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TNCC: THE NURSING PROCESS EXAM QUESTIONS
Actual Qs and Ans - Expert-Verified Explanation -Guaranteed passing score -12 Questions and Answers
-Format: Multiple-choice / Flashcard
Question 1: Exposure & Environment (E)
Answer:
- Remove all clothing
AND inspect for uncontrolled bleeding/obvious injuries.
2. Keep patient warm:
- blankets
- warming lights
- increased room temperature
- warmed fluids
- warmed oxygen
Question 2: Preparation and Triage
Answer:
- Activate the trauma team.
- Prepare the Trauma Room.
- Rapid infuser
- Chest trauma equipment
- States the need to don PPE
Question 3: Secondary Survey (H)
Answer:
History (MIST, SAMPLE) Head-to-Toe
- Head: Inspect for LACE feel for TIC
- Neck: obtain assistance to stabilize the cervical spine while removing the collar to inspect & palpate.
- Chest: Inspect for LACE feel for TIC, auscultate breath sounds & heart sounds.
- Abdomen: Inspect, auscultate, palpate.
- Pelvis: Inspect pelvis & perineum for injuries, apply gentle pressure over iliac crests downward &
medially, then apply gentle pressure on the symphys pubis. Consider a foley.
- Extremities: inspect & palpate, CSM, pulses.
Question 4: Disability/Neurologic Status (D)
Answer:
- Assess GCS **
- Eye Opening
- Verbal Response
- Motor Response
- Assess Pupils (PERRL)
- Assess the need for CT of the head & cervical spine.
** Question 5: Primary Survey: Circulation & Control of Hemorrhage (C)
Answer:
1. Determine the adequacy of circulation: **
- Inspect for uncontrolled hemorrhage.
- Palpate a central pulse.
- Inspect & palpate the skin for colour, temperature, & moisture.
- Assess the patency of prehospital IVs.
- Assess the need for additional large-caliber IV.**
- Assess the need for the administration of warmed, isotonic crystalloid w/ blood tubing
AND @ a controlled rate .
Question 6: Primary Survey: Breathing & Ventilation - Intubation
Answer:
Assess ET tube placement: **
(1) Attach CO2 detector (2) Observe for bilateral rise & fall of chest + auscultate over the epigastrium + bilateral breath sounds.(3) Observe the CO2 detector for 'yellow' after 5-6 breaths.(4) Assess for improvement in skin colour.
- Assess ETT position
- Assess the need to begin mechanical ventilation or continue assisted ventilation.
AND secure the ETT, identifying method used.
Question 7: Reevaluation Adjuncts
Answer:
- Summarize injuries identified.
- Reevaluation adjuncts
- CT
- Xray
- Clean & dress wounds
- Tetanus immunization
- Antibiotics
- FAST
- What findings would you re-evaluate?
(1) Primary Assessment (2) Vitals (3) Pain (4) Identified injuries & effectiveness of interventions.
- Determine the definitive care of the patient (transfer, admission, surgery, etc.)
Question 8: Across-the-room Observation
Answer:
Assess for obvious uncontrolled external hemorrhage.Question 9: Primary Survey: Airway + Cervical Spinal Stabilization (A)
Answer:
- Assess AVPU**
- Ask a 2nd person to provide manual cervical spinal stabilization
AND manually open the airway using the jaw-thrust maneuver.**
3. Determine airway patency:** (4)
- tongue obstruction
- loose teeth
- foreign objects
- blood, vomitus, or other secretions
- edema
- snoring, gurgling, or stridor
- Assess the need for an OPA**
- Assess the need for a definitive airway
- Reassess the airway after insertion of the OPA.
Question 10: Secondary Survey (I)
Answer:
Inspect Posterior Surfaces
- Maintain cervical & spinal stabilization to logroll patient.
- Inspect & palpate posterior spine.
- Consider removal of spine board.
Question 11: Resuscitation Adjuncts (F, G)
Answer:
- Full set of vitals
- Family presence
Get resuscitation adjuncts: (LMNOP)
- Labs
- Monitor (cardiac)
- NG tube
- Oxygen
- Pain + Nonpharmacologic comfort measures
***Consider obtatining order for analgesics.Question 12: Primary Survey: Breathing & Ventilation (B)
Answer:
1. Determine breathing effectiveness: ** (4)
Inspect:
- Spontaneous breathing?
- Symmetrical chest rise?
- Depth/pattern/rate of respirations?
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