TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VE, Exams of Nursing

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TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A a 22 yr old was struck by a vehicle while crossing the street, sustaining multiple fx she is alert and ANSwering qestions and crying what is the best method for initial pain assessment for this pt - ANSself report scale A a pt sustrained a penetrating injury of his upper leg. the pre hospital personnel states a large amount of blood loss before hemostasiswas achieved. he presents to the ER responding to painful stimuli with moaning. he is tachy 142 b/p 104/96 and RR 24 - ANSdecompensated A an unrestrained driver was involved in a frontal collision without airbag deployment. he is hypotensive and tachycardic with shallow respirations, distended JVD and muffled heart tones the nurse prepare for what - ANSpericardiocentesis A during assessment of an extremety with suspected pulses are - ANScan be normal A for a ptwho has undergone recent bariatric surgery, flouroscopy is recommended to place - ANSNG tube A identification of vulnerabilities is an example of what phase of disaster management - ANSmitigation A in mass casualty "doing the greatest good for the greatest number of people refers to a situation where - ANSthere may be more patients than resources A in neurogenic shock, alterations in vital signs include hypotension and which other abnormal VS - ANSbradycardia A In the primary survey AVPU is performed to determine if the patient can: - ANSProtect their aiway A prego trauma pt develops tachy, hypotension, a rigide board like uterus, and dark, red vaginal bleeding. she reports constant back pain which is increasing. the most likely cause of s/s is - ANSplacental abruption TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A several groups of people are at higher risk for maltreatment including children, elderly, prego, and ... - ANSpt's with disability A the nurse is preparing to cleANSe an extensive abrasion contaminated with dirt and gravel. which of the following intervention is indicated - ANSus copious amounts of NS A The systemic inflammatory response is a normal part of the body's response to shock from traumatic injury. what best describes this response - ANSit is activated by tissue hypoxia and sends neutrophils to injury site A what is an early assessment finding to increased ICP in pt with a brain injury - ANSvomiting TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ B when assessing a pt following a MVC the nurses asks how fsat the car was going - ANSwhen volocity is doubled speed is quadroupled B WHich may lead to unreliable pulse ox reading - ANScarboxyhemoglobin B which of hte following significant assessment findigns is frequently found in a patient with complete crANSiofacial separation involving the maxilla, zygoma, orbits, and bones of the cranial base. - ANSdiplopia B which of the following hemodynamic support strategies is the prioririty intervention for a pt with traumatic pulmonary contusion - ANSjudicios use of IV fluids Bduring the primary survery which of the following has the greatest priority - ANScervical spine injury C 32 wk pregnant lady arrives in er after trapped in a car that flipped. the initial assessment reveals s/s of shock, vaginal bleeding, a palpable asymmetrical uterus, and slowing fetal heart tones what is the most likely cause - ANSuterine rupture C a college student presents to the er stating afterarriving at a party , she awoke in a dorm rom. she didnt recognize with no memory of the previous evening the trauma nurse prepare for what exam. - ANSsexual assult C an adult pt involved in a brush fire arrives to the er. upon initial assessment in the er the most concerning finding is - ANShoarse voice and repeatedly decides to clear throat. C an older adult pt fell in the bathtub 3 days ago. now she is exihibiting decreasd LOC and difficulty with speaking and walking. which of the following injuries is most effective - ANSsubdural hematoma TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ C effective pain management in hte pt iwth rib fxwill promote what - ANScough with ability to clear secretions C properly restrained 6 wk old kid was involved in a MVC. after the assessment and stabilization the pt becomes more difficult to rouse. responding with a weak cry to painful stimuli. the pupils remain brisk and reactive. the anterior fontanel is soft and flat. what is the most likely cause and pririty interventions - ANShypoglycemia C What are the primary benefits of a team approach to trauma care - ANSit provides a systemic approach to care and organizes care C what organ might be injured in left lower rib fx - ANSspleen TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ C which of the following would be priority intervention for a pt with multiple rib fractures and chest wall instability follwoing a mvc collision - ANSassist with endotracheal intubation C which of the follwoing is a risk factor for DVT in the trauma pt. - ANSpelvic fx Cthe term worried well when refering to disaster preparedness planning refers to: - ANSindividuals hwo think they have been affected by the event but are asymptomatic Cthe trauma nurse would prepare for a definitive airwya for which of the following condition. - ANSGCS of 8 or ls D An unrestrained driver is brought into the emergency department following a frontal impact MVC. she is pale, anxious, and c/o SOB. what is the potential injury - ANSLumbar fx D elevated comaprtment pressure can be the result of - ANShemorrhage from within the muscle D pt with amputation of an index finger with a knife. amputaiton is brought in with pt. it is wrapped in sterile gauze with saline and sealed in a plastic bag. the next step amputation care is - ANSplace the bag on ice D restrained driver is involved in a severe head on MVC and presnts with a seatbelt mark along the neck and upper chest area. bilateral decreased breath sounds, hemoptysis and diffuse sub q emphysemato the neck and upper chest area - ANStracheobronchial injury D which of the following diagnostic intervention is most appropriate for the unstable pt with a suspectedinternal hemorrhage - ANSfocused assessment with sonography for trauma D which physiological change in airway of an odler adult pt places the pt at risk for difficult intubation - ANScervical arthritisA a 22 yr old was struck by a vehicle while crossing the street, sustaining multiple fx she is alert and ANSwering qestions and crying what is TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A when providing care for the pedicatric pt with burns the post resuscitation care, how are fluids delivered - ANSparkland formula with maintainence fluidss A which of hte following nursing interventions would be best for traumitc - ANSHOB 30 degrees A which of the following structures would be hte most affected by teh concept of caviation - ANSLiver A which of the following values is within the acceptable limits for trauma pt - ANSend tidal CO2 of 40 TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ B a pt father arrives in teh ER and needs to be told his son was severely injured in a MVC and is in surgery, the father si agitated, yelling, and smells of alcohol. in planning to talk with the father the trauma nurse will - ANSdeliver information regarding the son;s care in a calm voice B a pt involved in an MVC develops asymmetric pupillary reactivity, bilateral pupillary dilation and abnormal motor posturing. what does the nurse suspect as the most likely cause - ANSherniation syndrome B a pt with injury to the middle meningeal artery is at risk for which of the following - ANSepidural hematoma B an occlusive dressing has been applied to a pt with a penetrating injury to the chest. upon assessment the nurse notes that the patient is in respiratory distress nad has absnet breath sounds on hte affected side. what is the priroruty intervention - ANSremove the dressing to the wound B an unrestrained driver inlvolved in a MVC in which alcohol was involed. he denies any pain and numbness and tinlging. according to NEXUS critera which factors indicate need for radiological - ANSsuspected alcohol abuse B pt to ER after being pinned to brick retaining wall. knwoing crushing injuries can result to significant damage to muslces the priority asessment for trauma nruse is for - ANSmyoglobinemia nd renal failure B the most common cause of shock in the trauma pt is - ANSloss of circ volume B the unrestrained fron seat passenger in a MVC develops echymosis around umbillicus. this assessment finding is most commonly associated with: - ANSbleeding in the peritoneal cavity B thinning skin and diminished autonomic response in older adult can have what effect on primary assessment - ANScompromised thermoregulation TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ B when assessing a pt following a MVC the nurses asks how fsat the car was going - ANSwhen volocity is doubled speed is quadroupled B WHich may lead to unreliable pulse ox reading - ANScarboxyhemoglobin B which of hte following significant assessment findigns is frequently found in a patient with complete crANSiofacial separation involving the maxilla, zygoma, orbits, and bones of the cranial base. - ANSdiplopia B which of the following hemodynamic support strategies is the prioririty intervention for a pt with traumatic pulmonary contusion - ANSjudicios use of IV fluids TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ D An unrestrained driver is brought into the emergency department following a frontal impact MVC. she is pale, anxious, and c/o SOB. what is the potential injury - ANSLumbar fx D elevated comaprtment pressure can be the result of - ANShemorrhage from within the muscle D pt with amputation of an index finger with a knife. amputaiton is brought in with pt. it is wrapped in sterile gauze with saline and sealed in a plastic bag. the next step amputation care is - ANSplace the bag on ice D restrained driver is involved in a severe head on MVC and presnts with a seatbelt mark along the neck and upper chest area. bilateral decreased breath sounds, hemoptysis and diffuse sub q emphysemato the neck and upper chest area - ANStracheobronchial injury D which of the following diagnostic intervention is most appropriate for the unstable pt with a suspectedinternal hemorrhage - ANSfocused assessment with sonography for trauma D which physiological change in airway of an odler adult pt places the pt at risk for difficult intubation - ANScervical arthritis A 5-year old child presents to the ED with bruises to the upper arms and buttocks in various stages of healing and multiple small, clean, round burns to the back. There are no abnormalities found based on the pediatric assessment triangle or primary survey. Which of the following is the priority nursing intervention? A) report your suspicion of the maltreatment in accordance with local regulations B) apply ice to the bruises and consult wound care C) engage in therapeutic communication to determine the MOI D)provide the family with injury prevention recourses - ANSA) report your suspicion of the maltreatment in accordance with local regulations A 20-year old male presents to the ED c/o severe lower abd pain after landing hard on the bicycle cross bars which performing an aerial BMX maneuver. Secondary assessment reveals lower abd TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ tenderness and scrotal ecchymosis. Which of the following orders would the nurse questions? A) Fast exam B) CT scan C) straight cath for urine sample D)ice and elevation of the scrotum - ANSC) straight cath for urine sample A 35-year old male presents with facial trauma after bring struck in the face with a baseball. a tear-drop shaped left pupil is noted on exam. What type of injury is suspected? TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A) oculomotor nerve palsy B) globe rupture *** C) Uncal herniation D)retinal detachment - ANSB) globe rupture A 36-year old female has a deformity of the left wrist after a fall. She is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention? A) apply a sling and elevate the extremity to the level of the heart. B)apply a splint and elevate above the level of the heart C) Apply a sling and elevate the extremity above the level of the heart D)apply a splint and elevate the extremity to the level of the heart. - ANSB) apply a splint and ELEVATE ABOVE THE LEVEL OF THE HEART A 49-year old restrained driver involved in a MVC presents to the trauma center c/o abd, pelvic, and bil lower extremity pain Vitals signs are stable. The nurse can anticipate all of these negative fast exam except which of the following? A. Diagnostic peritoneal lavage B. Serial FAST exams C. Abdominal and pelvic CT scANS D. Serial abdominal assessments - ANSA) diagnostic peritoneal lavage The FAST exam is done at the bedside to identify pathological fluid in the abdominal and pelvic cavities. FAST exams reduce the use of more invasive diagnostic peritoneal lavage and can be repeated if clinical changes or hemodynamic changes occur. A negative FAST study does not rule out injury and may warrant a follow-up computed tomography scan. Serial FAST exams can identify increasing abdominal fluid collections from hemorrhage. Diagnostic peritoneal lavage/diagnostic peritoneal aspiration is performed by the surgical team to rapidly identify the presence of hemorrhage in patients who are hemodynamically unstable after trauma. TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A) elevated creatine kinase B) decreased potassium level C) decreased WBC D) elevated GFR - ANSA) elevated 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 cap refill. Which of the following interventions would be most appropriate for this patient based on the disaster triage principle? TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A) initiate two large bore intravenous lines for Ringers lactate solution administration B) Administer Dilaudid for pain control and provide comfort care C) Place the patient in an observation area for care within the next few hours D)Contact the command center for the personnel to notify next of kin. - ANSA) initiate two large bore intravenous lines for Ringers lactate solution administration A patient with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? A) Bradycardia and ipsilateral absences of motor function B) Tachycardia and respiratory depression C) Tachycardia and absent motor function below the level of injury D)Bradycardia and absent motor function below the level of the injury - ANSD) Bradycardia and absent motor function below the level of the injury A patient with 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 extremity above the level of the heart B) repositioning and apply ice C) Elevating the extremity to the level of the heart D)Preparing the patient for ultrasound - ANSC) Elevating the extremity to the level of the heart A trauma patient is en route to a rural ED. Radiology notifies the charge nurse that the CT scanner will be out of service for several of hours. The team gathers to plan accordingly. Which of the following terms best describes this trauma teams communication? A) Brief B) loop C) debrief D) huddle - ANSD) huddle TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A trauma patient is restless and repeatedly asking "where am I?" vital signs upon arrival were BP 100/60 mm Hg, HR 96 beats/min, and RR 24 breaths/min. Her skin is cool and dry. Current vital signs are BP 104/84mm Hg, HR 108, RR 28 breaths/min. The patient is demonstrating signs and symptoms of which stage of shock? A) compensate d B) Progressive C) irreversible D) decompensated - ANSA) compensated TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ D) insert an oropharyngeal airway if there is no gag reflex - ANSD) insert an oropharyngeal airway if there is no gag reflex EMS arrives with the intoxicated driver of a car involved in a MVC. EMS reports significant damage to the drivers side of the car. The patient is asking to have the cervical color removed. when is it appropriate to remove the cervical collar? A)after a physical examination if the patient has no radiologic abnormalities on a computed tomography scan *** B)after physician evaluation if the patient has not neurologic abnormalities on exam C) after palpation of the spine if the patient has no point tenderness the the vertebral column D) after physical examination if the patient has not neck pain with movement - ANSA) after a physical examination if the patient has no radiologic abnormalities on a computed tomography scan EMS brings a patient who fell riding his bicycle. Using the American College of Surgeons screening guidelines, which assessment finding would prompt the nurse to prepare the patient for radiologic spine clearance? A)Alert with no neurologic deficits B)Multiple abrasions to the extremities C) Multiple requests of water D) Smell of alcohol on breath - ANSD) Smell 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 future disaster. Which phase of the disaster life cycle does this describe? A)mitigation B)preparedness C) response D) recovery - ANSA) mitigation TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ If a patient has received multiple trANSfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation? A) potassium B) magnesiu m C) sodium D) calcium - ANSD) calcium Patients with a crush injury should be monitored for which of the following conditions? A) Hypernatremi a B) Hypercalcemi a TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ C) Dysrhythmias D)polyuria - ANSC) Dysrhythmias Tearing of the bridging veins is most frequently associated with which brain injury? A)epidural hematoma B)subdural hematoma *** C) diffuse axonal injury D) intracerebral hematoma - ANSB) subdural hematoma The most reassuring finding for a male patient with hop pain after a fall is which of the following? A)a normal prostate exam B)absence of abdominal distension C) a normal fast exam D) pelvic stability - ANSD) pelvic stability The nurse is caring for a 120 kg male is 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 BSA burned, how much IV fluids would be administered in the first 8 hours? A)2280 mL B)3840 mL C) 4560 mL D)7680 mL - ANSA) 2280 mL (upper arm 4+4 / lower arm 3+3 / hand 2.5+2.5) = 19% TBSA. 120 kg x (2 mL) x (19% TBSA) = 4560 mL 4560 / 2 (half of fluids given in first 8 hours) = 2280 mL TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ D) hypotension that worsens with inspiration - ANSD) hypotension that worsens with inspiration. Assessment findings associated with tension pneumothorax include anxiety, severe restlessness, severe respiratory distress, and absent breath sounds on the injured side. Hypotension due to compression of the heart and great vessels is consistent with obstructive shock. Hypotension worsens with inspiration due to increased intrathoracic pressure. Late signs include distended neck veins, tracheal deviation, and cyanosis. Which of the following considerations is most important when caring for a geriatric trauma patient? A) head to to exam B) medical history C) incontinence TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ D) falls - ANSB) medical history Which of the following injuries is LEAST likely to be promptly identified? A) spleen B) lung C) bowel D) brain - ANSC) bowel Which of the following is a component of the trauma triad of death? A)Acidosis B)hyperthermia C) hemorrhage D) sepsis - ANSA) Acidosis hypothermia, metabolic acidosis, coagulopathy Which of the following is a late sign of increased intracranial pressure? A) Restlessness or drowsiness B) Nausea and vomiting C) Decreased respiratory effort D)Amnesia and anxiety - ANSC) Decreased respiratory effort Which of the following is an expected finding in a patient with a thoracostomy connected to a chest drainage system? A)output of 200 mL/hr B)tubing clamp closed for trANSport C) dependent loops in the tubing to promote drainage D)fluctuations in the water serial chamber - ANSD) fluctuations in the water serial chamber TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Which of the following is NOT considered goal-directed therapy of cardiogenic shock? A)controlled fluid boluses B)antidysrhythmic administration C) pericardiocentesis D) cardiac cath - ANSC) pericardiocentesis Which of the following is possible complication of positive-pressure ventilation? A) worsening pneumothorax B) worsening flail chest C) reabsorption of pleural air TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ D)weak - ANSB) narrowed Why is a measure of serum lactate obtained in the initial assessment of the trauma patient? a)to measure oxygenation and ventilation b) to quantify the base deficit for the adequacy of cellular perfusion c) to gauge end-organ perfusion and tissue hypoxia d) to determine the underlying cause of shock - ANSc) to gauge end-organ perfusion and tissue hypoxia You are caring for a patient who was involved in a MVA and is 32 weeks pregnant. Findings of your secondary survey include abd pain on palpation, fundal high at the costal margin, and some dark bloody show. Varying, accelerations and decelerations are noted on the cardiotocography. These findings are most consistent with which of the following? A)placental abruption B) preterm labor C) uterine rupture D)fetal demise - ANSA) placental abruption You are treating a 27-year old male in respiratory distress who was involved in a house fire. Calculating TBSA burned is deferred d/t the need for emergent intubation. At what rate should you begin fluid resuscitation? A)1000 mL/hr B)500 mL/hr C) 250 mL/hr D)125 mL/hr - ANSB) 500 mL/hr A (AVPU) - ANSAlert. Will be able to maintain airway once clear. A (Primary Survey) - ANSAirway and alertness with simultaneous cervical spinal stabilization. TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Airway Assessment - ANSInspect: tongue obstruction, loose/missing teeth, foreign objects, blood, vomitus, secretions, edema, burns or evidence of inhalation injury Auscultate: listen for obstructive airway sounds (ie. snoring, gurgling, stridor) Palpate: palpate for possible occlusive maxillofacial bony deformity, subcutaneous emphysema Airway Interventions: - ANSSuction Remove foreign body if noted Jaw thrust maneuver (maintain cspine) TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag) Consider definitive airway Alertness Assessment - ANSA-Alert V-Verbal P-Painful U-Unresponsive B (Primary Survey) - ANSBreathing and Ventilation Breathing and Ventilation Assessment - ANSInspect: spontaneous breathing, symmetrical rise and fall, depth/pattern/rate of respirations, accessory muscle use, diaphragmatic breathing, skin color (normal, pale, flushed, cyanotic), contusions/abrasions/deformities (signs of underlying injury), open pneumothoraces (sucking chest wound), JVD, tracheal position, signs of inhalation injury Auscultate: presence, absence and equality of breath sounds at 2nd intercostal space midclavicular line and bases at the fifth intercostal space anterior axillary line Palpate: bony structures, possible rib fractures, SQ emphysema, soft tissue injury, JV pulsations at suprasternal notch or supraclavicular area Life-threatening pulmonary injuries requiring immediate intervention: open pneumothorax, tension pneumothorax, flail chest, hemothorax. Breathing and Ventilation Intervention - ANSBreathing absent: jaw- thrust maneuver, oral airway adjunct, assist ventilation with bag- mask device, prepare for definitive airway Breathing present: NRB. Determine if ventilation effective: etCO2 35-45, SpO2 94% or higher. If ineffective: assist with bag-mask and determine need for definitive airway C (Primary Survey) - ANSCirculation and Control of Hemorrhage TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Findings: photophobia, tearing, pain, injected conjunctiva (redness), lid swelling, irritation Treatment: Ophthalmic ABX, Cycloplegic agent to decrease spasms and pain, ophthalmic NSAIDS to decrease swelling, oral analgesics, Ophthalmic f/u in 24 hours. (Do NOT patch - increases infection) Corneal Foreign Body - ANSRoutinely metal, plastic or wood. Findings: photophobia, pain, injected conjunctiva (redness), lid swelling TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Treatment: topical anesthetic, removal of foreign body, ophthalmic ABX, cycloplegics, oral analgesia Corneal Laceration - ANSInvolves one or more layers of the cornea. Visualized with a slit lamp. Findings: similar to abrasion, pain out of proportion to findings, decreased vision Treatment: treat small lacerations similar to an abrasion, larger lacerations need ophthalmology referral and possible surgery Cycloplegic agent - ANSCycloplegia is paralysis of the ciliary muscle of the eye, resulting in a loss of accommodation. Because of the paralysis of the ciliary muscle, the curvature of the lens can no longer be adjusted to focus on nearby objects. D (Primary Survey) - ANSDisability (Neurologic Status) Disability Assessment - ANSAssess GCS on arrival and repeat per policy. Assess pupils for equality, shape and reactivity (PERRL) Disability interventions - ANSEvaluate for need for CT. Assume AMS to be the result of CNS injury until proven otherwise. Consider ABGs - AMS may be indicator of decreased cerebral perfusion, hypoventilation or acid-base imbalance. Consider bedside glucose. Distributive Shock - ANSOccurs as a result of maldistribution of an adequate circulating volume with a loss of vascular tone or increased permeability. Diffuse vasodilation lowers the systemic pressure, creating a relative hypovolemia or reduction of the mean systemic volume and TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ venous return to the heart or drop in preload, resulting in distributive shock. Anaphylactic: release of inflammatory mediators, such as histamine, which contracts bronchial smooth muscle and increases vascular permeability and vasodilation. Septic Shock: systemic release of bacterial endotoxins, resulting in an increased vascular permeability and vasodilation Neurogenic shock: loss of sympathetic nervous system control of vascular tone, which produces venous and arterial vasodilation. With the loss of sympathetic nervous system input in spinal cord injury, unopposed vagal activity may result in decreased cardiac output through bradycardia. TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ H (Secondary Survey) - ANSHistory Prehospital Report (MIST) M: MOI I: Injuries sustained S: Signs and symptoms in the field T: Treatment in field Patient History (SAMPLE): S: Symptoms A: Allergies and tetanus status M: Medications P: Past medical history L: Last oral intake E: Events and Environmental factors related to injury. H: Head and Face Head to Toe Assessment (secondary survey) - ANSSOFT TISSUE: Inspect: lacerations, puncture wounds, abrasions, contusions, edema, ecchymosis, impaled objects. Palpate: areas of tenderness, step-offs, crepitus BONY DEFORMITIES: Inspect: asymmetry of facial expressions, exposed tissue or bone for brain matter Palpate: depressions, angulations, tenderness Hepatic Injuries - ANSIn blunt trauma the liver may lacerate from increased abdominal pressure. TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Hematoma - bleeding contained within the capsule Laceration - the capsule is disrupted Findings: Cullen sign (ecchymosis around the umbilicus or RUQ), tenderness, guarding or rigidity RUQ, 9-12 rib FXs, elevated LFT Graded I-VI, I = minor trauma Nonoperative management is standard of care in hemodynamically stable patient. Observed with serial abdominal exams. Findings of contrast extravasation may be embolized by IR. TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ For surgical patients - fluid resuscitation is essential. Risks of surgery include disruption of the natural tamponade process due to the evacuation of large amounts of blood resulting in hypovolemia. Hypovolemic Shock - ANSCaused by a decrease in the amount of circulating blood volume. In trauma typically results from hemorrhage, but can result in a precipitous loss of volume, ie vomiting or diarrhea. Burn trauma can result in hypovolemic shock from damage to the cell membranes leading to plasma and protein leakage. of body water, results in inadequate perfusion. Hyperventilation can cause increased intrathoracic pressure resulting in compression of the heart and decreased cardiac output. Initial Assessment - ANS1. Preparation and Triage 2. Primary Survey 3.Reevaluation 4.Secondary Survey 5.Reevaluation Adjuncts 6.Reevaluation and Post Resuscitation Care 7. Definitive Care or TrANSport Intraocular Foreign Body - ANS*TRUE EMERGENCY AND EARLY INTERVENTION IS ESSENTIAL. Findings: compromised visual acuity, misshapen pupils, pain Treatment: elevate HOB, ophthalmology, immobilize foreign body, patch UNAFFECTED eye to limit concomitant eye movement, globe closure ASAP, systemic and ophthalmic ABX, analgesics. Postop infection, retinal detachment and vision loss are common complications. lid injury - ANS TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Stores 200-300ml of blood and leads to hemodynamic instability quickly if damaged. Splenic Injuries - ANSIn blunt trauma the spleen may lacerate from increased abdominal pressure. Graded I-V, I = minor trauma Assessment findings: signs of trauma LUQ, abdominal distention, asymmetry, abnormal contour, tenderness, guarding, rigidity, pain left shoulder when supine. CT: Hemoperitoneum. Hypodensity - represents parenchymal disruption, intraparenchymal hematoma or subcapsular hematoma. Contrast blush or extravasation TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ - hyperdense area that represent traumatic disruption. Active extravasation implies ongoing bleeding. Nonoperative management is preferred if hemodynamically stable, stable H/H x 12-24 hours, minimal trANSfusion requirements (<2units), grade I or II without blush, age <55, alert able to assist in assessment of abdomen. Surgical options: total splenectomy for severe injury, for less severe - direct pressure packing, embolization, splenorrhaphy (suturing spleen), partial removal. Asplenic patients have difficulty destroying encapsulated bacteria - Streptococcus pneumonia, Neisseria meningitides and Haemophilus influenza. At risk for pneumococcal sepsis. Need annual flu shot and q5yr meningococcal and pneumococcal vaccines. U (AVPU) - ANSUnresponsive. Does not respond to any stimuli. V (AVPU) - ANSVerbal. Needs verbal stimuli to respond. (Airway adjunct may be needed to prevent tongue obstruction) - ANSPrehospital shock index pg. 85 Injury: shearing or tearing. Diagnosed with MRI. Widespread microscopic hemorrhage. - ANSDiffuse Axonal Injury (Cannot recover from this; shearing/tearing portion DOES NOT heal) Injury: shearing or tearing. Diagnosed with MRI. Widespread microscopic hemorrhage. - ANSDiffuse Axonal Injury (Cannot recover from this; shearing/tearing portion DOES NOT heal) Shock: Spinal cord injury at any level. TrANSient loss of reflex below the level of injury. Variable duration. S & S: flaccidity, loss of reflexes, bowel/bladder dysfunction. - ANSSpinal TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Shock: Spinal cord injury at any level. TrANSient loss of reflex below the level of injury. Variable duration. S & S: flaccidity, loss of reflexes, bowel/bladder dysfunction. - ANSSpinal Shock: Spinal cord injury at T6 or above. Temporary loss of vasomotor tone and sympathetic innervation. Temporary duration usually <72 hours. S & S: hypotension, bradycardia, loss of ability to sweat below level of injury. - ANSNeurogenic Shock: Spinal cord injury at T6 or above. Temporary loss of vasomotor tone and sympathetic innervation. Temporary duration usually <72 hours. S & S: hypotension, bradycardia, loss of ability to sweat below level of injury. - ANSNeurogenic TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ ... is a test that requires fluid to be sent to the lab and is considered the gold standard for identifying CSF - ANSBeta2- TrANSferrin ... is a test that requires fluid to be sent to the lab and is considered the gold standard for identifying CSF - ANSBeta2- TrANSferrin ... is a triad of assessment findings; widening pulse pressure, bradycardia, and diminished respiratory effort - ANSCushing ( it is an attempt to increase MAP against elevated ICP, ultimately trying to cause a rise in CPP) ... is a triad of assessment findings; widening pulse pressure, bradycardia, and diminished respiratory effort - ANSCushing ( it is an attempt to increase MAP against elevated ICP, ultimately trying to cause a rise in CPP) ... is a triad of assessment findings; widening pulse pressure, bradycardia, and diminished respiratory effort - ANSCushing ( it is an attempt to increase MAP against elevated ICP, ultimately trying to cause a rise in CPP) ... is damaged brain tissue usually caused by blunt trauma - ANSCerebral contusion ... is damaged brain tissue usually caused by blunt trauma - ANSCerebral contusion ... is damaged brain tissue usually caused by blunt trauma - ANSCerebral contusion ... is defined as the pressure gradient across the brain tissue, or the difference between the pressures of the cerebral artery and venous vessels. - ANSCPP; CPP = map - icp ... is defined as the pressure gradient across the brain tissue, or the difference between the pressures of the cerebral artery and venous vessels. - ANSCPP; CPP = map - icp TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ ... is defined as the pressure gradient across the brain tissue, or the difference between the pressures of the cerebral artery and venous vessels. - ANSCPP; CPP = map - icp ... is the initial post traumatic inflammatory response activates this response and. . .are sent to the injury sites, activating signaling pathways that mobilize inflammatory cells. - ANSImmune response; tissue hypoxia;neutrophils ... is the initial post traumatic inflammatory response activates this response and. . .are sent to the injury sites, activating signaling pathways that mobilize inflammatory cells. - ANSImmune response; tissue hypoxia;neutrophils ... is the initial post traumatic inflammatory response activates this response and. . .are sent to the injury sites, activating signaling pathways that mobilize inflammatory cells. - ANSImmune response; tissue hypoxia;neutrophils TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ ... is the shifting of brain tissue with displacement into another compartment as the result of bleeding or edema. - ANSHerniation ... is the shifting of brain tissue with displacement into another compartment as the result of bleeding or edema. - ANSHerniation ... is the shifting of brain tissue with displacement into another compartment as the result of bleeding or edema. - ANSHerniation ... pain is persistent and usually lasts longer than 3 to 6 months. - ANSChronic ... pain is persistent and usually lasts longer than 3 to 6 months. - ANSChronic ... pain is persistent and usually lasts longer than 3 to 6 months. - ANSChronic ... pain originates from orgANS and may lead to referred pain. (Trauma) - ANSVisceral ... pain originates from orgANS and may lead to referred pain. (Trauma) - ANSVisceral ... pain originates from orgANS and may lead to referred pain. (Trauma) - ANSVisceral ... pain originates from skin and musculoskeletal structures (burns) - ANSSomatic ... pain originates from skin and musculoskeletal structures (burns) - ANSSomatic ... pain originates from skin and musculoskeletal structures (burns) - ANSSomatic TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ leading to decreased preload, stroke volume,CO and end organ perfusion) ... shock results from hypoperfusion of the tissue due to an obstruction in either the vasculature or heart. Two examples include.... - ANSObstructive;tension pneumothorax, cardiac tamponade. (With tension pneumo the increase in intrathoracic pressure leads to displacement of the vena cava, obstruction to arrival filling leading to decreased preload and decreased cardiac output) ( with cardiac tamponade there is an accumulation of fluid in the pericardial sac impeding diastolic expANSion and filling leading to decreased preload, stroke volume,CO and end organ perfusion) ... shock results from hypoperfusion of the tissue due to an obstruction in either the vasculature or heart. Two examples include.... - ANSObstructive;tension pneumothorax, cardiac tamponade. (With tension pneumo the increase in intrathoracic pressure leads to displacement of the vena cava, obstruction to arrival filling leading to decreased preload and decreased cardiac output) ( with cardiac tamponade there is an TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ accumulation of fluid in the pericardial sac impeding diastolic expANSion and filling leading to decreased preload, stroke volume,CO and end organ perfusion) .... activationare found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure - ANSBaroreceptor activation; baroreceptors .... activationare found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure - ANSBaroreceptor activation; baroreceptors .... activationare found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure - ANSBaroreceptor activation; baroreceptors .... are frequently associated with minor injury in older adults, patients taking anticoagulation medications and patients with chronic alcohol abuse. - ANSChronic subdural Hematoma .... are frequently associated with minor injury in older adults, patients taking anticoagulation medications and patients with chronic alcohol abuse. - ANSChronic subdural Hematoma TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ .... are frequently associated with minor injury in older adults, patients taking anticoagulation medications and patients with chronic alcohol abuse. - ANSChronic subdural Hematoma .... can produce bleeding that may not be evident until several hours after injury - ANSBasilar skull fractures .... can produce bleeding that may not be evident until several hours after injury - ANSBasilar skull fractures .... can produce bleeding that may not be evident until several hours after injury - ANSBasilar skull fractures .... is suspected in any patient with multi system trauma. - ANSCervical spine injury TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ 1 unit of PRBC will raise HGB and HCT by how much? - ANSOnce hemostasis is achieve it is est that 1 unit will raise hgb by 1 g/dL and hct by 3%. 1. A- airway and Alertness with simultaneous cervical spinal stabilization 2. B- breathing and Ventilation 3. circulation and control of hemorrhage 4. D - disability (neurologic status) 5. F - full set of vitals and Family presence 6. G - Get resuscitation adjuncts L- Lab results (arterial gases, blood type and crossmatch) M- monitor for continuous cardiac rhythm and rate assessment N- naso or orogastric tube consideration O- oxygenation and ventilation analysis: Pulse oxygemetry and end- tidal caron dioxide (ETC02) monitoring and capnopgraphy H- History and head to toe assessment I- Inspect posterior surfaces - ANSABCDEFGHI 1.Apnea 2.GCS 8 or less 3.Maxillary fractures 4.Evidence of inhalation injury (facial burns) 5.Laryngeal or tracheal injury or neck hematoma 6.High risk of aspiration and patients inability to protect the airway 7.Compromised or ineffective ventilation - ANSFollowing conditions might require a definitive airway 1. bony fractures and possible rib fractures, which may impact ventilation 2. palpate for crepitus 3. subcutaneous emphysema which may be a sign for a pneumothorax 4. soft tissue injury - ANSPalpate the chest for TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ 1. Check the presence of adequate rise and fall of the chest with assisted ventilation 2. Absence of gurgling on auscultation over the epigastrium 3.Bilateral breath sounds present on auscultation 4.Presence of carbon dioxide (CO2) verified by a CO2 device or monitor - ANSIf the pt has a definitive airway in what should you do? 1.Dyspnea 2.Tachycardia 3.Decreased or absent breath sounds on the injured side 4. CP - ANSSimple Pneumo assessment: 1. equal breath sounds bilaterally at the second intercostal space midclavicular line and the bases for fifth intercostal space at the axillary line - ANSAuscultate the chest for: TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ 1.Get a CT 2.Consider ABG 's if decreased LOC 3.Consider glucose check - ANSD Interventions 1.Hypotension 2.JVD 3.Muffled heart sounds - ANSBecks Triad: 1. open the airway, use jaw thrust 2. insert an oral airway 3.assist ventilations with a bag mask 4.prepare for definitive airway - ANSIf breathing is absent.. 1. pain - hallmark sign, early sign 2. pressure - early sign 3. pallor, pules, paresthesia, paralysis - late sign - ANSSix P's of compartment syndrome: 1.Preparation 2.Preoxygenation 3.Pretreatment 4.Paralysis and Induction 5.Protecting and positioning - v 6.Placement of proof - secure the tube 7.Post intubation - secure ETT Tube, get X-ray for placement - ANSSteps of Rapid Sequence Intubation 1.Preparation and Triage 2.Primary Survery (ABCDE) with resuscitation adjuncts (F,G) 3. Reevaluation (consideration of trANSfer) 4. Secondary Survey (HI) with reevaluation adjuncts 5. Reevaluation and post resuscitation care 6. Definitive care of trANSfer to an appropriate trauma nurse - ANSInitial Assessment 1. Suction the airway TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ -More than 20% of their TBSA burned require: *Adults: 2-4 ml of crystalloid solution x kg x % *Peds: 3-4 ml of crystalloid solution x kg x % *Infants: fluid with 5% dextrose at a maintenance rate in addition to the Peds rate protocol (1/2 the amount should be infused in first 8 hours) 24 Hour Burn Fluid Calculation - ANSDosage x Kg x % - ml in first 24 hours -More than 20% of their TBSA burned require: *Adults: 2-4 ml of crystalloid solution x kg x % *Peds: 3-4 ml of crystalloid solution x kg x % *Infants: fluid with 5% dextrose at a maintenance rate in addition to the Peds rate protocol (1/2 the amount should be infused in first 8 hours) TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ 50 to 150 - ANSMAP Range A and approach is used by all members of the trauma team to provide optimal care for the trauma pt. - ANSSystematic , Organized A and approach is used by all members of the trauma team to provide optimal care for the trauma pt. - ANSSystematic , Organized A and approach is used by all members of the trauma team to provide optimal care for the trauma pt. - ANSSystematic , Organized A - ANS-AVPU -Cervical spine (2nd person and jaw-thrust maneuver - inspect palate ausvultate + 4 issues -state need for OPA -or definitive airway -reassess airway after insertion of opa (no snoring heard) A ... fracture is a complete craniofacial separation - ANSLefort III A ... fracture is a complete craniofacial separation - ANSLefort III A ... fracture is a complete craniofacial separation - ANSLefort III A 14 gauge needle that is inserted into the 2nd intercostal space in the midclavicular line on the affected side over the top of the rib to avoid neuromuscular bundle that runs under the rib. Prepare for chest tube placement. - ANSTension pneumo intervention A a 22 yr old was struck by a vehicle while crossing the street, sustaining multiple fx she is alert and ANSwering qestions and crying what is the best method for initial pain assessment for this pt - ANSself report scale TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A a pt sustrained a penetrating injury of his upper leg. the pre hospital personnel states a large amount of blood loss before hemostasiswas achieved. he presents to the ER responding to painful stimuli with moaning. he is tachy 142 b/p 104/96 and RR 24 - ANSdecompensated A an unrestrained driver was involved in a frontal collision without airbag deployment. he is hypotensive and tachycardic with shallow respirations, distended JVD and muffled heart tones the nurse prepare for what - ANSpericardiocentesis A body at rest will remain at rest, a body in motion will stay in motion - ANSNewton's first law TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A traumatic incident may be classified as ....(assault or suicide) or ... (falls or collisions) - ANSIntentional;unintentional A traumatic incident may be classified as ....(assault or suicide) or ... (falls or collisions) - ANSIntentional;unintentional A what is an early assessment finding to increased ICP in pt with a brain injury - ANSvomiting A when providing care for the pedicatric pt with burns the post resuscitation care, how are fluids delivered - ANSparkland formula with maintainence fluidss A which of hte following nursing interventions would be best for traumitc - ANSHOB 30 degrees A which of the following structures would be hte most affected by teh concept of caviation - ANSLiver A which of the following values is within the acceptable limits for trauma pt - ANSend tidal CO2 of 40 A- Alertness, Airway, Cspine - ANS-*APVU -*Hold c-spine and use jaw thrust if not talking (2 people) -*Determine patency and protection of airway using inspection, palpation, auscultation -*States need for OPA ABCDEFG(LMNOP)HI - ANSAirway+Alertness Breathing+Ventilation Circulation/Control of Hemorrhage Disability (neuro stat) Exposure/Environmental Control Full set of vitals + family TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Get resuscitation adjuncts -monitor cardiac rhythm, naso/gastric tube, oxygen, ETCO2, pain History +Head to toe Inspect posterior surface Abdominal Compartment Syndrome - ANSgut swelling, inflammatory process use foley catheter to measure pressure in bladder, if bladder pressure high=high intra- abdominal pressure Across-the-room Observation - ANSassess for obvious uncontrolled hemorrhage activation: consist of carotid and aortic bodies detect changes in blood oxygen and Co2 and pH. When Co2 rises or oxygen level of pH falls these receptors are activated TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ and information is relayed to the CNS and the cardiorespiratory centers in the medulla , which increases respiratory rage and depth and BP - ANSChemoreceptors: Adequate perfusion of oxygen and supply of nutrients to the brain tissue is dependent on ... and ... - ANSCPP; CBF Adequate perfusion of oxygen and supply of nutrients to the brain tissue is dependent on ... and ... - ANSCPP; CBF Adequate perfusion of oxygen and supply of nutrients to the brain tissue is dependent on ... and ... - ANSCPP; CBF Adrenal response - ANSRelease of catecholamines (epi and norepi) that increase contractility and HR Air cannot escape intrapleural space.. can begin to compress heart. pt will have sever resp distress, hypotension, JVD. - ANSTension pneumo Air enters the intrapleural space but cannot escape on expiration. The increasing intrathoracic pressure causes the lung on the injured side to collapse. If pressure is not relieved, the mediastinum can shift toward the uninjured side compressing the heart/great vessels/and opposite lung. S & S: anxiety, severe restlessness, severe respiratory distress, significantly diminished or absent breath sounds on injured side, hypotension, distended neck/head/upper extremity veins, tracheal deviation, or a shift toward uninjured side. Treatment: Needle thoracentesis and chest tube insertion - ANSTension Pneumothorax Air enters the intrapleural space but cannot escape on expiration. The increasing intrathoracic pressure causes the lung on the injured side to collapse. If pressure is not relieved, the mediastinum can shift toward the uninjured side compressing the heart/great vessels/and opposite lung. S & S: anxiety, severe restlessness, severe respiratory distress, significantly diminished or absent breath sounds on injured side, hypotension, distended neck/head/upper extremity veins, tracheal deviation, or a shift toward uninjured side. Treatment: Needle thoracentesis and chest tube insertion - ANSTension Pneumothorax TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ apply direct pressure to bleeding elevate extremity apply pressure over arterial sites Consider a pelvic binder for pelvic fractures consider a tourniquet cannulate two veins with large caliber IV - if unable to gain assess consider IO a. obtain labs, type and cross b. infuse warm isotonic fluids c. consider balanced resuscitation TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ d. use rapid infusion device - ANSC Interventions: As ICP increases CPP decreases resulting in ... - ANSCerebral ischemia, hypoxemia and lethal secondary insult As ICP increases CPP decreases resulting in ... - ANSCerebral ischemia, hypoxemia and lethal secondary insult As ICP increases CPP decreases resulting in ... - ANSCerebral ischemia, hypoxemia and lethal secondary insult ask pt to pen his or her mouth - ANSWhile assessing airway the patient is alert and responds to verbal stimuli you should.. Assessment findings with maxillary fractures include - ANSFacial edema, ecchymoses and diplopoa (lefort III) Assessment findings with maxillary fractures include - ANSFacial edema, ecchymoses and diplopoa (lefort III) Assessment findings with maxillary fractures include - ANSFacial edema, ecchymoses and diplopoa (lefort III) Avoid when administering oxygen/ventilation - ANShyperoxia Avoid when administering oxygen/ventilation - ANShyperoxia AVPU - ANSAlert, Verbal, Pain, Unresponsive AVPU - ANSID pt Need intubation B - ANS-Determine breathing effectiveness -state need for assisted ventilation with bag-valve mask device TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ -assess ET placement -Et secure, number at teeth documented -need for manuel ventilation B a pt father arrives in teh ER and needs to be told his son was severely injured in a MVC and is in surgery, the father si agitated, yelling, and smells of alcohol. in planning to talk with the father the trauma nurse will - ANSdeliver information regarding the son;s care in a calm voice B a pt involved in an MVC develops asymmetric pupillary reactivity, bilateral pupillary dilation and abnormal motor posturing. what does the nurse suspect as the most likely cause - ANSherniation syndrome TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ B which of the following hemodynamic support strategies is the prioririty intervention for a pt with traumatic pulmonary contusion - ANSjudicios use of IV fluids B-breathing and ventilation - ANS-*determine effectiveness of breathing using inspection, palpation, auscultation -*state need for BVM (10-12/min) Baby ok Then decrease LOC Weak cry - ANSHypoglycemia Base Excess (BE) - ANSnormal = -2 to +2 mEq/L base deficit < -6 is poor prognosis and develop acute traumatic coagulopathy (ATC) within 30 min basilar - ANSbase of skull, CSF leaks, periorbital edema, mastoid ecchymosis is battles sign Bduring the primary survery which of the following has the greatest priority - ANScervical spine injury Beck triad of cardiac tamponade - ANShypotension, distended neck veins, distant heart sounds Beck's Triad for Cardiac Tamponade - ANS1. Positive JVD 2. Muffled Heart Sounds 3. HOTN Becks triad - ANShypotension, JVD, muffled heart sounds pericardial surgery or aspiration of fluids Before the arrival of the pt - ANSWhen should PPE be placed: TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Bilaterally fixed and pinpoint pupils may indicate an injury where? - ANS@ the pons or be from the effects of opioids Bleeding around belly button - ANSCullen's Sign Bleeding around belly button - ANSCullen's Sign Blunt Cardiac Injury (BCI) - ANSBruising of the heart BLUNT ESOPHAGEAL INJURY - ANSair in the mediastinum with possible widening, sub q emphysema TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Bowel sounds heard in the L chest. What is this a symptom of? - ANSRuptured diaphragm Bowel sounds heard in the L chest. What is this a symptom of? - ANSRuptured diaphragm brachial pulse - ANSUnder age of 1 where do you find a pulse Breathing- *8 - ANS-spontaneous breathing -symmetrical chest rise and fall- flail -depth, pattern, rate of respiration -increase WOB -skin color -open wounds, deformities, sub q emphysema -tracheal deviation, JVD -breath sounds equal and present Breathing: To assess breathing expose the chest: 1.Inspect for a. spontaneous breathing b. symmetrical rise and fall c. depth, pattern, and rate of respiration d. signs of difficulty breathing such as accessory muscle use e. skin color (normal, pale, flushed, cyanotic) f. contusions, abrasions, deformities (flail chest) g. open pneumothoraces (sucking chest wounds) h. JVD i. signs of inhalation injury (singed nasal hairs, carbonaceous sputum) - ANSB C - ANScirculation and control of hemorrhage -3 inspects for uncontrolled hemorrhage, palates central pulse, inspects and palpates skin for color, temp and moisture. TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ can be caused by blunt trauma. air escapes from injured lung to pleural space and negative intrapleural pressure is lost causing partial or collapsed lung - ANSSimple Pneumothorax Can be caused by blunt trauma. Air escapes from the injured lung into the pleural space, and negative intrapleural pressure is lost resulting in partial or complete collapse of the lung. S & S: dyspnea, tachypnea, decreased/absent breath sounds on injured side, chest pain. Treatment: based on size, symptoms, and stability. Chest tube may be placed to evacuate pleural air and maintain lung expANSion - ANSPneumothorax Can be caused by blunt trauma. Air escapes from the injured lung into the pleural space, and negative intrapleural pressure is lost resulting in partial or complete collapse of the lung. S & S: dyspnea, tachypnea, decreased/absent breath sounds on injured TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ side, chest pain. Treatment: based on size, symptoms, and stability. Chest tube may be placed to evacuate pleural air and maintain lung expANSion - ANSPneumothorax can result from penetrating wound through chest wall causing air to be trapped in to the intrapleural place. Might hear "sucking" Tx: nonporous dressing tapes on 3 sided, then Chest tube and would closure surgical repair. - ANSOpen Pneumo: Capnography monitors numeric value, as well as continuous waveform, indicating real- time measurement and trending over time. - ANSQuantitative: Cardiac Tamponade - ANScompression of heart due to fluid accumulation within pericardium Cardiac tamponade - ANSPericardial window Cardiogenic - ANS-ineffective perfusion caused by inadequate contractility of heart -blunt cardiac injury -pressors, dop, epi, NO FLUIDS Cardiogenic shock - ANSAntiarrythmics Care of Amputations - ANS-Remember ABCDs -Focus on Life-Threatening Injuries -Circulation: control bleeding, elevate & apply pressure on artery -Vasoconstriction reflex: decreases bleeding Save life over limb! Cause of Spleen & Liver Injuries - ANSMVC/T-bone TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Caused by a sudden stop of the body's motion - ANSDeceleration forces Caused by a sudden stop of the body's motion - ANSDeceleration forces Caused by a sudden stop of the body's motion - ANSDeceleration forces Caused by blood in the intrapleural space/ May also occur from lac to live or spleen combined with injury to the diaphragm. Ensure two large bore IVS are placed. Prepare for thoracentesis and chest tube insertion. If open thoracotomy is done chest tube is deferred. - ANSHemothorax: TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Inspect first for any uncontrolled bleeding Skin color palpate for central pulses - carotid and femoral - rate, rhythm, and strength Skin temp: cool, diaphoretic, or warm and dry - ANSC Circulation- *3 - ANS-uncontrolled hemorrhage-elevate to heart, pressure, tourniquet -central and peripheral pulses -skin color, temp, moisture, cap refill Class 1 hemorrhagic shock - ANS- Loss of 15% (less than 750mL) of blood volume - Minimal tachycardia - less than 100BPM - No measureable change in BP, Pulse pressure, and RR - Body can compensate well -Anxious Class 2 Hemorrhage - ANSVasoconstriction still maintains BP, but with difficulty Blood flow is increased to vital orgANS (midbrain, heart, kidneys?) - Flow is decreased to kidneys, intestines, and skin -Loos of 15-30% of blood volume (750-1,500mL) Effects - Patient may be aggitated - Pale, cool, dry or moist skin - Pulse pressure narrows - Rapid heart rate - over 100 - Respiratory rate increases -20-30 - Delayed capillary refill Class 3 Hemorrhage - ANSVasoconstriction no longer maintains BP TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ -blood loss 30-40% or 1,500-2,000mL Cardiac output decreases and becomes life-threatening Effects - Patient becomes more confused, restless, and agitated - Rapid heart rate - over 120 - Decreased systolic BP - Rapid respiratory rate 30-40 - Pale, cool, clammy extremities Class 4 Hemorrhage - ANSVasoconstriction is problematic and further impairs tissue perfusion and cellular oxygenation -blood loss greater than 40% and 2,000mL. TNCC FINAL EXAM 4 LATEST VERSIONS 2024-2025 CONTAINS 500 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Effects - Severely decreased mental status or loss of consciousness - lethargic - Marked tachycardia - over 140 -RR over 35 - Ultimately leads to organ failure and death CO - ANS=stroke volume+HR Co2 ... causes dilation of cerebral arterial vasculature and increased blood flood and increased ICP causes constriction and decreased blood flow.! - ANSHypercapnia; hypocapnia Co2 ... causes dilation of cerebral arterial vasculature and increased blood flood and increased ICP causes constriction and decreased blood flow.! - ANSHypercapnia; hypocapnia Co2 ... causes dilation of cerebral arterial vasculature and increased blood flood and increased ICP causes constriction and decreased blood flow.! - ANSHypercapnia; hypocapnia Collaborative Care of Flail Chest - ANS-Adequate Oxygenation-100% mask -Monitor for Hypoxemia-ABGs, SpO2 -Pain Management-Intercostal Block, Epidural, PCA -Possible Mechanical Ventilation Collaborative Care of Tension Pneumothorax - ANS-Oxygen -Needle Thoracentesis -Heimlich Valve: one way valve, allows air out but not in -Monitor SpO2, ABGs, RR, depth, BS -Chest Tube