicle collides with the steering wheel
B) the vehicle collides with a tree
C) the aorta is torn at its attachment with the ligamentum arteriosum
D) the airbag deploys and strikes the front seat passenger ***
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 - ANS-A) initiate transfer to a trauma center **
B) provide report to the operating room nurse
C) Obtained imaging studies
D) Place a gastric tube
Which of the following injuries is LEAST likely to be promptly identified?
Answer: C - ANS-A) spleen
, B) lung
C) bowel ***
D) brain
Patients with a crush injury should be monitored for which of the following conditions?
Answer: C - ANS-A) Hypernatremia
B) Hypercalcemia
C) Dysrhthmias **
D) polyuria
What finding raises suspicion of complete spinal cord injury?
Answer: B - ANS-A) Weakness in the lower extremities
B) Priapism ***
C) voluntary anal sphincter tone
D) intact reflexes distal to the injury
A patient with a complete spinal cord injury in neurogenic shock will demonstrate hypotension
and which other clinical signs?
Answer: D - ANS-A) Bradycardia and ipsilateral absences of motor function
B) Tachycardia and respiratory depression
C) Tachycardia and absent motor function below the level of injury
D) Bradycardia and absent motor function below the level of the injury ***
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?
SOLUTIONS (GRADED A+) 2025/2026
Why is a measure of serum lactate obtained in the initial assessment of the trauma patient?
Answer: c - ANS-a) to measure oxygenation and ventilation
b) to quantify the base deficit for the adequacy of cellular perfusion
c) *to gauge end-organ perfusion and tissue hypoxia **
d) to determine the underlying cause of shock
A trauma patient is restless and repeatedly asking "where am I?" vital signs upon arrival were BP
100/60 mm Hg, HR 96 beats/min, and RR 24 breaths/min. Her skin is cool and dry. Current vital
signs are BP 104/84mm Hg, HR 108, RR 28 breaths/min. The patient is demonstrating signs and
symptoms of which stage of shock?
Answer: A - ANS-A) compensated **
B) Progressive
C) irreversible
D) decompensated
An elderly patient with a history of anticoagulant use presents after a fall at home that day. she
denies any loss of consciousness. She has a hematoma to her forehead and complains of
headache, dizziness, and nausea. Which is a most likely cause of her symptoms?
Answer: D - ANS-A) epidural hematoma
B) diffuse axonal injury
C) post-concussive syndrome
,D) subdural hematoma ***
EMS brings a patient who fell riding his bicycle. Using the American College of Surgeons
screening guidelines, which assessment finding would prompt the nurse to prepare the patient for
radiologic spine clearance?
Answer: D - ANS-A) Alert with no neurologic deficits
B) Multiple abrasions to the extremities
C) Multiple requests of water
D) Smell of alcohol on breath ***
Which of the following occurs during the third impact of a motor vehicle crash?
Answer: C - ANS-A) The driver of the vehicle collides with the steering wheel
B) the vehicle collides with a tree
C) the aorta is torn at its attachment with the ligamentum arteriosum
D) the airbag deploys and strikes the front seat passenger ***
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 - ANS-A) initiate transfer to a trauma center **
B) provide report to the operating room nurse
C) Obtained imaging studies
D) Place a gastric tube
Which of the following injuries is LEAST likely to be promptly identified?
Answer: C - ANS-A) spleen
, B) lung
C) bowel ***
D) brain
Patients with a crush injury should be monitored for which of the following conditions?
Answer: C - ANS-A) Hypernatremia
B) Hypercalcemia
C) Dysrhthmias **
D) polyuria
What finding raises suspicion of complete spinal cord injury?
Answer: B - ANS-A) Weakness in the lower extremities
B) Priapism ***
C) voluntary anal sphincter tone
D) intact reflexes distal to the injury
A patient with a complete spinal cord injury in neurogenic shock will demonstrate hypotension
and which other clinical signs?
Answer: D - ANS-A) Bradycardia and ipsilateral absences of motor function
B) Tachycardia and respiratory depression
C) Tachycardia and absent motor function below the level of injury
D) Bradycardia and absent motor function below the level of the injury ***
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?
