TNCC 10th Edition Practice Exam 3 Version A and B with Answers (740 Solved Questions)
Master your subject with TNCC 10th Edition Practice Exam 3 Version A and B with Answers, designed to simulate real exams.
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TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
"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:
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
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
"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:
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
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
"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:
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
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
"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:
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
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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
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
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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
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
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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
D.Ventilate with a bag-mask device
B.During the secondary surveyt - ansWhen should the definitive calculation for
intravenous fluid resuscitation rate be performed for a patient with burns?
A.As soon as the patient arrives
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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
D.Ventilate with a bag-mask device
B.During the secondary surveyt - ansWhen should the definitive calculation for
intravenous fluid resuscitation rate be performed for a patient with burns?
A.As soon as the patient arrives
Loading page 4...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
B.During the secondary survey
C.Should only be done at a burn center
D.During the primary survey
B.Increased oxygen consumption - ansA trauma patient who is 30-weeks pregnant
arrives at the emergency department following a motor vehicle collision. Which normal
physiologic change should be considered when assessing ventilatory status?
A.Increased functional reserve capacity
B.Increased oxygen consumption
C.Decreased minute ventilation
D.Slower desaturation rates with apnea
B.It can be used in hypotensive patients too unstable for computed tomography scan -
ansWhich of the following is true about use of the focused assessment sonography for
trauma exam for a patient with abdominal trauma?
A.It has a higher sensitivity than diagnostic peritoneal lavage for fluid detection
B.It can be used in hypotensive patients too unstable for computed tomography scan
C.It can detect as little as 30 mL of fluid in the abdominal cavity
D.It has high sensitivity in pediatric patients for identifying fluid in the peritoneum
B.Loss of reflexes - ansA patient is diagnosed with a T12 spinal cord injury following a
20-foot fall. Which finding is consistent with spinal shock?
A.Bradycardia
B.Loss of reflexes
C.Widened pulse pressure
D.Warm skin
B.Maintaining spinal motion restriction - ansWhat is the priority intervention for a child
who has been diagnosed with an atlanto-occipital dislocation following a high-speed
motor vehicle collision?
A.Initiating a second large caliber intravenous line
B.Maintaining spinal motion restriction
C.Placing the patient on pulse oximetry
D.Turning the patient to remove the backboard
B.Medical history including current medications - ansWhat is the most important
consideration during the initial assessment when caring for an older adult who has
sustained serious injuries?
A.They are likely to be fearful in the emergency department
B.Medical history including current medications
C.Availability of support systems after discharge
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
B.During the secondary survey
C.Should only be done at a burn center
D.During the primary survey
B.Increased oxygen consumption - ansA trauma patient who is 30-weeks pregnant
arrives at the emergency department following a motor vehicle collision. Which normal
physiologic change should be considered when assessing ventilatory status?
A.Increased functional reserve capacity
B.Increased oxygen consumption
C.Decreased minute ventilation
D.Slower desaturation rates with apnea
B.It can be used in hypotensive patients too unstable for computed tomography scan -
ansWhich of the following is true about use of the focused assessment sonography for
trauma exam for a patient with abdominal trauma?
A.It has a higher sensitivity than diagnostic peritoneal lavage for fluid detection
B.It can be used in hypotensive patients too unstable for computed tomography scan
C.It can detect as little as 30 mL of fluid in the abdominal cavity
D.It has high sensitivity in pediatric patients for identifying fluid in the peritoneum
B.Loss of reflexes - ansA patient is diagnosed with a T12 spinal cord injury following a
20-foot fall. Which finding is consistent with spinal shock?
A.Bradycardia
B.Loss of reflexes
C.Widened pulse pressure
D.Warm skin
B.Maintaining spinal motion restriction - ansWhat is the priority intervention for a child
who has been diagnosed with an atlanto-occipital dislocation following a high-speed
motor vehicle collision?
A.Initiating a second large caliber intravenous line
B.Maintaining spinal motion restriction
C.Placing the patient on pulse oximetry
D.Turning the patient to remove the backboard
B.Medical history including current medications - ansWhat is the most important
consideration during the initial assessment when caring for an older adult who has
sustained serious injuries?
A.They are likely to be fearful in the emergency department
B.Medical history including current medications
C.Availability of support systems after discharge
Loading page 5...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
D.Accessibility to a primary care physician
B.Notify the provider of the change - ansYour patient is a pedestrian struck by a car and
thrown 35 feet. They were unconscious at the scene but became responsive with initial
and subsequent Glasgow Coma Scale (GCS) scores of 13 (E-3, V-4, M-6). The patient
has bilateral subdural hematomas and is awaiting transfer to the ICU. Your next
assessment reveals a GCS of 9 (E-2, V-2, M-5). What is the priority nursing
intervention?
A.Hold all pain medications
B.Notify the provider of the change
C.Repeat the GCS in 30 minutes
D.Place the patient in Trendelenburg position
blankets, room temp increase, warmed fluids, warming lights - ansIn Step 16 of
"Exposure and Environment", you must name at least one of these interventions:
bony deformity, loose teeth, edema, inhalation injury, sounds, tongue obstruction,
burns, fluids, foreign objects, vocalization - ansFour of these must be identified to
assess patency and protection of the airway:
Bowel sounds heard in the left lower chest - ansA patient involved in a high-speed
rollover is complaining of increased difficulty breathing. There is a small penetrating
wound to the sixth intercostal space in the left lateral chest. Which finding is most
consistent with an injury to the diaphragm?
A.Severe left-sided abdominal pain
B.Bowel sounds heard in the left lower chest
C.Pain radiating to the left shoulder.
D.Decreased breath sounds on the left side
Breath sounds, depth/pattern/rate, spontaneous breathing, subcutaneous emphysema,
increased work of breathing, symmetrical chest rise and fall, tracheal deviation/JVD,
open wounds/deformities, skin color - ansFour of these must be identified to assess
breathing effectiveness:
C.3240 mL - ansA patient who weighs 120 kg is brought to the emergency department
after sustaining partial thickness burns to both upper extremities and chest with a total
body surface area burned of 27%. How much intravenous fluid should be administered
in the first 8 hours?
A.1620 mL
B.2160 mL
C.3240 mL
D.6480 mL
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
D.Accessibility to a primary care physician
B.Notify the provider of the change - ansYour patient is a pedestrian struck by a car and
thrown 35 feet. They were unconscious at the scene but became responsive with initial
and subsequent Glasgow Coma Scale (GCS) scores of 13 (E-3, V-4, M-6). The patient
has bilateral subdural hematomas and is awaiting transfer to the ICU. Your next
assessment reveals a GCS of 9 (E-2, V-2, M-5). What is the priority nursing
intervention?
A.Hold all pain medications
B.Notify the provider of the change
C.Repeat the GCS in 30 minutes
D.Place the patient in Trendelenburg position
blankets, room temp increase, warmed fluids, warming lights - ansIn Step 16 of
"Exposure and Environment", you must name at least one of these interventions:
bony deformity, loose teeth, edema, inhalation injury, sounds, tongue obstruction,
burns, fluids, foreign objects, vocalization - ansFour of these must be identified to
assess patency and protection of the airway:
Bowel sounds heard in the left lower chest - ansA patient involved in a high-speed
rollover is complaining of increased difficulty breathing. There is a small penetrating
wound to the sixth intercostal space in the left lateral chest. Which finding is most
consistent with an injury to the diaphragm?
A.Severe left-sided abdominal pain
B.Bowel sounds heard in the left lower chest
C.Pain radiating to the left shoulder.
D.Decreased breath sounds on the left side
Breath sounds, depth/pattern/rate, spontaneous breathing, subcutaneous emphysema,
increased work of breathing, symmetrical chest rise and fall, tracheal deviation/JVD,
open wounds/deformities, skin color - ansFour of these must be identified to assess
breathing effectiveness:
C.3240 mL - ansA patient who weighs 120 kg is brought to the emergency department
after sustaining partial thickness burns to both upper extremities and chest with a total
body surface area burned of 27%. How much intravenous fluid should be administered
in the first 8 hours?
A.1620 mL
B.2160 mL
C.3240 mL
D.6480 mL
Loading page 6...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
C.Allowing family to participate in the care of the patient - ansWhile caring for a child
who has been injured, what nursing intervention is consistent with a family-center
approach?
A.Identifying a single family member to speak with
B.Having the family make all the care decisions
C.Allowing family to participate in the care of the patient
D.Limiting dissemination of complex information
C.Apply direct pressure to the wound - ansA patient has uncontrolled bleeding from a
wound to his right upper extremity. What is the priority intervention?
A.Initiate two intravenous access sites
B.Place the patient on supplemental oxygen
C.Apply direct pressure to the wound
D.Use a tourniquet to control the bleeding
C.Decreased body temperature - ansA severely injured patient has been intubated and
is being mechanically ventilated. The patient has received a balanced resuscitation
including multiple blood products. Under which circumstance will it be harder for the
hemoglobin to release oxygen to the tissues?
A.Decreased pH
B.Elevated carbon dioxide level
C.Decreased body temperature
D.Increased metabolic demand
C.Decreased respiratory effort - ansWhich of the following is a late sign of increased
intracranial pressure?
A.Restlessness
B.Vomiting
C.Decreased respiratory effort
D.Narrowing pulse pressure
C.Disseminated intravascular coagulopathy - ansA trauma patient is being held in the
emergency department because there are no available inpatient beds. The patient
sustained a femur fracture and required multiple blood products. The patient now has
blood oozing from abrasions, IV sites, the nose, and gums. What condition is most
consistent with these findings?
A.Rhabdomyolysis
B.Fat embolism
C.Disseminated intravascular coagulopathy
D.Multiple organ dysfunctions syndrome
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
C.Allowing family to participate in the care of the patient - ansWhile caring for a child
who has been injured, what nursing intervention is consistent with a family-center
approach?
A.Identifying a single family member to speak with
B.Having the family make all the care decisions
C.Allowing family to participate in the care of the patient
D.Limiting dissemination of complex information
C.Apply direct pressure to the wound - ansA patient has uncontrolled bleeding from a
wound to his right upper extremity. What is the priority intervention?
A.Initiate two intravenous access sites
B.Place the patient on supplemental oxygen
C.Apply direct pressure to the wound
D.Use a tourniquet to control the bleeding
C.Decreased body temperature - ansA severely injured patient has been intubated and
is being mechanically ventilated. The patient has received a balanced resuscitation
including multiple blood products. Under which circumstance will it be harder for the
hemoglobin to release oxygen to the tissues?
A.Decreased pH
B.Elevated carbon dioxide level
C.Decreased body temperature
D.Increased metabolic demand
C.Decreased respiratory effort - ansWhich of the following is a late sign of increased
intracranial pressure?
A.Restlessness
B.Vomiting
C.Decreased respiratory effort
D.Narrowing pulse pressure
C.Disseminated intravascular coagulopathy - ansA trauma patient is being held in the
emergency department because there are no available inpatient beds. The patient
sustained a femur fracture and required multiple blood products. The patient now has
blood oozing from abrasions, IV sites, the nose, and gums. What condition is most
consistent with these findings?
A.Rhabdomyolysis
B.Fat embolism
C.Disseminated intravascular coagulopathy
D.Multiple organ dysfunctions syndrome
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TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
C.Dressing removal - ansA patient arrives with a large open chest wound after being
assaulted with a machete. Prehospital providers placed a nonporous dressing over the
chest wound and taped it on three sides. The patient is now showing signs of anxiety,
restlessness, severe respiratory distress, cyanosis, and decreasing blood pressure.
Which of the following is the MOST appropriate immediate intervention?
A.Needle decompression
B.Tube thoracostomy
C.Dressing removal
D.Surgical repair
C.Elevating the leg to the level of the heart - ansA patient with a lower extremity fracture
complains of severe pain and tightness in his calf, minimally relieved by pain
medications. Which of the following is the priority nursing intervention?
A.Elevating the leg above the level of the heart
B.Repositioning the leg and applying ice
C.Elevating the leg to the level of the heart
D.Preparing the patient for ultrasound of the leg
C.Expedite transfer to the closest trauma center - ansAn adult patient involved in a
motor vehicle collision is brought to the emergency department of a rural critical access
facility. They complain of neck pain, shortness of breath, and diffuse abdominal pain.
The Glasgow Coma Score is 15. Vital signs are: BP 98/71 mm Hg, HR 125
beats/minute, RR 26 breaths/minute, and SpO2 94% on high-flow oxygen via non-
rebreather mask. Which of the following is the priority intervention for this patient?
A.Expedite transport to the CT scanner
B.Prepare the patient for spinal radiographs
C.Expedite transfer to the closest trauma center
D.Notify the patient's family
C.Gauges end-organ perfusion and tissue hypoxia - ansWhat is the rationale for
obtaining a serum lactate level during the initial assessment of a trauma patient?
A.Measures oxygenation and ventilation
B.Assesses the degree of alkalosis and base deficit
C.Gauges end-organ perfusion and tissue hypoxia
D.Determines the underlying cause of shock
C.Increasing work of breathing - ansThe trauma nurse is caring for an unrestrained
driver who struck their head on the windshield following a high-speed MVC. The patient
has been diagnosed with an anterior spinal cord injury at the level of C6. Which
assessment finding would be most concerning?
A.Distension of the bladder
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
C.Dressing removal - ansA patient arrives with a large open chest wound after being
assaulted with a machete. Prehospital providers placed a nonporous dressing over the
chest wound and taped it on three sides. The patient is now showing signs of anxiety,
restlessness, severe respiratory distress, cyanosis, and decreasing blood pressure.
Which of the following is the MOST appropriate immediate intervention?
A.Needle decompression
B.Tube thoracostomy
C.Dressing removal
D.Surgical repair
C.Elevating the leg to the level of the heart - ansA patient with a lower extremity fracture
complains of severe pain and tightness in his calf, minimally relieved by pain
medications. Which of the following is the priority nursing intervention?
A.Elevating the leg above the level of the heart
B.Repositioning the leg and applying ice
C.Elevating the leg to the level of the heart
D.Preparing the patient for ultrasound of the leg
C.Expedite transfer to the closest trauma center - ansAn adult patient involved in a
motor vehicle collision is brought to the emergency department of a rural critical access
facility. They complain of neck pain, shortness of breath, and diffuse abdominal pain.
The Glasgow Coma Score is 15. Vital signs are: BP 98/71 mm Hg, HR 125
beats/minute, RR 26 breaths/minute, and SpO2 94% on high-flow oxygen via non-
rebreather mask. Which of the following is the priority intervention for this patient?
A.Expedite transport to the CT scanner
B.Prepare the patient for spinal radiographs
C.Expedite transfer to the closest trauma center
D.Notify the patient's family
C.Gauges end-organ perfusion and tissue hypoxia - ansWhat is the rationale for
obtaining a serum lactate level during the initial assessment of a trauma patient?
A.Measures oxygenation and ventilation
B.Assesses the degree of alkalosis and base deficit
C.Gauges end-organ perfusion and tissue hypoxia
D.Determines the underlying cause of shock
C.Increasing work of breathing - ansThe trauma nurse is caring for an unrestrained
driver who struck their head on the windshield following a high-speed MVC. The patient
has been diagnosed with an anterior spinal cord injury at the level of C6. Which
assessment finding would be most concerning?
A.Distension of the bladder
Loading page 8...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
B.Incontinence of stool
C.Increasing work of breathing
D.Inability to move the legs
C.Inotropic support - ansA driver involved in a high-speed motor vehicle collision arrives
in the emergency department. The vehicle's air-bag failed to deploy. The patient is
drowsy but arousable and complaining of chest pain with ecchymosis noted to the
chest. The patient is tachycardic and hypotensive with no evidence of uncontrolled
bleeding. Cardiac monitor shows premature ventricular contractions. Which of the
following is the most appropriate intervention for this patient?
A.Rapid fluid boluses
B.Tranexamic acid administration
C.Inotropic support
D.Hemostatic resuscitation
C.Liver - ansYour patient was the unrestrained driver involved in a moderate speed
motor vehicle collision. Assessment reveals tenderness in the upper right quadrant,
crepitus in the lower right ribs, and ecchymosis around the umbilicus. The nurse is
concerned about injury to which organ?
A.Transverse colon
B.Pancreas
C.Liver
D.Spleen
C.Ramped - ansAn obese trauma patient requires intubation. Assuming there are no
contraindications, which position will provide the best visualization for insertion of the
endotracheal tube?
A.Reverse Trendelenburg
B.Lying on side
C.Ramped
D.Supine
C.Tertiary - ansAn adult was thrown against a concrete wall during a factory explosion
and sustained a femur fracture, liver laceration, and a small subdural hematoma. These
injuries most likely occurred during what level of blast trauma?
A.Primary
B.Secondary
C.Tertiary
D.Quaternary
C.Use a jaw thrust to open the airway and look for signs of obstruction. - ansAn adult
patient was brought to the emergency department following a motorcycle crash. On
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
B.Incontinence of stool
C.Increasing work of breathing
D.Inability to move the legs
C.Inotropic support - ansA driver involved in a high-speed motor vehicle collision arrives
in the emergency department. The vehicle's air-bag failed to deploy. The patient is
drowsy but arousable and complaining of chest pain with ecchymosis noted to the
chest. The patient is tachycardic and hypotensive with no evidence of uncontrolled
bleeding. Cardiac monitor shows premature ventricular contractions. Which of the
following is the most appropriate intervention for this patient?
A.Rapid fluid boluses
B.Tranexamic acid administration
C.Inotropic support
D.Hemostatic resuscitation
C.Liver - ansYour patient was the unrestrained driver involved in a moderate speed
motor vehicle collision. Assessment reveals tenderness in the upper right quadrant,
crepitus in the lower right ribs, and ecchymosis around the umbilicus. The nurse is
concerned about injury to which organ?
A.Transverse colon
B.Pancreas
C.Liver
D.Spleen
C.Ramped - ansAn obese trauma patient requires intubation. Assuming there are no
contraindications, which position will provide the best visualization for insertion of the
endotracheal tube?
A.Reverse Trendelenburg
B.Lying on side
C.Ramped
D.Supine
C.Tertiary - ansAn adult was thrown against a concrete wall during a factory explosion
and sustained a femur fracture, liver laceration, and a small subdural hematoma. These
injuries most likely occurred during what level of blast trauma?
A.Primary
B.Secondary
C.Tertiary
D.Quaternary
C.Use a jaw thrust to open the airway and look for signs of obstruction. - ansAn adult
patient was brought to the emergency department following a motorcycle crash. On
Loading page 9...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
arrival, the patient is only responsive to pain, has bleeding from the nose, and multiple
abrasions and contusions to the face. What is the priority intervention?
A.Use a bulb syringe to suction out secretions from the mouth.
B.Insert a nasopharyngeal airway to maintain an open airway.
C.Use a jaw thrust to open the airway and look for signs of obstruction.
D.Ask the patient to open their mouth to inspect the airway.
cardiac monitor - ansWhat can be applied in step 12 of "Circulation and Control of
Hemorrhage" for which credit is given in the LMNOP section?
D.Assist ventilation with a bag-mask device - ansFollowing a gun shot wound, pre-
hospital providers report diminished breath sounds bilaterally. Upon emergency
department arrival, the patient is unresponsive with shallow respirations and an O2 sat
of 88%. What is the priority intervention for this patient?
A.Administer 15 L oxygen via nonrebreather mask
B.Attach patient to a CO2 detector
C.Prepare for a definitive airway
D.Assist ventilation with a bag-mask device
D.Coagulopathy - ansA patient who sustained severe injuries was brought to the
emergency department following a high-speed motor vehicle collision. Interventions for
hypovolemic shock have been initiated. What component of the trauma triad of death is
most likely to have begun at the time of injury?
A.Acidosis
B.Hypothermia
C.Hypocalcemia
D.Coagulopathy
D.Gently rewarm over 15 to 30 minutes - ansA patient arrives following prolonged
exposure of their left hand to the cold. The patient is awake and alert and complains of
a tingling sensation to the fingers. Assessment reveals swelling and bright red skin to
the left hand and a 1-inch round clear blister to the dorsum of that hand. Which of the
following nursing interventions is most appropriate for this patient?
A.Massage the injured areas to promote circulation
B.Drain and debride the blister on the hand
C.Immerse in water between 37.5oC and 39.5oC (99.5oF to 103.1oF).
D.Gently rewarm over 15 to 30 minutes
D.Insert an oropharyngeal airway if there is no gag reflex - ansDuring the primary
survey of an unconscious patient with multi-system trauma, the nurse notes snoring
respirations. Which priority nursing intervention should be performed next?
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
arrival, the patient is only responsive to pain, has bleeding from the nose, and multiple
abrasions and contusions to the face. What is the priority intervention?
A.Use a bulb syringe to suction out secretions from the mouth.
B.Insert a nasopharyngeal airway to maintain an open airway.
C.Use a jaw thrust to open the airway and look for signs of obstruction.
D.Ask the patient to open their mouth to inspect the airway.
cardiac monitor - ansWhat can be applied in step 12 of "Circulation and Control of
Hemorrhage" for which credit is given in the LMNOP section?
D.Assist ventilation with a bag-mask device - ansFollowing a gun shot wound, pre-
hospital providers report diminished breath sounds bilaterally. Upon emergency
department arrival, the patient is unresponsive with shallow respirations and an O2 sat
of 88%. What is the priority intervention for this patient?
A.Administer 15 L oxygen via nonrebreather mask
B.Attach patient to a CO2 detector
C.Prepare for a definitive airway
D.Assist ventilation with a bag-mask device
D.Coagulopathy - ansA patient who sustained severe injuries was brought to the
emergency department following a high-speed motor vehicle collision. Interventions for
hypovolemic shock have been initiated. What component of the trauma triad of death is
most likely to have begun at the time of injury?
A.Acidosis
B.Hypothermia
C.Hypocalcemia
D.Coagulopathy
D.Gently rewarm over 15 to 30 minutes - ansA patient arrives following prolonged
exposure of their left hand to the cold. The patient is awake and alert and complains of
a tingling sensation to the fingers. Assessment reveals swelling and bright red skin to
the left hand and a 1-inch round clear blister to the dorsum of that hand. Which of the
following nursing interventions is most appropriate for this patient?
A.Massage the injured areas to promote circulation
B.Drain and debride the blister on the hand
C.Immerse in water between 37.5oC and 39.5oC (99.5oF to 103.1oF).
D.Gently rewarm over 15 to 30 minutes
D.Insert an oropharyngeal airway if there is no gag reflex - ansDuring the primary
survey of an unconscious patient with multi-system trauma, the nurse notes snoring
respirations. Which priority nursing intervention should be performed next?
Loading page 10...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
A.Open the airway with the head-tilt/chin-lift maneuver
B.Auscultate bilateral breath sounds
C.Assist respirations using a bag-mask device
D.Insert an oropharyngeal airway if there is no gag reflex
D.Moral injury - ansA nurse verbalizes guilt and remorse after caring for multiple
severely injured patients during a staffing crisis. The nurse expresses anger stating that
the patients did not receive quality care and begins exhibiting aggression toward
colleagues. This is most consistent with which condition?
A.Compassion fatigue
B.Vicarious trauma
C.Secondary traumatic stress
D.Moral injury
D.Prepare the patient for surgery to remove the rod. - ansA patient arrives with a large
metal rod embedded in their left thigh and no active bleeding. Which intervention is
most appropriate for this patient?
A.Remove the rod immediately to facilitate cleansing.
B.Apply a tourniquet to the leg above the metal rod.
C.Hold antibiotics until after the rod is removed.
D.Prepare the patient for surgery to remove the rod.
D.Widening pulse pressure - ansA patient with a traumatic brain injury has a mean
arterial pressure (MAP) of 65 mm Hg (8.66 kPa) and an intracranial pressure (ICP) of
22 mm Hg (2.93 kPa). Which finding is most likely an indication of the body's response
to these findings?
A.Reflex hypotension
B.Increased respiratory effort
C.Reflex tachycardia
D.Widening pulse pressure
Distraction, family presence, padding bony prominences, repositioning, splinting, verbal
reassurance - ansWhat are examples of nonpharmacologic measures? (must identify at
least one during testing)
During "Circulation" assessment - ansWhen should 2 IV sites be established?
EKG - ansIn step M of "Get Adjuncts", what else might be indicated besides cardiac
monitor?
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
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
A.Open the airway with the head-tilt/chin-lift maneuver
B.Auscultate bilateral breath sounds
C.Assist respirations using a bag-mask device
D.Insert an oropharyngeal airway if there is no gag reflex
D.Moral injury - ansA nurse verbalizes guilt and remorse after caring for multiple
severely injured patients during a staffing crisis. The nurse expresses anger stating that
the patients did not receive quality care and begins exhibiting aggression toward
colleagues. This is most consistent with which condition?
A.Compassion fatigue
B.Vicarious trauma
C.Secondary traumatic stress
D.Moral injury
D.Prepare the patient for surgery to remove the rod. - ansA patient arrives with a large
metal rod embedded in their left thigh and no active bleeding. Which intervention is
most appropriate for this patient?
A.Remove the rod immediately to facilitate cleansing.
B.Apply a tourniquet to the leg above the metal rod.
C.Hold antibiotics until after the rod is removed.
D.Prepare the patient for surgery to remove the rod.
D.Widening pulse pressure - ansA patient with a traumatic brain injury has a mean
arterial pressure (MAP) of 65 mm Hg (8.66 kPa) and an intracranial pressure (ICP) of
22 mm Hg (2.93 kPa). Which finding is most likely an indication of the body's response
to these findings?
A.Reflex hypotension
B.Increased respiratory effort
C.Reflex tachycardia
D.Widening pulse pressure
Distraction, family presence, padding bony prominences, repositioning, splinting, verbal
reassurance - ansWhat are examples of nonpharmacologic measures? (must identify at
least one during testing)
During "Circulation" assessment - ansWhen should 2 IV sites be established?
EKG - ansIn step M of "Get Adjuncts", what else might be indicated besides cardiac
monitor?
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
Loading page 11...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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.
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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.
Loading page 12...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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
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
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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
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
Loading page 13...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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:
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
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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:
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
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TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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
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?
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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
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?
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TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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?
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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?
Loading page 16...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
A.Check for a patent airway
B.Control the bleeding
C.Start a second intravenous line
D.Ventilate with a bag-mask device
B.During the secondary surveyt - ansWhen should the definitive calculation for
intravenous fluid resuscitation rate be performed for a patient with burns?
A.As soon as the patient arrives
B.During the secondary survey
C.Should only be done at a burn center
D.During the primary survey
B.Increased oxygen consumption - ansA trauma patient who is 30-weeks pregnant
arrives at the emergency department following a motor vehicle collision. Which normal
physiologic change should be considered when assessing ventilatory status?
A.Increased functional reserve capacity
B.Increased oxygen consumption
C.Decreased minute ventilation
D.Slower desaturation rates with apnea
B.It can be used in hypotensive patients too unstable for computed tomography scan -
ansWhich of the following is true about use of the focused assessment sonography for
trauma exam for a patient with abdominal trauma?
A.It has a higher sensitivity than diagnostic peritoneal lavage for fluid detection
B.It can be used in hypotensive patients too unstable for computed tomography scan
C.It can detect as little as 30 mL of fluid in the abdominal cavity
D.It has high sensitivity in pediatric patients for identifying fluid in the peritoneum
B.Loss of reflexes - ansA patient is diagnosed with a T12 spinal cord injury following a
20-foot fall. Which finding is consistent with spinal shock?
A.Bradycardia
B.Loss of reflexes
C.Widened pulse pressure
D.Warm skin
B.Maintaining spinal motion restriction - ansWhat is the priority intervention for a child
who has been diagnosed with an atlanto-occipital dislocation following a high-speed
motor vehicle collision?
A.Initiating a second large caliber intravenous line
B.Maintaining spinal motion restriction
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
A.Check for a patent airway
B.Control the bleeding
C.Start a second intravenous line
D.Ventilate with a bag-mask device
B.During the secondary surveyt - ansWhen should the definitive calculation for
intravenous fluid resuscitation rate be performed for a patient with burns?
A.As soon as the patient arrives
B.During the secondary survey
C.Should only be done at a burn center
D.During the primary survey
B.Increased oxygen consumption - ansA trauma patient who is 30-weeks pregnant
arrives at the emergency department following a motor vehicle collision. Which normal
physiologic change should be considered when assessing ventilatory status?
A.Increased functional reserve capacity
B.Increased oxygen consumption
C.Decreased minute ventilation
D.Slower desaturation rates with apnea
B.It can be used in hypotensive patients too unstable for computed tomography scan -
ansWhich of the following is true about use of the focused assessment sonography for
trauma exam for a patient with abdominal trauma?
A.It has a higher sensitivity than diagnostic peritoneal lavage for fluid detection
B.It can be used in hypotensive patients too unstable for computed tomography scan
C.It can detect as little as 30 mL of fluid in the abdominal cavity
D.It has high sensitivity in pediatric patients for identifying fluid in the peritoneum
B.Loss of reflexes - ansA patient is diagnosed with a T12 spinal cord injury following a
20-foot fall. Which finding is consistent with spinal shock?
A.Bradycardia
B.Loss of reflexes
C.Widened pulse pressure
D.Warm skin
B.Maintaining spinal motion restriction - ansWhat is the priority intervention for a child
who has been diagnosed with an atlanto-occipital dislocation following a high-speed
motor vehicle collision?
A.Initiating a second large caliber intravenous line
B.Maintaining spinal motion restriction
Loading page 17...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
C.Placing the patient on pulse oximetry
D.Turning the patient to remove the backboard
B.Medical history including current medications - ansWhat is the most important
consideration during the initial assessment when caring for an older adult who has
sustained serious injuries?
A.They are likely to be fearful in the emergency department
B.Medical history including current medications
C.Availability of support systems after discharge
D.Accessibility to a primary care physician
B.Notify the provider of the change - ansYour patient is a pedestrian struck by a car and
thrown 35 feet. They were unconscious at the scene but became responsive with initial
and subsequent Glasgow Coma Scale (GCS) scores of 13 (E-3, V-4, M-6). The patient
has bilateral subdural hematomas and is awaiting transfer to the ICU. Your next
assessment reveals a GCS of 9 (E-2, V-2, M-5). What is the priority nursing
intervention?
A.Hold all pain medications
B.Notify the provider of the change
C.Repeat the GCS in 30 minutes
D.Place the patient in Trendelenburg position
blankets, room temp increase, warmed fluids, warming lights - ansIn Step 16 of
"Exposure and Environment", you must name at least one of these interventions:
bony deformity, loose teeth, edema, inhalation injury, sounds, tongue obstruction,
burns, fluids, foreign objects, vocalization - ansFour of these must be identified to
assess patency and protection of the airway:
Bowel sounds heard in the left lower chest - ansA patient involved in a high-speed
rollover is complaining of increased difficulty breathing. There is a small penetrating
wound to the sixth intercostal space in the left lateral chest. Which finding is most
consistent with an injury to the diaphragm?
A.Severe left-sided abdominal pain
B.Bowel sounds heard in the left lower chest
C.Pain radiating to the left shoulder.
D.Decreased breath sounds on the left side
Breath sounds, depth/pattern/rate, spontaneous breathing, subcutaneous emphysema,
increased work of breathing, symmetrical chest rise and fall, tracheal deviation/JVD,
open wounds/deformities, skin color - ansFour of these must be identified to assess
breathing effectiveness:
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
C.Placing the patient on pulse oximetry
D.Turning the patient to remove the backboard
B.Medical history including current medications - ansWhat is the most important
consideration during the initial assessment when caring for an older adult who has
sustained serious injuries?
A.They are likely to be fearful in the emergency department
B.Medical history including current medications
C.Availability of support systems after discharge
D.Accessibility to a primary care physician
B.Notify the provider of the change - ansYour patient is a pedestrian struck by a car and
thrown 35 feet. They were unconscious at the scene but became responsive with initial
and subsequent Glasgow Coma Scale (GCS) scores of 13 (E-3, V-4, M-6). The patient
has bilateral subdural hematomas and is awaiting transfer to the ICU. Your next
assessment reveals a GCS of 9 (E-2, V-2, M-5). What is the priority nursing
intervention?
A.Hold all pain medications
B.Notify the provider of the change
C.Repeat the GCS in 30 minutes
D.Place the patient in Trendelenburg position
blankets, room temp increase, warmed fluids, warming lights - ansIn Step 16 of
"Exposure and Environment", you must name at least one of these interventions:
bony deformity, loose teeth, edema, inhalation injury, sounds, tongue obstruction,
burns, fluids, foreign objects, vocalization - ansFour of these must be identified to
assess patency and protection of the airway:
Bowel sounds heard in the left lower chest - ansA patient involved in a high-speed
rollover is complaining of increased difficulty breathing. There is a small penetrating
wound to the sixth intercostal space in the left lateral chest. Which finding is most
consistent with an injury to the diaphragm?
A.Severe left-sided abdominal pain
B.Bowel sounds heard in the left lower chest
C.Pain radiating to the left shoulder.
D.Decreased breath sounds on the left side
Breath sounds, depth/pattern/rate, spontaneous breathing, subcutaneous emphysema,
increased work of breathing, symmetrical chest rise and fall, tracheal deviation/JVD,
open wounds/deformities, skin color - ansFour of these must be identified to assess
breathing effectiveness:
Loading page 18...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
C.3240 mL - ansA patient who weighs 120 kg is brought to the emergency department
after sustaining partial thickness burns to both upper extremities and chest with a total
body surface area burned of 27%. How much intravenous fluid should be administered
in the first 8 hours?
A.1620 mL
B.2160 mL
C.3240 mL
D.6480 mL
C.Allowing family to participate in the care of the patient - ansWhile caring for a child
who has been injured, what nursing intervention is consistent with a family-center
approach?
A.Identifying a single family member to speak with
B.Having the family make all the care decisions
C.Allowing family to participate in the care of the patient
D.Limiting dissemination of complex information
C.Apply direct pressure to the wound - ansA patient has uncontrolled bleeding from a
wound to his right upper extremity. What is the priority intervention?
A.Initiate two intravenous access sites
B.Place the patient on supplemental oxygen
C.Apply direct pressure to the wound
D.Use a tourniquet to control the bleeding
C.Decreased body temperature - ansA severely injured patient has been intubated and
is being mechanically ventilated. The patient has received a balanced resuscitation
including multiple blood products. Under which circumstance will it be harder for the
hemoglobin to release oxygen to the tissues?
A.Decreased pH
B.Elevated carbon dioxide level
C.Decreased body temperature
D.Increased metabolic demand
C.Decreased respiratory effort - ansWhich of the following is a late sign of increased
intracranial pressure?
A.Restlessness
B.Vomiting
C.Decreased respiratory effort
D.Narrowing pulse pressure
C.Disseminated intravascular coagulopathy - ansA trauma patient is being held in the
emergency department because there are no available inpatient beds. The patient
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
C.3240 mL - ansA patient who weighs 120 kg is brought to the emergency department
after sustaining partial thickness burns to both upper extremities and chest with a total
body surface area burned of 27%. How much intravenous fluid should be administered
in the first 8 hours?
A.1620 mL
B.2160 mL
C.3240 mL
D.6480 mL
C.Allowing family to participate in the care of the patient - ansWhile caring for a child
who has been injured, what nursing intervention is consistent with a family-center
approach?
A.Identifying a single family member to speak with
B.Having the family make all the care decisions
C.Allowing family to participate in the care of the patient
D.Limiting dissemination of complex information
C.Apply direct pressure to the wound - ansA patient has uncontrolled bleeding from a
wound to his right upper extremity. What is the priority intervention?
A.Initiate two intravenous access sites
B.Place the patient on supplemental oxygen
C.Apply direct pressure to the wound
D.Use a tourniquet to control the bleeding
C.Decreased body temperature - ansA severely injured patient has been intubated and
is being mechanically ventilated. The patient has received a balanced resuscitation
including multiple blood products. Under which circumstance will it be harder for the
hemoglobin to release oxygen to the tissues?
A.Decreased pH
B.Elevated carbon dioxide level
C.Decreased body temperature
D.Increased metabolic demand
C.Decreased respiratory effort - ansWhich of the following is a late sign of increased
intracranial pressure?
A.Restlessness
B.Vomiting
C.Decreased respiratory effort
D.Narrowing pulse pressure
C.Disseminated intravascular coagulopathy - ansA trauma patient is being held in the
emergency department because there are no available inpatient beds. The patient
Loading page 19...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
sustained a femur fracture and required multiple blood products. The patient now has
blood oozing from abrasions, IV sites, the nose, and gums. What condition is most
consistent with these findings?
A.Rhabdomyolysis
B.Fat embolism
C.Disseminated intravascular coagulopathy
D.Multiple organ dysfunctions syndrome
C.Dressing removal - ansA patient arrives with a large open chest wound after being
assaulted with a machete. Prehospital providers placed a nonporous dressing over the
chest wound and taped it on three sides. The patient is now showing signs of anxiety,
restlessness, severe respiratory distress, cyanosis, and decreasing blood pressure.
Which of the following is the MOST appropriate immediate intervention?
A.Needle decompression
B.Tube thoracostomy
C.Dressing removal
D.Surgical repair
C.Elevating the leg to the level of the heart - ansA patient with a lower extremity fracture
complains of severe pain and tightness in his calf, minimally relieved by pain
medications. Which of the following is the priority nursing intervention?
A.Elevating the leg above the level of the heart
B.Repositioning the leg and applying ice
C.Elevating the leg to the level of the heart
D.Preparing the patient for ultrasound of the leg
C.Expedite transfer to the closest trauma center - ansAn adult patient involved in a
motor vehicle collision is brought to the emergency department of a rural critical access
facility. They complain of neck pain, shortness of breath, and diffuse abdominal pain.
The Glasgow Coma Score is 15. Vital signs are: BP 98/71 mm Hg, HR 125
beats/minute, RR 26 breaths/minute, and SpO2 94% on high-flow oxygen via non-
rebreather mask. Which of the following is the priority intervention for this patient?
A.Expedite transport to the CT scanner
B.Prepare the patient for spinal radiographs
C.Expedite transfer to the closest trauma center
D.Notify the patient's family
C.Gauges end-organ perfusion and tissue hypoxia - ansWhat is the rationale for
obtaining a serum lactate level during the initial assessment of a trauma patient?
A.Measures oxygenation and ventilation
B.Assesses the degree of alkalosis and base deficit
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
sustained a femur fracture and required multiple blood products. The patient now has
blood oozing from abrasions, IV sites, the nose, and gums. What condition is most
consistent with these findings?
A.Rhabdomyolysis
B.Fat embolism
C.Disseminated intravascular coagulopathy
D.Multiple organ dysfunctions syndrome
C.Dressing removal - ansA patient arrives with a large open chest wound after being
assaulted with a machete. Prehospital providers placed a nonporous dressing over the
chest wound and taped it on three sides. The patient is now showing signs of anxiety,
restlessness, severe respiratory distress, cyanosis, and decreasing blood pressure.
Which of the following is the MOST appropriate immediate intervention?
A.Needle decompression
B.Tube thoracostomy
C.Dressing removal
D.Surgical repair
C.Elevating the leg to the level of the heart - ansA patient with a lower extremity fracture
complains of severe pain and tightness in his calf, minimally relieved by pain
medications. Which of the following is the priority nursing intervention?
A.Elevating the leg above the level of the heart
B.Repositioning the leg and applying ice
C.Elevating the leg to the level of the heart
D.Preparing the patient for ultrasound of the leg
C.Expedite transfer to the closest trauma center - ansAn adult patient involved in a
motor vehicle collision is brought to the emergency department of a rural critical access
facility. They complain of neck pain, shortness of breath, and diffuse abdominal pain.
The Glasgow Coma Score is 15. Vital signs are: BP 98/71 mm Hg, HR 125
beats/minute, RR 26 breaths/minute, and SpO2 94% on high-flow oxygen via non-
rebreather mask. Which of the following is the priority intervention for this patient?
A.Expedite transport to the CT scanner
B.Prepare the patient for spinal radiographs
C.Expedite transfer to the closest trauma center
D.Notify the patient's family
C.Gauges end-organ perfusion and tissue hypoxia - ansWhat is the rationale for
obtaining a serum lactate level during the initial assessment of a trauma patient?
A.Measures oxygenation and ventilation
B.Assesses the degree of alkalosis and base deficit
Loading page 20...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
C.Gauges end-organ perfusion and tissue hypoxia
D.Determines the underlying cause of shock
C.Increasing work of breathing - ansThe trauma nurse is caring for an unrestrained
driver who struck their head on the windshield following a high-speed MVC. The patient
has been diagnosed with an anterior spinal cord injury at the level of C6. Which
assessment finding would be most concerning?
A.Distension of the bladder
B.Incontinence of stool
C.Increasing work of breathing
D.Inability to move the legs
C.Inotropic support - ansA driver involved in a high-speed motor vehicle collision arrives
in the emergency department. The vehicle's air-bag failed to deploy. The patient is
drowsy but arousable and complaining of chest pain with ecchymosis noted to the
chest. The patient is tachycardic and hypotensive with no evidence of uncontrolled
bleeding. Cardiac monitor shows premature ventricular contractions. Which of the
following is the most appropriate intervention for this patient?
A.Rapid fluid boluses
B.Tranexamic acid administration
C.Inotropic support
D.Hemostatic resuscitation
C.Liver - ansYour patient was the unrestrained driver involved in a moderate speed
motor vehicle collision. Assessment reveals tenderness in the upper right quadrant,
crepitus in the lower right ribs, and ecchymosis around the umbilicus. The nurse is
concerned about injury to which organ?
A.Transverse colon
B.Pancreas
C.Liver
D.Spleen
C.Ramped - ansAn obese trauma patient requires intubation. Assuming there are no
contraindications, which position will provide the best visualization for insertion of the
endotracheal tube?
A.Reverse Trendelenburg
B.Lying on side
C.Ramped
D.Supine
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
C.Gauges end-organ perfusion and tissue hypoxia
D.Determines the underlying cause of shock
C.Increasing work of breathing - ansThe trauma nurse is caring for an unrestrained
driver who struck their head on the windshield following a high-speed MVC. The patient
has been diagnosed with an anterior spinal cord injury at the level of C6. Which
assessment finding would be most concerning?
A.Distension of the bladder
B.Incontinence of stool
C.Increasing work of breathing
D.Inability to move the legs
C.Inotropic support - ansA driver involved in a high-speed motor vehicle collision arrives
in the emergency department. The vehicle's air-bag failed to deploy. The patient is
drowsy but arousable and complaining of chest pain with ecchymosis noted to the
chest. The patient is tachycardic and hypotensive with no evidence of uncontrolled
bleeding. Cardiac monitor shows premature ventricular contractions. Which of the
following is the most appropriate intervention for this patient?
A.Rapid fluid boluses
B.Tranexamic acid administration
C.Inotropic support
D.Hemostatic resuscitation
C.Liver - ansYour patient was the unrestrained driver involved in a moderate speed
motor vehicle collision. Assessment reveals tenderness in the upper right quadrant,
crepitus in the lower right ribs, and ecchymosis around the umbilicus. The nurse is
concerned about injury to which organ?
A.Transverse colon
B.Pancreas
C.Liver
D.Spleen
C.Ramped - ansAn obese trauma patient requires intubation. Assuming there are no
contraindications, which position will provide the best visualization for insertion of the
endotracheal tube?
A.Reverse Trendelenburg
B.Lying on side
C.Ramped
D.Supine
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TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
C.Tertiary - ansAn adult was thrown against a concrete wall during a factory explosion
and sustained a femur fracture, liver laceration, and a small subdural hematoma. These
injuries most likely occurred during what level of blast trauma?
A.Primary
B.Secondary
C.Tertiary
D.Quaternary
C.Use a jaw thrust to open the airway and look for signs of obstruction. - ansAn adult
patient was brought to the emergency department following a motorcycle crash. On
arrival, the patient is only responsive to pain, has bleeding from the nose, and multiple
abrasions and contusions to the face. What is the priority intervention?
A.Use a bulb syringe to suction out secretions from the mouth.
B.Insert a nasopharyngeal airway to maintain an open airway.
C.Use a jaw thrust to open the airway and look for signs of obstruction.
D.Ask the patient to open their mouth to inspect the airway.
cardiac monitor - ansWhat can be applied in step 12 of "Circulation and Control of
Hemorrhage" for which credit is given in the LMNOP section?
D.Assist ventilation with a bag-mask device - ansFollowing a gun shot wound, pre-
hospital providers report diminished breath sounds bilaterally. Upon emergency
department arrival, the patient is unresponsive with shallow respirations and an O2 sat
of 88%. What is the priority intervention for this patient?
A.Administer 15 L oxygen via nonrebreather mask
B.Attach patient to a CO2 detector
C.Prepare for a definitive airway
D.Assist ventilation with a bag-mask device
D.Coagulopathy - ansA patient who sustained severe injuries was brought to the
emergency department following a high-speed motor vehicle collision. Interventions for
hypovolemic shock have been initiated. What component of the trauma triad of death is
most likely to have begun at the time of injury?
A.Acidosis
B.Hypothermia
C.Hypocalcemia
D.Coagulopathy
D.Gently rewarm over 15 to 30 minutes - ansA patient arrives following prolonged
exposure of their left hand to the cold. The patient is awake and alert and complains of
a tingling sensation to the fingers. Assessment reveals swelling and bright red skin to
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
C.Tertiary - ansAn adult was thrown against a concrete wall during a factory explosion
and sustained a femur fracture, liver laceration, and a small subdural hematoma. These
injuries most likely occurred during what level of blast trauma?
A.Primary
B.Secondary
C.Tertiary
D.Quaternary
C.Use a jaw thrust to open the airway and look for signs of obstruction. - ansAn adult
patient was brought to the emergency department following a motorcycle crash. On
arrival, the patient is only responsive to pain, has bleeding from the nose, and multiple
abrasions and contusions to the face. What is the priority intervention?
A.Use a bulb syringe to suction out secretions from the mouth.
B.Insert a nasopharyngeal airway to maintain an open airway.
C.Use a jaw thrust to open the airway and look for signs of obstruction.
D.Ask the patient to open their mouth to inspect the airway.
cardiac monitor - ansWhat can be applied in step 12 of "Circulation and Control of
Hemorrhage" for which credit is given in the LMNOP section?
D.Assist ventilation with a bag-mask device - ansFollowing a gun shot wound, pre-
hospital providers report diminished breath sounds bilaterally. Upon emergency
department arrival, the patient is unresponsive with shallow respirations and an O2 sat
of 88%. What is the priority intervention for this patient?
A.Administer 15 L oxygen via nonrebreather mask
B.Attach patient to a CO2 detector
C.Prepare for a definitive airway
D.Assist ventilation with a bag-mask device
D.Coagulopathy - ansA patient who sustained severe injuries was brought to the
emergency department following a high-speed motor vehicle collision. Interventions for
hypovolemic shock have been initiated. What component of the trauma triad of death is
most likely to have begun at the time of injury?
A.Acidosis
B.Hypothermia
C.Hypocalcemia
D.Coagulopathy
D.Gently rewarm over 15 to 30 minutes - ansA patient arrives following prolonged
exposure of their left hand to the cold. The patient is awake and alert and complains of
a tingling sensation to the fingers. Assessment reveals swelling and bright red skin to
Loading page 22...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
the left hand and a 1-inch round clear blister to the dorsum of that hand. Which of the
following nursing interventions is most appropriate for this patient?
A.Massage the injured areas to promote circulation
B.Drain and debride the blister on the hand
C.Immerse in water between 37.5oC and 39.5oC (99.5oF to 103.1oF).
D.Gently rewarm over 15 to 30 minutes
D.Insert an oropharyngeal airway if there is no gag reflex - ansDuring the primary
survey of an unconscious patient with multi-system trauma, the nurse notes snoring
respirations. Which priority nursing intervention should be performed next?
A.Open the airway with the head-tilt/chin-lift maneuver
B.Auscultate bilateral breath sounds
C.Assist respirations using a bag-mask device
D.Insert an oropharyngeal airway if there is no gag reflex
D.Moral injury - ansA nurse verbalizes guilt and remorse after caring for multiple
severely injured patients during a staffing crisis. The nurse expresses anger stating that
the patients did not receive quality care and begins exhibiting aggression toward
colleagues. This is most consistent with which condition?
A.Compassion fatigue
B.Vicarious trauma
C.Secondary traumatic stress
D.Moral injury
D.Prepare the patient for surgery to remove the rod. - ansA patient arrives with a large
metal rod embedded in their left thigh and no active bleeding. Which intervention is
most appropriate for this patient?
A.Remove the rod immediately to facilitate cleansing.
B.Apply a tourniquet to the leg above the metal rod.
C.Hold antibiotics until after the rod is removed.
D.Prepare the patient for surgery to remove the rod.
D.Widening pulse pressure - ansA patient with a traumatic brain injury has a mean
arterial pressure (MAP) of 65 mm Hg (8.66 kPa) and an intracranial pressure (ICP) of
22 mm Hg (2.93 kPa). Which finding is most likely an indication of the body's response
to these findings?
A.Reflex hypotension
B.Increased respiratory effort
C.Reflex tachycardia
D.Widening pulse pressure
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
the left hand and a 1-inch round clear blister to the dorsum of that hand. Which of the
following nursing interventions is most appropriate for this patient?
A.Massage the injured areas to promote circulation
B.Drain and debride the blister on the hand
C.Immerse in water between 37.5oC and 39.5oC (99.5oF to 103.1oF).
D.Gently rewarm over 15 to 30 minutes
D.Insert an oropharyngeal airway if there is no gag reflex - ansDuring the primary
survey of an unconscious patient with multi-system trauma, the nurse notes snoring
respirations. Which priority nursing intervention should be performed next?
A.Open the airway with the head-tilt/chin-lift maneuver
B.Auscultate bilateral breath sounds
C.Assist respirations using a bag-mask device
D.Insert an oropharyngeal airway if there is no gag reflex
D.Moral injury - ansA nurse verbalizes guilt and remorse after caring for multiple
severely injured patients during a staffing crisis. The nurse expresses anger stating that
the patients did not receive quality care and begins exhibiting aggression toward
colleagues. This is most consistent with which condition?
A.Compassion fatigue
B.Vicarious trauma
C.Secondary traumatic stress
D.Moral injury
D.Prepare the patient for surgery to remove the rod. - ansA patient arrives with a large
metal rod embedded in their left thigh and no active bleeding. Which intervention is
most appropriate for this patient?
A.Remove the rod immediately to facilitate cleansing.
B.Apply a tourniquet to the leg above the metal rod.
C.Hold antibiotics until after the rod is removed.
D.Prepare the patient for surgery to remove the rod.
D.Widening pulse pressure - ansA patient with a traumatic brain injury has a mean
arterial pressure (MAP) of 65 mm Hg (8.66 kPa) and an intracranial pressure (ICP) of
22 mm Hg (2.93 kPa). Which finding is most likely an indication of the body's response
to these findings?
A.Reflex hypotension
B.Increased respiratory effort
C.Reflex tachycardia
D.Widening pulse pressure
Loading page 23...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
Distraction, family presence, padding bony prominences, repositioning, splinting, verbal
reassurance - ansWhat are examples of nonpharmacologic measures? (must identify at
least one during testing)
During "Circulation" assessment - ansWhen should 2 IV sites be established?
EKG - ansIn step M of "Get Adjuncts", what else might be indicated besides cardiac
monitor?
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
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
Distraction, family presence, padding bony prominences, repositioning, splinting, verbal
reassurance - ansWhat are examples of nonpharmacologic measures? (must identify at
least one during testing)
During "Circulation" assessment - ansWhen should 2 IV sites be established?
EKG - ansIn step M of "Get Adjuncts", what else might be indicated besides cardiac
monitor?
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
Loading page 24...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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
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
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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
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
Loading page 25...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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:
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
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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:
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
Loading page 26...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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?
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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?
Loading page 27...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
A.Reverse Trendelenburg
B.Supine
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
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
A.Reverse Trendelenburg
B.Supine
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
Loading page 28...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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
D.Ventilate with a bag-mask device
B.During the secondary surveyt - ansWhen should the definitive calculation for
intravenous fluid resuscitation rate be performed for a patient with burns?
A.As soon as the patient arrives
B.During the secondary survey
C.Should only be done at a burn center
D.During the primary survey
B.Increased oxygen consumption - ansA trauma patient who is 30-weeks pregnant
arrives at the emergency department following a motor vehicle collision. Which normal
physiologic change should be considered when assessing ventilatory status?
A.Increased functional reserve capacity
B.Increased oxygen consumption
C.Decreased minute ventilation
D.Slower desaturation rates with apnea
B.It can be used in hypotensive patients too unstable for computed tomography scan -
ansWhich of the following is true about use of the focused assessment sonography for
trauma exam for a patient with abdominal trauma?
A.It has a higher sensitivity than diagnostic peritoneal lavage for fluid detection
B.It can be used in hypotensive patients too unstable for computed tomography scan
C.It can detect as little as 30 mL of fluid in the abdominal cavity
D.It has high sensitivity in pediatric patients for identifying fluid in the peritoneum
B.Loss of reflexes - ansA patient is diagnosed with a T12 spinal cord injury following a
20-foot fall. Which finding is consistent with spinal shock?
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
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
D.Ventilate with a bag-mask device
B.During the secondary surveyt - ansWhen should the definitive calculation for
intravenous fluid resuscitation rate be performed for a patient with burns?
A.As soon as the patient arrives
B.During the secondary survey
C.Should only be done at a burn center
D.During the primary survey
B.Increased oxygen consumption - ansA trauma patient who is 30-weeks pregnant
arrives at the emergency department following a motor vehicle collision. Which normal
physiologic change should be considered when assessing ventilatory status?
A.Increased functional reserve capacity
B.Increased oxygen consumption
C.Decreased minute ventilation
D.Slower desaturation rates with apnea
B.It can be used in hypotensive patients too unstable for computed tomography scan -
ansWhich of the following is true about use of the focused assessment sonography for
trauma exam for a patient with abdominal trauma?
A.It has a higher sensitivity than diagnostic peritoneal lavage for fluid detection
B.It can be used in hypotensive patients too unstable for computed tomography scan
C.It can detect as little as 30 mL of fluid in the abdominal cavity
D.It has high sensitivity in pediatric patients for identifying fluid in the peritoneum
B.Loss of reflexes - ansA patient is diagnosed with a T12 spinal cord injury following a
20-foot fall. Which finding is consistent with spinal shock?
Loading page 29...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
A.Bradycardia
B.Loss of reflexes
C.Widened pulse pressure
D.Warm skin
B.Maintaining spinal motion restriction - ansWhat is the priority intervention for a child
who has been diagnosed with an atlanto-occipital dislocation following a high-speed
motor vehicle collision?
A.Initiating a second large caliber intravenous line
B.Maintaining spinal motion restriction
C.Placing the patient on pulse oximetry
D.Turning the patient to remove the backboard
B.Medical history including current medications - ansWhat is the most important
consideration during the initial assessment when caring for an older adult who has
sustained serious injuries?
A.They are likely to be fearful in the emergency department
B.Medical history including current medications
C.Availability of support systems after discharge
D.Accessibility to a primary care physician
B.Notify the provider of the change - ansYour patient is a pedestrian struck by a car and
thrown 35 feet. They were unconscious at the scene but became responsive with initial
and subsequent Glasgow Coma Scale (GCS) scores of 13 (E-3, V-4, M-6). The patient
has bilateral subdural hematomas and is awaiting transfer to the ICU. Your next
assessment reveals a GCS of 9 (E-2, V-2, M-5). What is the priority nursing
intervention?
A.Hold all pain medications
B.Notify the provider of the change
C.Repeat the GCS in 30 minutes
D.Place the patient in Trendelenburg position
blankets, room temp increase, warmed fluids, warming lights - ansIn Step 16 of
"Exposure and Environment", you must name at least one of these interventions:
bony deformity, loose teeth, edema, inhalation injury, sounds, tongue obstruction,
burns, fluids, foreign objects, vocalization - ansFour of these must be identified to
assess patency and protection of the airway:
Bowel sounds heard in the left lower chest - ansA patient involved in a high-speed
rollover is complaining of increased difficulty breathing. There is a small penetrating
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
A.Bradycardia
B.Loss of reflexes
C.Widened pulse pressure
D.Warm skin
B.Maintaining spinal motion restriction - ansWhat is the priority intervention for a child
who has been diagnosed with an atlanto-occipital dislocation following a high-speed
motor vehicle collision?
A.Initiating a second large caliber intravenous line
B.Maintaining spinal motion restriction
C.Placing the patient on pulse oximetry
D.Turning the patient to remove the backboard
B.Medical history including current medications - ansWhat is the most important
consideration during the initial assessment when caring for an older adult who has
sustained serious injuries?
A.They are likely to be fearful in the emergency department
B.Medical history including current medications
C.Availability of support systems after discharge
D.Accessibility to a primary care physician
B.Notify the provider of the change - ansYour patient is a pedestrian struck by a car and
thrown 35 feet. They were unconscious at the scene but became responsive with initial
and subsequent Glasgow Coma Scale (GCS) scores of 13 (E-3, V-4, M-6). The patient
has bilateral subdural hematomas and is awaiting transfer to the ICU. Your next
assessment reveals a GCS of 9 (E-2, V-2, M-5). What is the priority nursing
intervention?
A.Hold all pain medications
B.Notify the provider of the change
C.Repeat the GCS in 30 minutes
D.Place the patient in Trendelenburg position
blankets, room temp increase, warmed fluids, warming lights - ansIn Step 16 of
"Exposure and Environment", you must name at least one of these interventions:
bony deformity, loose teeth, edema, inhalation injury, sounds, tongue obstruction,
burns, fluids, foreign objects, vocalization - ansFour of these must be identified to
assess patency and protection of the airway:
Bowel sounds heard in the left lower chest - ansA patient involved in a high-speed
rollover is complaining of increased difficulty breathing. There is a small penetrating
Loading page 30...
TNCC 10TH EDITION EXAM 3 LATEST VERSIONS (VERSION A & B) COMPLETE 200 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
wound to the sixth intercostal space in the left lateral chest. Which finding is most
consistent with an injury to the diaphragm?
A.Severe left-sided abdominal pain
B.Bowel sounds heard in the left lower chest
C.Pain radiating to the left shoulder.
D.Decreased breath sounds on the left side
Breath sounds, depth/pattern/rate, spontaneous breathing, subcutaneous emphysema,
increased work of breathing, symmetrical chest rise and fall, tracheal deviation/JVD,
open wounds/deformities, skin color - ansFour of these must be identified to assess
breathing effectiveness:
C.3240 mL - ansA patient who weighs 120 kg is brought to the emergency department
after sustaining partial thickness burns to both upper extremities and chest with a total
body surface area burned of 27%. How much intravenous fluid should be administered
in the first 8 hours?
A.1620 mL
B.2160 mL
C.3240 mL
D.6480 mL
C.Allowing family to participate in the care of the patient - ansWhile caring for a child
who has been injured, what nursing intervention is consistent with a family-center
approach?
A.Identifying a single family member to speak with
B.Having the family make all the care decisions
C.Allowing family to participate in the care of the patient
D.Limiting dissemination of complex information
C.Apply direct pressure to the wound - ansA patient has uncontrolled bleeding from a
wound to his right upper extremity. What is the priority intervention?
A.Initiate two intravenous access sites
B.Place the patient on supplemental oxygen
C.Apply direct pressure to the wound
D.Use a tourniquet to control the bleeding
C.Decreased body temperature - ansA severely injured patient has been intubated and
is being mechanically ventilated. The patient has received a balanced resuscitation
including multiple blood products. Under which circumstance will it be harder for the
hemoglobin to release oxygen to the tissues?
A.Decreased pH
B.Elevated carbon dioxide level
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) TESTBANK
|ALREADY GRADED A+ 100% COMLETE
wound to the sixth intercostal space in the left lateral chest. Which finding is most
consistent with an injury to the diaphragm?
A.Severe left-sided abdominal pain
B.Bowel sounds heard in the left lower chest
C.Pain radiating to the left shoulder.
D.Decreased breath sounds on the left side
Breath sounds, depth/pattern/rate, spontaneous breathing, subcutaneous emphysema,
increased work of breathing, symmetrical chest rise and fall, tracheal deviation/JVD,
open wounds/deformities, skin color - ansFour of these must be identified to assess
breathing effectiveness:
C.3240 mL - ansA patient who weighs 120 kg is brought to the emergency department
after sustaining partial thickness burns to both upper extremities and chest with a total
body surface area burned of 27%. How much intravenous fluid should be administered
in the first 8 hours?
A.1620 mL
B.2160 mL
C.3240 mL
D.6480 mL
C.Allowing family to participate in the care of the patient - ansWhile caring for a child
who has been injured, what nursing intervention is consistent with a family-center
approach?
A.Identifying a single family member to speak with
B.Having the family make all the care decisions
C.Allowing family to participate in the care of the patient
D.Limiting dissemination of complex information
C.Apply direct pressure to the wound - ansA patient has uncontrolled bleeding from a
wound to his right upper extremity. What is the priority intervention?
A.Initiate two intravenous access sites
B.Place the patient on supplemental oxygen
C.Apply direct pressure to the wound
D.Use a tourniquet to control the bleeding
C.Decreased body temperature - ansA severely injured patient has been intubated and
is being mechanically ventilated. The patient has received a balanced resuscitation
including multiple blood products. Under which circumstance will it be harder for the
hemoglobin to release oxygen to the tissues?
A.Decreased pH
B.Elevated carbon dioxide level
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Subject
Trauma Nursing Core Course