TNCC 8th Edition 2024. Questions with Correct & Verified Answers. Already Graded A+., Exams of Nursing

Download TNCC 8th Edition 2024. Questions with Correct & Verified Answers. Already Graded A+. and more Exams Nursing in PDF only on Docsity! TNCC 8th Edition 2024. Questions with Correct & Verified Answers. Already Graded A+. According to newton law which of these two force is greater: size or force? – ans Neither. For each force there is an equal and opposite reaction. Define Cushing's triad – ans Bradycardia, progressive hypertension (widening pulse pressure), and decreased respiratory effort Define the characteristics of neurogenic shock – ans Distributive shock with a T6 or higher injury results and vasodilation, bradycardia, flushed warm dry skin. Risk for temperature instability. Nursing interventions include maintaining warmth and spinal stabilization. Define the characteristics of spinal shock – ans Transient loss of function can include loss of reflexes and muscle tone below the level of industry with possible vascular response. Describe one fat embolism syndrome is most likely to occur in its characteristics – ans With longform fractures. Tachycardia, Thrombocytopenia, and petechiae rash. Describe the characteristics of cardiogenic shock – ans cardiogenic shock results from pump failure in the presence of adequate intravascular volume. Lack of cardiac output and an organ perfusion occurs secondary to a decrease in myocardial contractility and or valvular insufficiency. This can happen with blunt cardiac trauma or an MI. Symptoms can include low blood pressure increase heart rate and respiratory rate chest pain shortness of breath dysrhythmias increase troponin and pale cool moist skin Describe the characteristics of distributive shock. – ans Distributive shock occurs as a result of Mel distribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. This can occur with spinal cord injuries, sepsis, or anaphylaxis. Symptoms include low blood pressure heart rate respiratory rate preload and afterload, spinal tenderness, difficulty breathing, warm pink and dry skin with a cool core temperature. Describe the characteristics of hypovolemic shock – ans Hypovolemia is caused by a decrease in the amount of circulating volume usually caused by massive bleeding, but also can be from vomiting and diarrhea. Characteristics include low blood pressure and preload, increase heart rate respiratory rate and afterload, with contractility unchanged. Signs include obvious bleeding, weak peripheral pulses, pale cool and moist skin, distended abdomen, pelvic fracture, or bruise swollen and deformed extremities especially long bones. Describe the characteristics of obstructive shock – ans Obstructive shock is it mechanical problem that results from hypoperfusion of the tissue due to an obstruction in either the vasculature or the heart resulting in decreased cardiac output. Some causes include a tension pneumothorax, cardiac tamponade, or venous air embolism on the right side of the heart during systole in the pulmonary artery. Signs include anxiety, muffled heart sounds, JVD, hypertension, chest pain, difficulty breathing, or pulses paradoxes. Describe the four types of spinal cord injury - ansCentral cord injury results in greater weakness distally, anterior injury includes motor loss or weakness below the cord level of injury yet sensory is intact, Brown-Sequard (hemicord) is weak on one side with sensory deficit on opposite side, posterior cord syndrome although rare is when the patient is unable to use sense vibration in proprioception Describe the measurement of an NPA - ansMeasure from the tip of the patient's nose to the tip of the patients earlobe. Differentiate between the three impacts of motor vehicle impact sequence. - ansThe first impact occurs when the vehicle collided with another object. The second impact occurs after the initial impact when the occupant continues to move in the original direction of travel until they collide with the interior of the vehicle or meet resistance. The third impact occurs when internal structures collide within the body cavity. Measurement of an OPA - ansPlace the proximal end or flange of the airway adjunct at the corner of the mouth to the tip of the mandibular angle. Name the three ways to confirm ETT placement - ansPlacement of a CO2 monitoring device, Assessing for equal chest rise and fall, and listening at the epigastrium and four lung fields for equal breath sounds. True or false: NPAs and OPAs are definitive airways. - ansFalse. When placing one of these? One should consider the potential need for a definitive airway. What are contributing factors to injuries related to blunt traumas? - ansThe point of impact on the patient's body, the type of surface that is hit, the tissues ability to resist (bone versus soft tissue, air-filled versus solid organs), and the trajectory of force. What are the early signs of increased Intracranial pressure - ansheadache, vomiting, behavioral changes that begin with restlessness and may progress to confusion, drowsiness, or impaired judgment What are the four types of shock? - ansHypovolemic, Cardiogenic, Obstructive, & Distributive What are the four types of trauma related injuries? - ansBlunt, penetrating, thermal, or blast. What is the minimum permissive hypertension and a trauma patient? - ansA systolic of greater than or equal to 90 MMHG What is the minimum permissive oxygenation level of a trauma patient? - ansGreater than or equal to 94% What is the Munro-Kellie doctrine? - ansWithin the skull 80% his brain, 10% is blood, and 10% is CSF. Any increase of any of the products results in increased intracranial pressure. What is the recommended fluid bolus for a trauma? - ans500 ML's of warmed isotonic crystalloid. Ongoing fluid boluses of 500 ML's should be given judiciously with constant reassessments after administration. What is the relationship between mass and velocity to kinetic energy? - ansKinetic energy is equal to 1/2 the mass multiplied the square of its velocity therefore when mass is doubled so is the net energy, however, when velocity is doubled energy is quadrupled. What is the trauma triad of death? - anshypothermia, acidosis, coagulopathy What is torsion? - ansTorsion forces twist ends in opposite directions. When capnography measurement reads greater than 45MMHG, the nurse should consider increasing or decreasing the ventilation rate? - ansIncreasing the ventilation rate. Doing so would allow the patient to blow off retained CO2. When capnography measurement reads less than 35MMHG, the nurse should consider increasing or decreasing the ventilation rate? - ansDecreasing the ventilation rate. By doing so, the nurse allows the patient to retain CO2. When would you use a nasopharyngeal airway versus an oral pharyngeal airway? - ansNasopharyngeal airways is contraindicated in patients with facial trauma or a suspected basilar skull fracture. Oral pharyngeal airways is used in unresponsive patients unable to maintain their airway, without a gag reflex as a temporary measure to facilitate ventilation with a bag mask device or spontaneous ventilation until the patient can be intubated. 3 parts of the trauma triad of death - ANSHypothermia, coagulopathy, metabolic acidosise 3 things to assess for circulation - ANSPalpate central pulse Assess (again) for external hemorrhage Inspect and palpate skin for color, temp, and moisture. 3 ways to assess ETT placement - ANS1. Apply end tidal, assess CO2 after 5-6 breaths 2. Assess for symmetrical chest wall rise and fall 3. Auscultation over the epigastrium for gurgling and bilateral breath sounds. At what point to you evaluate need for transfer or definitive care? - ANSAfter the primary survey Big symptom of splenic injury - ANSLeft shoulder pain Examples of obstructive shock - ANSTension pneumo, cardiac tamponade, pulmonary artery embolism Examples of primary blast injuries - ANSBlast lung, ruptured tympanic membrane, TBI, abdominal hemorrhage Examples of quaternary blast injuries - ANSInjuries or illness related to explosion: burns, toxic injury from chemicals Examples of quinary blast injuries - ANSInjuries associated with exposure to hazardous materials from the components of the blast Examples of secondary blast injuries - ANSWounds from debris and bomb fragments Examples of tertiary blast injuries - ANSBlunt or penetrating trauma from the body being thrown by the blast For what reasons would you not give mannitol? - ANSAn active bleed or hypotension Hollow abdominal organs and what are they prone to - ANSStomach, bowels, uterus, bladder, prone to rupture How do you give the fluid over 24 hours in parkland formula? - ANSFirst half over 8 hours and second half over 16 hours How do you palpate the iliac crests? - ANSDownward and medially How much fluid do you give a kid? - ANS20mL/kg King airway - ANSA multidimensional esophageal airway that traps the glottis opening between an esophageal cuff and an oropharyngeal cuff Normal baseline FHR - ANS120-160 Parkland formula - ANS3mL x the weight in kg x % TBSA = the fluid to go over 24 hours Questions to ask during breathing assessment. (Need 4) - ANSIs there symmetrical chest rise? Is there spontaneous breathing? Is there tracheal deviation or JVD? What is their skin color? Are there open wounds or deformities in the chest? What's the depth, pattern, and rate of respirations? Is there increased work of breathing? Are breath sounds present and equal? Questions to ask for airway assessment (need 4) - ANSIs the tongue obstructing? Are there any foreign objects? Is there any edema? Are there loose or missing teeth? Is there snoring, gurgling, or stridor? Is there bony deformity? Is there blood, vomit, or secretions? Situations that require a definitive airway - ANSGCS 8 or less Apnea Inhalation injury Increased risk of aspiration Anticipate decreased neuro status Severe maxo fractures Laryngeal/tracheal injury Solid abdominal organs and what are they prone to? - ANSLiver, spleen, gallbladder, pancreas, prone to lacerations Symptoms of abruptly placentae - ANSDark red bleeding, sudden sharp abdominal pain, "board-like" uterus, increased FHR symptoms of epidural hematoma - ANSTransient LOC with a lucid period, HA, N/V, rapidly declining neuro status Symptoms of stage 1 of shock - ANSChange in neuro status, increased DBP, decreased UO, tachycardia Symptoms of stage 2 of shock - ANSDeclining neuro status, tachycardia, narrow pulse pressure, weak thready pulse, cool skin, abnormal base deficit, increased lactate Symptoms of uterine rupture - ANSSudden sharp abdominal or suprapibic pain, asymmetry of uterus, decreased FHR The 3 components of the pediatric assessment triangle - ANSSkin circulation, work of breathing, general appearance A patient is found lying on the floor after falling 13 hours ago. Which of the following laboratory values is expected with a musculoskeletal complication associated with this presentation? - ANSElevated creatine kinase A patient is thrown against a car during a tornado and presents with obvious bilateral femoral 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? - ANSInitiate two large-caliber intravenous lines for Ringer's lactate solution administration A patient with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? - ANSBradycardia and absent motor function below the level of injury A 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? - ANSElevating the extremity TO the level of the heart A trauma patient is en route to a rural emergency department. Radiology notifies the charge nurse that the computed tomography (CT) scanner will be out of service for several hours. The team gathers to plan accordingly. Which of the following terms best describes this trauma team's communication? - ANShuddle A trauma patient is restless and repeatedly asking "Where am I?" Vital signs upon arrival were BP 110/60 mm Hg, HR 96 beats/minute and RR 24 breaths/minute. Her skin is cool and dry. Currently vital signs are BP 104/84 mm Hg, HR 108 beats/minute, and RR 28 breaths/minute. The patient is demonstrating signs and symptoms of which stage of shock? - ANScompensated An elderly patient with a history of anticoagulant use presents after a fall at home that day. She denies any loss of consciousness. She has a hematoma to her forehead and complains of headache, dizziness, and nausea. What is the most likely cause of her symptoms? - ANSsubdural hematoma An intubated trauma patient is being transferred to a tertiary care center. After moving the patient to the stretcher for transport, a drop in pulse oximetry to 85% is noted. Which of the following is the priority intervention? - ANSCheck to make sure the ventilator is plugged in An unresponsive trauma patient has an oropharyngeal airway in place, shallow and labored respirations, and dusky skin. The trauma team has administered medications for drug-assisted intubation and attempted intubation but was unsuccessful. What is the most appropriate immediate next step? - ANSVentilate with a bag-mask device Caregivers carry a 2-year-old into the emergency department who fell out of a second- story window. The patient is awake and crying with increased work of breathing and pale skin. Which of the following interventions has the highest priority? - ANSPadding the upper back while stabilizing the cervical spine During the primary survey of an unconscious patient with multi-system trauma, the nurse notes snoring respirations. Which priority nursing intervention should be performed next? - ANSInsert an oropharyngeal airway if there is no gag reflex EMS arrives with the intoxicated driver of a car involved in a motor vehicle crash. EMS reports significant damage to the driver's side of the car. The patient is asking to have the cervical collar removed. When is it appropriate to remove the cervical collar? - ANSAfter a physical examination if the patient has no radiologic abnormalities on a computed tomography scan EMS brings a patient who fell while riding his bicycle. Using the American College of Surgeons screening guidelines, which assessment finding would prompt the nurse to prepare the patient for radiologic-spine clearance? - ANSsmell of alcohol on breath Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of a future disaster. Which phase of the disaster life cycle does this describe? - ANSmitigation If a patient has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation? - ANScalcium Patients with a crush injury should be monitored for which of the following conditions? - ANSdysrhythmias Tearing of the bridging veins is most frequently associated with which brain injury? - ANSsubdural hematoma The most reassuring finding for a male patient with hip pain after a fall is which of the following? - ANSPelvic stability The nurse is caring for a 120 kg male brought in after a warehouse fire and is calculating the patient's fluid resuscitation needs. He has painful red blistering to the entire surface of both upper extremities and superficial burns to the anterior chest. Using the modified Lund and Browder chart to calculate the total body surface area burned, how much intravenous fluid would be administered in the first 8 hours? - ANS2280 mL The trauma nurse knows that placing a bariatric patient in a "ramped position" provides better visualization during the insertion of which device? - ANSendotracheal tube What bedside monitoring parameters are used to assess for adequacy of oxygenation and effectiveness of ventilation? - ANSPulse oximetry and capnography What factor contributes most to the kinetic energy of a body in motion? - ANSvelocity What finding raises suspicion of a complete spinal cord injury? - ANSpriapism What is the effect of hypothermia on the oxyhemoglobin dissociation curve? - ANSHemoglobin does not readily release oxygen for use by the tissues Which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax? - ANSHypotension that worsens with inspiration Which of the following considerations is most important when caring for geriatric trauma patient? - ANSmedical history Which of the following injuries is LEAST likely to be promptly identified? - ANSbowel Which of the following is a component of the trauma triad of death? - ANSacidosis Which of the following is a late sign of increased intracranial pressure? - ANSDecreased respiratory effort Which of the following is a possible complication of positive-pressure ventilation? - ANSWorsening pneumothorax Which of the following is an expected finding in a patient with a tube thoracotomy connected to a chest drainage system? - ANSFluctuation in the water seal chamber Which of the following is NOT considered goal-directed therapy for cardiogenic shock? - ANSpericardiocentesis Which of the following is true about the log-roll maneuver? - ANSIt can worsen cord damage from a unstable spinal injury Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? - ANSMARCH Which of the following occurs during the third impact of a motor vehicle crash? - ANSThe aorta is torn at its attachment with the ligmentum arteriosum Which of the following patients warrants referral to a burn center? - ANSA 52-year-old diabetic male with a partial-thickness burn to the left lower leg Which of the following values indicates the need for alcohol withdrawal interventions? - ANSCIWA-Ar of 36 Which pulse pressure description is an indication of early hypovolemic shock? - ANSnarrowed