TCRN Certification Exam — Questions and Answers

Question 1: Current evidence-based guidelines regarding high-dose methylprednisolone for acute spinal cord injury state that it:

Should be given within 8 hours for all complete cervical injuries
Is no longer recommended as standard care due to complications outweighing benefit (Correct answer)
Is recommended as standard of care within 24 hours of injury
Should be reserved for thoracic injuries only

Correct answer: Is no longer recommended as standard care due to complications outweighing benefit

High-dose methylprednisolone has been removed from standard SCI protocols because risks — including infection, GI bleeding, and pulmonary complications — outweigh the marginal neurological benefit shown in older trials.

Question 2: An intubated TBI patient has a sudden rise in ICP from 18 to 32 mmHg with simultaneous SpO2 drop. What is the most likely cause?

Seizure activity
Cerebral vasospasm
Osmotic diuresis from mannitol
Endotracheal tube obstruction or dislodgement (Correct answer)

Correct answer: Endotracheal tube obstruction or dislodgement

Simultaneous ICP spike and SpO2 drop suggest airway compromise such as ETT obstruction or dislodgement, causing hypoxia and secondary ICP elevation.

Question 3: A trauma patient with spinal cord injury at T6 complains of severe headache and has a BP of 220/115 mmHg. What condition should the nurse immediately suspect?

Cushing's reflex from intracranial hypertension
Neurogenic shock converting to hypertension
Hypertensive emergency from pain
Autonomic dysreflexia (Correct answer)

Correct answer: Autonomic dysreflexia

Autonomic dysreflexia (AD) is a sudden hypertensive crisis in patients with SCI at T6 or above triggered by noxious stimuli below the injury level, most commonly a full bladder.

Question 4: A patient sustains a stab wound to the right chest and develops absent breath sounds on the right with tracheal deviation to the left. The priority intervention is:

Immediate chest X-ray
High-flow oxygen via non-rebreather mask
Placement of a chest tube on the right
Needle decompression of the right chest (Correct answer)

Correct answer: Needle decompression of the right chest

Tracheal deviation away from the affected side with absent breath sounds indicates tension pneumothorax, requiring immediate needle decompression at the 2nd intercostal space, midclavicular line.

Question 5: When using the Parkland formula for fluid resuscitation in a 70 kg adult with 40% TBSA burns, how much lactated Ringer's should be given in the first 8 hours?

11,200 mL
2,800 mL
8,400 mL
5,600 mL (Correct answer)

Correct answer: 5,600 mL

Parkland formula: 4 mL × kg × %TBSA = 4×70×40=11,200 mL total; half (5,600 mL) is given in the first 8 hours post-burn.

Question 6: Spinal shock is defined as which of the following phenomena following acute spinal cord injury?

Cardiovascular collapse from loss of sympathetic vasomotor tone
Transient depression of all spinal reflexes and flaccid paralysis below the injury level (Correct answer)
Vasodilation with hypotension and compensatory tachycardia
Severe neuropathic pain radiating from the spinal cord injury site

Correct answer: Transient depression of all spinal reflexes and flaccid paralysis below the injury level

Spinal shock is a transient state of depressed cord function below the injury, characterized by flaccidity and absent reflexes; return of the bulbocavernosus reflex marks its resolution.

Question 7: A patient sustains burns to the anterior trunk, both arms, and the head. Using the Rule of Nines, what is the estimated TBSA burned?

63%
36%
45% (Correct answer)
54%

Correct answer: 45%

Anterior trunk = 18%, each arm = 9% (×2 = 18%), head = 9%, totaling 45% TBSA.

Question 8: Intra-abdominal pressure (IAP) is most accurately measured using which method in the trauma ICU?

Direct peritoneal catheter manometry
Nasogastric tube manometry
Bladder (intravesical) pressure via Foley catheter (Correct answer)
Rectal pressure transducer

Correct answer: Bladder (intravesical) pressure via Foley catheter

Intravesical pressure measurement via the Foley catheter is the standard surrogate for intra-abdominal pressure measurement and is recommended by the WSACS guidelines.

Question 9: A trauma nurse is subpoenaed to testify about a patient's care. The nurse's best source of information during testimony is:

Memory of events recalled after reviewing social media posts
A colleague's verbal account of the events
A summary written the night before the deposition
The contemporaneous medical record documented at the time of care (Correct answer)

Correct answer: The contemporaneous medical record documented at the time of care

The contemporaneous medical record is the most legally credible and reliable account of the care provided.

Question 10: When assessing a 7-year-old trauma patient, the nurse notes that the child is able to follow commands but is crying and inconsolable. Using the Pediatric Glasgow Coma Scale, how should verbal response be scored?

Score of 5 — oriented
Score of 4 — confused (Correct answer)
Score of 2 — incomprehensible sounds
Score of 3 — inappropriate words

Correct answer: Score of 4 — confused

In the pediatric GCS, a child who is crying but not using appropriate conversational words scores a 3 for inappropriate words.

Question 11: Which sign indicates that a burn patient's inhalation injury has progressed to involve the lower airway?

Soot in the oropharynx
Wheezing and bronchospasm on auscultation (Correct answer)
Stridor and hoarseness on presentation
Singed nasal hairs and facial burns

Correct answer: Wheezing and bronchospasm on auscultation

Wheezing and bronchospasm indicate lower airway involvement from inhaled toxins and heat, while stridor and hoarseness suggest upper airway injury.

Question 12: A patient with a T4 SCI suddenly develops a pounding headache, profuse sweating above the injury level, and BP of 210/110 mmHg. What is the FIRST nursing action?

Sit the patient upright and assess for bladder distension or fecal impaction (Correct answer)
Administer IV labetalol immediately
Call the physician for an antihypertensive order
Apply supplemental oxygen via non-rebreather mask

Correct answer: Sit the patient upright and assess for bladder distension or fecal impaction

Autonomic dysreflexia is first managed by sitting the patient upright (orthostatic BP reduction) and identifying and removing the triggering noxious stimulus, most commonly bladder distension.

Question 13: A patient arrives after being struck in the anterior neck with a baseball bat. They are hoarse, have subcutaneous emphysema, and are in moderate respiratory distress. What is the most appropriate initial airway management strategy for this patient?

Rapid sequence intubation (RSI)
Nasotracheal intubation
Placement of a supraglottic airway device
Awake surgical cricothyroidotomy or tracheostomy (Correct answer)

Correct answer: Awake surgical cricothyroidotomy or tracheostomy

In patients with suspected severe laryngeal or tracheal trauma, attempts at endotracheal intubation can worsen the injury, create a false passage, or cause complete airway obstruction. [16, 21, 22] Therefore, the safest and most definitive airway is an awake surgical airway (cricothyroidotomy or tracheostomy), performed by an experienced provider, to bypass the injured area.

Question 14: The Parkland formula for fluid resuscitation in a burn patient with 40% TBSA burn weighing 80 kg orders how much LR in the first 8 hours?

6,400 mL (Correct answer)
4,800 mL
12,800 mL
3,200 mL

Correct answer: 6,400 mL

Parkland formula: 4 mL × kg × %TBSA = 4 × 80 × 40 = 12,800 mL total; half (6,400 mL) is given in the first 8 hours from time of injury.

Question 15: Which finding suggests an intraperitoneal bladder rupture rather than an extraperitoneal rupture on cystogram?

Flame-shaped contrast leakage at the bladder base
Contrast outlining bowel loops and paracolic gutters (Correct answer)
Contrast extravasation confined to the perivesical space
Contrast confined below the peritoneal reflection

Correct answer: Contrast outlining bowel loops and paracolic gutters

Intraperitoneal bladder rupture allows contrast to flow freely into the peritoneal cavity, outlining bowel loops and paracolic gutters on cystogram.

Question 16: A patient with a basilar skull fracture most likely exhibits which sign indicating cerebrospinal fluid leak from the ear?

Rhinorrhea
Raccoon eyes
Otorrhea with a halo sign (Correct answer)
Battle's sign

Correct answer: Otorrhea with a halo sign

Otorrhea with a positive halo (ring) sign on filter paper indicates CSF leaking from the ear, consistent with a basilar skull fracture.

Question 17: Using the Rule of Nines in an adult, what percentage of TBSA does a burn covering the entire anterior trunk represent?

9%
36%
27%
18% (Correct answer)

Correct answer: 18%

The anterior trunk (chest and abdomen) represents 18% of TBSA in adults using the Rule of Nines.

Question 18: In a patient with a femur fracture, the nurse should monitor for which potentially life-threatening complication that can occur within 24–72 hours?

Fat embolism syndrome (Correct answer)
Osteomyelitis
Compartment syndrome
Deep vein thrombosis

Correct answer: Fat embolism syndrome

Fat embolism syndrome typically occurs 24–72 hours after long bone fractures, presenting with the classic triad of hypoxemia, neurological changes, and petechial rash.

Question 19: A trauma patient develops worsening abdominal distension, increasing vasopressor requirements, oliguria, and elevated peak airway pressures 24 hours post-laparotomy with temporary abdominal closure. What syndrome is developing?

Abdominal compartment syndrome (Correct answer)
Acute respiratory distress syndrome
Systemic inflammatory response syndrome
Tension pneumothorax

Correct answer: Abdominal compartment syndrome

Abdominal compartment syndrome is defined by intra-abdominal pressure >20 mmHg with new organ dysfunction, presenting with exactly these signs after abdominal trauma or surgery.

Question 20: A trauma patient's compartment pressure is measured at 32 mmHg. Diastolic blood pressure is 60 mmHg. What does the delta pressure indicate?

Delta pressure of 28 mmHg — fasciotomy is indicated (Correct answer)
Delta pressure of 92 mmHg — safe to observe
Delta pressure of 32 mmHg — fasciotomy is indicated
Delta pressure of 28 mmHg — safe to observe

Correct answer: Delta pressure of 28 mmHg — fasciotomy is indicated

Delta pressure = diastolic BP minus compartment pressure (60 − 32 = 28 mmHg); a delta ≤30 mmHg is the threshold for fasciotomy.

Question 21: A patient with a high thoracic SCI is noted to have a body temperature that mirrors the room temperature. The nurse documents this as:

Hypothermia secondary to spinal shock
Poikilothermia (Correct answer)
Malignant hyperthermia
Autonomic dysreflexia

Correct answer: Poikilothermia

Poikilothermia occurs when high-level SCI disrupts the autonomic hypothalamic-to-peripheral thermoregulation pathway, causing the patient's temperature to passively equilibrate with the environment.

Question 22: A trauma patient receives 10 units of PRBCs during massive transfusion. Which complication is specifically associated with this volume of transfusion?

Transfusion-associated circulatory overload (TACO) (Correct answer)
Immediate hemolytic reaction
Polycythemia
ARDS from hyperoxygenation

Correct answer: Transfusion-associated circulatory overload (TACO)

Massive transfusion increases risk of TACO, characterized by pulmonary edema, hypertension, and respiratory distress from volume overload.

Question 23: Using the Rule of Nines in an adult patient, a burn covering the entire right arm and the front of the right leg equals what total body surface area (TBSA)?

13.5%
22.5% (Correct answer)
18%
27%

Correct answer: 22.5%

The right arm is 9% TBSA and the front of one leg is 9% divided by 2 = 4.5% — but standard teaching: right arm = 9%, anterior right leg = 9%/2 = 4.5%, but front of right leg alone is 9%; combined = 9 + 9 = 18% — however anterior leg only = 9%; right arm = 9%; total = 18%. Answer depends on interpretation; anterior right leg = 9%, right arm = 9%, total = 18%.

Question 24: A patient with a pelvic fracture is hemodynamically unstable despite 2L crystalloid. The MOST appropriate next intervention is:

Bilateral femoral artery cutdowns for rapid access
Pelvic binder application and activation of massive transfusion protocol (Correct answer)
Foley catheter insertion to monitor urinary output
Immediate CT pelvis to characterize the fracture pattern

Correct answer: Pelvic binder application and activation of massive transfusion protocol

A pelvic binder reduces pelvic volume and tamponades venous bleeding while the massive transfusion protocol addresses hemorrhagic shock.

Question 25: Which parameter is the most sensitive early indicator of hemorrhagic shock in a healthy young trauma patient?

Tachycardia (Correct answer)
Systolic blood pressure drop
Decreased urine output
Altered mental status

Correct answer: Tachycardia

Tachycardia is the earliest and most sensitive compensatory response to hemorrhage, occurring before a significant drop in blood pressure.

Question 26: A patient has a midshaft humerus fracture. Which nerve injury should the nurse assess for?

Radial nerve palsy causing wrist drop (Correct answer)
Ulnar nerve injury causing clawing of the ring and small fingers
Median nerve injury causing thenar atrophy
Axillary nerve injury causing deltoid weakness

Correct answer: Radial nerve palsy causing wrist drop

The radial nerve spirals around the posterior humerus in the radial groove and is commonly injured in midshaft humerus fractures, causing wrist drop.

Question 27: A blunt trauma patient has absent breath sounds on the left, tracheal deviation to the right, hypotension, and SpO2 of 82%. What is the immediate action?

Chest tube insertion
Needle decompression of the left chest (Correct answer)
Chest X-ray confirmation
Intubation and positive pressure ventilation

Correct answer: Needle decompression of the left chest

Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression; do not delay for imaging in a hemodynamically unstable patient.

Question 28: A trauma patient develops Beck's triad. Which intervention is MOST immediately appropriate?

Immediate thoracotomy
Chest tube insertion
Pericardiocentesis (Correct answer)
Fluid bolus and vasopressors

Correct answer: Pericardiocentesis

Beck's triad (hypotension, muffled heart sounds, JVD) indicates cardiac tamponade; pericardiocentesis decompresses the pericardial sac emergently.

Question 29: Cushing's triad, the late sign of increased ICP, includes which three findings?

Tachycardia, hypotension, and bradypnea
Tachycardia, hypertension, and tachypnea
Bradycardia, hypotension, and apnea
Bradycardia, hypertension, and irregular respirations (Correct answer)

Correct answer: Bradycardia, hypertension, and irregular respirations

Cushing's triad—bradycardia, hypertension, and irregular respirations—is a late, ominous sign of brainstem herniation.

Question 30: What does the L stand for when using the acronym AMPLE to quickly acquire crucial information about the patient's history?

legal directives.
last meal (Correct answer)
loss of blood
length of time since injury.

Correct answer: last meal

The letter L stands for ""Last Meal"" when the acronym AMPLE is used to quickly gather vital information about the patient's history; this information is that which is required to give the patient emergency care. In the event that the patient is unconscious, a friend or family member may give information: A = Allergies M = stands for medicines, all current. P = Previous conditions and operations L = stands for last meal (time, volume, and size). E = The Injury's Environment or Related Events

Question 31: A patient with a complete T2 SCI is 48 hours post-injury. Which early complication poses the GREATEST immediate threat to life?

Urinary tract infection
Adjustment disorder and depression
Heterotopic ossification
Deep vein thrombosis and pulmonary embolism (Correct answer)

Correct answer: Deep vein thrombosis and pulmonary embolism

DVT and PE are leading causes of early mortality in acute SCI due to complete venous stasis from lower extremity paralysis; prophylaxis should be initiated within 72 hours.

Question 32: A patient arrives following a diving accident with suspected cervical spine injury. What is the FIRST priority for the trauma nurse?

Perform a complete ASIA neurological assessment
Establish two large-bore IV lines immediately
Maintain cervical spine immobilization while managing the airway (Correct answer)
Administer high-dose methylprednisolone within 8 hours

Correct answer: Maintain cervical spine immobilization while managing the airway

Airway management with simultaneous cervical spine stabilization is the first priority in any suspected spinal cord injury, following the primary survey framework.

Question 33: A trauma patient is in shock with penetrating abdominal trauma. The FAST exam shows free fluid. Despite two large-bore IVs and rapid infusion, BP remains 68/40. What is the definitive management?

Administer vasopressors to bridge to OR
Emergent surgical hemorrhage control in the operating room (Correct answer)
Continue aggressive IV fluid resuscitation until normotensive
Interventional radiology embolization

Correct answer: Emergent surgical hemorrhage control in the operating room

Hemorrhagic shock from penetrating abdominal trauma with free fluid requires emergent operative hemorrhage control; ongoing resuscitation without source control is futile.

Question 34: A trauma nurse who begins experiencing nightmares, emotional numbing, and avoidance of trauma cases is likely experiencing:

Normal adjustment to a high-acuity environment
Burnout only
Compassion fatigue or secondary traumatic stress (Correct answer)
Depression unrelated to work

Correct answer: Compassion fatigue or secondary traumatic stress

Compassion fatigue/secondary traumatic stress occurs when caregivers absorb the trauma of their patients, producing PTSD-like symptoms.

Question 35: A patient arrives after a gunshot wound to the abdomen with eviscerated bowel through the wound. What is the appropriate initial management of the eviscerated bowel?

Irrigate the bowel with normal saline and apply an occlusive dressing
Cover with warm, moist saline-soaked dressings and prepare for surgery (Correct answer)
Attempt to replace the bowel back into the abdomen
Apply dry sterile gauze and wait for surgical consultation

Correct answer: Cover with warm, moist saline-soaked dressings and prepare for surgery

Eviscerated bowel should be covered with warm, moist saline dressings to prevent desiccation while the patient is urgently taken to the operating room.

Question 36: A pediatric trauma patient weighing 20 kg is in hemorrhagic shock. What is the initial fluid bolus dose?

300 mL of normal saline (Correct answer)
1,000 mL of lactated Ringer's
500 mL of normal saline
200 mL of normal saline

Correct answer: 300 mL of normal saline

Pediatric initial fluid resuscitation for hemorrhagic shock is 10-20 mL/kg; for a 20 kg child, 300 mL represents a 15 mL/kg bolus within this range.

Question 37: When calculating fluid resuscitation using the Parkland formula for a 70 kg patient with 30% TBSA burns, what is the total 24-hour lactated Ringer's volume?

2,100 mL
8,400 mL (Correct answer)
4,200 mL
12,000 mL

Correct answer: 8,400 mL

Parkland formula: 4 mL × 70 kg × 30% TBSA = 8,400 mL total over 24 hours.

Question 38: A trauma patient has BP 78/50, HR 128, distended neck veins, and muffled heart sounds after a steering wheel injury. Which intervention is the priority?

Pericardiocentesis (Correct answer)
Emergency thoracotomy
Needle thoracostomy
Massive transfusion protocol

Correct answer: Pericardiocentesis

Beck's triad (hypotension, distended neck veins, muffled heart sounds) indicates cardiac tamponade, treated emergently with pericardiocentesis.

Question 39: Which coagulopathy triad is associated with worsening hemorrhagic shock and increased mortality in trauma?

Hypothermia, acidosis, and coagulopathy (Correct answer)
Hyperthermia, alkalosis, and thrombocytosis
Bradycardia, hyperthermia, and polycythemia
Hypertension, alkalosis, and hypercoagulability

Correct answer: Hypothermia, acidosis, and coagulopathy

The lethal triad of hypothermia, acidosis, and coagulopathy creates a self-reinforcing cycle that is associated with high mortality in hemorrhagic shock.

Question 40: Which of the following is the primary goal of damage control resuscitation (DCR) in a patient with exsanguinating hemorrhage?

To normalize all vital signs and laboratory values to pre-injury levels in the emergency department.
To restore physiologic stability and correct coagulopathy before surgical intervention. (Correct answer)
To aggressively infuse crystalloid fluids to achieve a systolic blood pressure greater than 120 mmHg.
To rapidly transport the patient to the operating room for definitive surgical hemorrhage control.

Correct answer: To restore physiologic stability and correct coagulopathy before surgical intervention.

Damage control resuscitation (DCR) is a strategy that prioritizes restoring physiologic stability to prevent or reverse the trauma triad of death, allowing the patient to survive until definitive surgical repair can be performed. Key components include permissive hypotension, hemostatic resuscitation with blood products over crystalloids, and prevention of hypothermia and acidosis. The goal is not to normalize all parameters immediately, but to stabilize the patient enough to tolerate surgery.

Question 41: Which intervention is the priority when a spinal cord injury patient develops autonomic dysreflexia with BP 220/130 mmHg?

Administer IV normal saline 500 mL bolus
Administer IV morphine for pain
Lay the patient flat and apply a cooling blanket
Sit the patient upright and identify and remove the triggering stimulus immediately (Correct answer)

Correct answer: Sit the patient upright and identify and remove the triggering stimulus immediately

Sitting the patient upright uses gravity to lower BP while rapid identification and removal of the offending stimulus is the definitive treatment.

Question 42: An Rh-negative pregnant trauma patient at 20 weeks gestation requires Rh immunoglobulin (RhoGAM). What is the standard initial dose and timing?

600 mcg at any time post-trauma
300 mcg within 72 hours (Correct answer)
300 mcg within 24 hours only
50 mcg within 72 hours

Correct answer: 300 mcg within 72 hours

Standard RhoGAM dose is 300 mcg IM within 72 hours of potential fetal-maternal hemorrhage to prevent Rh sensitization; additional doses may be needed if KB test shows large bleed.

Question 43: Grief following traumatic death of a patient is a normal response for trauma nurses. Which statement about nurse grief is true?

Nurse grief should always be expressed openly in front of patients
Grief in nurses only becomes problematic if it lasts more than 24 hours
Nurses who grieve patient deaths are not suited for trauma nursing
Acknowledging grief and participating in debriefs or memorials promotes resilience and reduces burnout (Correct answer)

Correct answer: Acknowledging grief and participating in debriefs or memorials promotes resilience and reduces burnout

Debriefing, peer support, and rituals of acknowledgment allow nurses to process grief healthily, supporting long-term resilience.

Question 44: A 75-year-old patient is on warfarin for atrial fibrillation and presents after a ground-level fall with a head CT showing subdural hematoma. What is the priority reversal agent?

Vitamin K alone (IV)
Protamine sulfate
Fresh frozen plasma alone
4-factor prothrombin complex concentrate (4F-PCC) plus vitamin K (Correct answer)

Correct answer: 4-factor prothrombin complex concentrate (4F-PCC) plus vitamin K

4F-PCC provides immediate factor replacement for rapid reversal of warfarin, while concurrent vitamin K sustains reversal; FFP is slower and volume-intensive.

Question 45: A trauma patient with a scalp laceration is found to have a depressed skull fracture on CT. Which finding would most clearly indicate the need for urgent surgical intervention?

Fracture depression greater than the thickness of the skull with dural tear (Correct answer)
Fracture overlying the parietal bone only
Isolated linear fracture with overlying hematoma
Fracture depth equal to skull thickness

Correct answer: Fracture depression greater than the thickness of the skull with dural tear

A depressed skull fracture with depression greater than skull thickness and an associated dural tear typically warrants surgical elevation to prevent infection and neurological deficit.

Question 46: Tranexamic acid (TXA) is most effective when administered to hemorrhagic trauma patients within what time frame?

Within 6 hours of injury
Within 1 hour of injury
Within 12 hours of injury
Within 3 hours of injury (Correct answer)

Correct answer: Within 3 hours of injury

The CRASH-2 trial established TXA is most effective when given within 3 hours of injury; administration after 3 hours may increase mortality.

Question 47: A patient is extricated from a structural collapse with severe crush injuries to both lower extremities. The trauma nurse should anticipate which hallmark laboratory finding and prioritize which intervention to prevent acute kidney injury?

Hyperkalemia; administration of intravenous insulin and dextrose
Decreased hemoglobin; transfusion of packed red blood cells
Elevated creatinine kinase (CK); aggressive intravenous fluid resuscitation (Correct answer)
Hypocalcemia; administration of calcium gluconate

Correct answer: Elevated creatinine kinase (CK); aggressive intravenous fluid resuscitation

The hallmark laboratory finding for rhabdomyolysis is a markedly elevated creatinine kinase (CK) level, often greater than 5 times the upper limit of normal. The breakdown of muscle releases myoglobin, which is nephrotoxic. The primary intervention to prevent acute kidney injury is aggressive intravenous fluid resuscitation to maintain high urine output and flush the myoglobin through the renal tubules. While electrolyte abnormalities like hyperkalemia occur, treating the underlying cause with fluids is the priority.

Question 48: A patient with crush syndrome involving both lower extremities is at HIGHEST risk for which life-threatening complication?

Disseminated intravascular coagulation
Respiratory alkalosis
Acute renal failure from myoglobinuria (Correct answer)
Hypernatremia

Correct answer: Acute renal failure from myoglobinuria

Crush syndrome releases myoglobin from damaged muscle, which precipitates in renal tubules causing acute tubular necrosis and renal failure, requiring aggressive fluid resuscitation to prevent it.

Question 49: A patient with inhalation injury has a PaO2 of 55 mmHg on 100% non-rebreather mask. Which intervention should be initiated?

Perform bronchoscopy for airway clearance
Initiate prone positioning immediately
Administer IV methylprednisolone
Increase PEEP on the ventilator (Correct answer)

Correct answer: Increase PEEP on the ventilator

Refractory hypoxemia in intubated inhalation injury patients is treated with increased PEEP to recruit collapsed alveoli and improve oxygenation.

Question 50: Under EMTALA, a trauma center is obligated to do which of the following for any patient who presents to the emergency department?

Provide a medical screening examination regardless of ability to pay (Correct answer)
Contact the patient's primary care physician before evaluation
Transfer the patient to a facility that accepts their insurance
Obtain insurance authorization before treatment

Correct answer: Provide a medical screening examination regardless of ability to pay

EMTALA requires hospitals to provide a medical screening examination and stabilizing treatment to all patients regardless of insurance or payment status.

Question 51: A ventilator-dependent C5 SCI patient develops increased secretions and diminished breath sounds in the right lower lobe. What is the PRIORITY nursing intervention?

Increase FiO2 to 100% until secretions clear
Perform chest physiotherapy and assisted (quad) cough technique (Correct answer)
Increase PEEP on the ventilator settings
Request urgent bedside bronchoscopy

Correct answer: Perform chest physiotherapy and assisted (quad) cough technique

Pulmonary hygiene with chest physiotherapy and assisted coughing is the priority nursing intervention to clear secretions in high-level SCI patients who have lost the independent ability to cough.

Question 52: Which finding on point-of-care ultrasound (POCUS/FAST exam) indicates a hemodynamically significant pericardial effusion causing obstructive shock?

Hyperkinetic left ventricle
Left ventricular hypertrophy
Right ventricular diastolic collapse (Correct answer)
Dilated inferior vena cava with respiratory variation

Correct answer: Right ventricular diastolic collapse

Right ventricular diastolic collapse on ultrasound is the hallmark sign of cardiac tamponade causing hemodynamically significant pericardial effusion.

Question 53: Which type of facial fracture involves the orbital floor and can cause entrapment of the inferior rectus muscle?

Mandibular condyle fracture
Nasal bone fracture
Orbital blowout fracture (Correct answer)
Zygomatic arch fracture

Correct answer: Orbital blowout fracture

Orbital blowout fractures fracture the orbital floor, potentially trapping the inferior rectus muscle and causing diplopia and restricted upward gaze.

Question 54: A patient with facial trauma and suspected Le Fort III fracture is at greatest risk for which airway complication?

Complete craniofacial separation with airway loss (Correct answer)
Laryngeal fracture
Bilateral vocal cord paralysis
Tracheal tear

Correct answer: Complete craniofacial separation with airway loss

Le Fort III fractures involve craniofacial disjunction, placing the patient at risk for total airway obstruction due to posterior displacement of the midfacial skeleton.

Question 55: Which finding in a wound suggests the presence of necrotizing fasciitis requiring emergent surgical debridement?

Localized fluctuance indicating abscess formation
Skin that appears normal overlying a rapidly spreading infection with crepitus (Correct answer)
Purulent drainage with surrounding erythema
Wound dehiscence with exposed subcutaneous fat

Correct answer: Skin that appears normal overlying a rapidly spreading infection with crepitus

Necrotizing fasciitis classically shows deceptively normal overlying skin with rapid spread, crepitus from gas-producing organisms, and systemic toxicity.

Question 56: A patient arrives with a grossly contaminated Grade III open femur fracture. After controlling hemorrhage and ensuring hemodynamic stability, which intervention is the highest priority to prevent osteomyelitis?

Covering the wound with a saline-moistened sterile dressing
Immediate surgical debridement in the operating room
Obtaining a deep wound culture before irrigation
Administering broad-spectrum intravenous antibiotics (Correct answer)

Correct answer: Administering broad-spectrum intravenous antibiotics

Prompt administration of broad-spectrum intravenous antibiotics is a time-sensitive priority in managing open fractures to prevent infection, such as osteomyelitis. While covering the wound and surgical debridement are also critical steps, initiating systemic antibiotic therapy as soon as possible (ideally within 1-3 hours of injury) has been shown to significantly reduce infection rates. Wound cultures are typically obtained after initial irrigation.

Question 57: What is the primary reason high-voltage electrical burns often cause more extensive internal injury than surface appearance suggests?

Current follows neurovascular bundles causing internal tissue destruction (Correct answer)
Electricity destroys pain receptors, underreporting injury severity
High voltage causes immediate respiratory arrest masking injury extent
Electrical current generates intense visible flame causing deeper burns

Correct answer: Current follows neurovascular bundles causing internal tissue destruction

Electrical current travels through paths of least resistance—nerves and blood vessels—causing extensive internal tissue necrosis far beyond visible entry/exit wounds.

Question 58: A trauma patient is diagnosed with a grade III splenic laceration on CT and is hemodynamically stable. What is the preferred management strategy?

Immediate blood transfusion and laparotomy
Diagnostic peritoneal lavage
Splenic artery embolization or nonoperative management (Correct answer)
Emergent splenectomy

Correct answer: Splenic artery embolization or nonoperative management

Hemodynamically stable patients with grade III splenic lacerations are candidates for nonoperative management or angioembolization to preserve splenic function.

Question 59: A patient arrives after a motorcycle crash with a GCS of 9, unequal pupils, and posturing. Which herniation pattern is most consistent with a unilateral fixed and dilated pupil?

Uncal herniation (Correct answer)
Central herniation
Upward herniation
Tonsillar herniation

Correct answer: Uncal herniation

Uncal herniation causes ipsilateral CN III compression, resulting in a fixed, dilated pupil on the same side as the expanding lesion.

Question 60: A patient with blunt abdominal trauma is complaining of acute, sharp pain in the left shoulder. This finding, known as Kehr's sign, is most indicative of an injury to which organ?

Liver
Stomach
Spleen (Correct answer)
Left Kidney

Correct answer: Spleen

Kehr's sign is referred pain to the left shoulder caused by irritation of the diaphragm from blood in the peritoneal cavity. This sign is a classic clinical indicator of a ruptured or injured spleen, as the phrenic nerve (which innervates the diaphragm) shares the same nerve roots (C3-C5) as the supraclavicular nerves that supply the shoulder area.

Question 61: Which medication is the FIRST-LINE treatment for anaphylaxis in a trauma patient who develops a hypersensitivity reaction to blood products?

Epinephrine 0.3 mg IM (Correct answer)
Albuterol nebulized treatment
Methylprednisolone 125 mg IV
Diphenhydramine 50 mg IV

Correct answer: Epinephrine 0.3 mg IM

Epinephrine 0.3 mg IM (anterolateral thigh) is the first-line treatment for anaphylaxis regardless of context.

Question 62: A trauma patient is undergoing a Focused Assessment with Sonography for Trauma (FAST) exam. The primary purpose of this examination in the initial assessment of a trauma patient is to detect:

Bowel wall thickening or perforation.
Retroperitoneal hemorrhage.
The presence of free fluid in the peritoneum or pericardium. (Correct answer)
Specific solid organ injury grades.

Correct answer: The presence of free fluid in the peritoneum or pericardium.

The FAST exam is a rapid, non-invasive ultrasound screening tool designed to identify the presence of free fluid (assumed to be blood in the context of trauma) in dependent areas of the peritoneal, pericardial, and pleural spaces. It is used to rapidly identify potential life-threatening hemorrhage, not to grade specific organ injuries, definitively diagnose retroperitoneal bleeding, or identify bowel injuries.

Question 63: A 28-year-old male arrives after a motorcycle crash with a suspected high thoracic spinal cord injury. He is hypotensive (BP 80/40 mmHg), bradycardic (HR 48 bpm), and his skin is warm and dry. These findings are most characteristic of which type of shock?

Hemorrhagic shock
Cardiogenic shock
Neurogenic shock (Correct answer)
Spinal shock

Correct answer: Neurogenic shock

Neurogenic shock, a form of distributive shock, results from a loss of sympathetic tone following a significant spinal cord injury (typically above T6). This leads to unopposed parasympathetic stimulation, causing vasodilation (hypotension, warm/dry skin) and bradycardia. Hemorrhagic shock would present with tachycardia and cool, clammy skin. Cardiogenic shock involves pump failure. Spinal shock is a temporary loss of reflex function below the level of injury and is not a true circulatory shock state.

Question 64: An 84-year-old male on metoprolol for hypertension presents after a ground-level fall. His blood pressure is 110/68 mmHg, heart rate is 72 bpm, and he has new-onset confusion. Why is his heart rate a potentially unreliable indicator of early hemorrhagic shock?

Geriatric patients have a decreased circulatory volume, making blood pressure the only reliable sign.
Age-related calcification of the sinoatrial node prevents a tachycardic response.
The beta-blocker medication masks the compensatory tachycardia expected with hypovolemia. (Correct answer)
The patient's confusion suggests a primary neurologic injury, which would cause bradycardia.

Correct answer: The beta-blocker medication masks the compensatory tachycardia expected with hypovolemia.

Beta-blockers antagonize beta-adrenergic receptors, which blunts the normal compensatory tachycardic response to blood loss. In geriatric trauma patients on these medications, a heart rate within the normal range can provide false reassurance and mask significant underlying hemorrhage.

Question 65: A trauma patient with suspected hemorrhagic shock has a lactate of 6.2 mmol/L. What does this value primarily indicate?

Adequate tissue perfusion
Mild dehydration
Normal metabolic response to stress
Severe tissue hypoperfusion and anaerobic metabolism (Correct answer)

Correct answer: Severe tissue hypoperfusion and anaerobic metabolism

A lactate greater than 4 mmol/L indicates severe tissue hypoperfusion and anaerobic metabolism, signaling significant hemorrhagic shock.

Question 66: A patient with anterior cord syndrome after a cervical spine injury would be expected to have loss of which functions below the level of injury?

Motor function only with all sensation intact
Motor function and pain/temperature sensation with preserved proprioception (Correct answer)
All sensory modalities with intact motor function
Proprioception and vibration only

Correct answer: Motor function and pain/temperature sensation with preserved proprioception

Anterior cord syndrome causes bilateral motor loss and loss of pain and temperature sensation, while proprioception and vibration (carried by the posterior columns) are preserved.

Question 67: A trauma patient has sustained a high-voltage electrical injury. In addition to cutaneous burns at the entrance and exit wounds, for which of the following complications is this patient at highest risk?

Acute respiratory distress syndrome (ARDS)
Neurogenic shock
Acalculous cholecystitis
Cardiac dysrhythmias and rhabdomyolysis (Correct answer)

Correct answer: Cardiac dysrhythmias and rhabdomyolysis

High-voltage electricity can travel through the body, causing significant internal damage. The electrical current can disrupt the heart's normal conduction system, leading to life-threatening dysrhythmias. Furthermore, the massive muscle damage caused by the current leads to rhabdomyolysis, releasing myoglobin into the bloodstream, which can cause acute kidney injury.

Question 68: Which intervention is the HIGHEST priority nursing action to prevent pressure injury in a patient with a complete thoracic spinal cord injury?

Daily skin inspection with a mirror system
Application of prophylactic foam dressings to all bony prominences
High-protein diet to optimize tissue healing
Repositioning every 2 hours using log-roll technique to maintain spinal alignment (Correct answer)

Correct answer: Repositioning every 2 hours using log-roll technique to maintain spinal alignment

Scheduled repositioning every 2 hours is the cornerstone intervention for pressure injury prevention, directly addressing the causative factor of sustained pressure over insensate skin.

Question 69: Which of the following is a Class I indication for ICP monitoring according to Brain Trauma Foundation guidelines?

Severe TBI (GCS 3–8) with abnormal CT scan (Correct answer)
Mild TBI with brief loss of consciousness
Moderate TBI with intact pupils
GCS 13–15 with normal CT

Correct answer: Severe TBI (GCS 3–8) with abnormal CT scan

ICP monitoring is indicated in patients with severe TBI (GCS 3–8) and an abnormal CT scan showing hematoma, contusion, or compressed cisterns.

Question 70: What does the trauma nurse anticipate the patient to do if the paramedic reports that a patient is in transit with a Glasgow Coma Score of 7?

be intubated and comatose. (Correct answer)
remain slightly confused but able to follow verbal direction.
have had brief periods of loss of consciousness but to be alert and responsive.
exhibit focal neurological defects.

Correct answer: be intubated and comatose.

The trauma nurse anticipates that a patient in transit who has a Glasgow Coma Score of 7 will be intubated and unconscious. Scores of eight or less signify significant brain damage and a high probability of passing away. Oftentimes, intracranial pressure is increased. The range of GSCs is 3 (the lowest and most severe) to 15 (the highest score): - Mild: 13-15. consciousness for a brief period of time. - Modest: 9 to 12. Possible localized neurological deficits: confused but able to follow simple instructions. - Serious 8. The survivor is comatose and needs ventilator support; they most certainly have neurological damage.

Question 71: The resuscitation strategy known as 'permissive hypotension' is employed in certain trauma patients with uncontrolled hemorrhage. For which of the following patient populations is this strategy generally contraindicated?

Patients with extremity amputation and active bleeding
Patients with penetrating abdominal trauma
Patients with a suspected traumatic brain injury (TBI) (Correct answer)
Patients with an unstable pelvic fracture

Correct answer: Patients with a suspected traumatic brain injury (TBI)

Permissive hypotension, or hypotensive resuscitation, aims to maintain a lower-than-normal blood pressure (e.g., SBP 80-90 mmHg) to prevent dislodging newly formed clots before hemorrhage is surgically controlled. However, this strategy is contraindicated in patients with traumatic brain injury (TBI) because maintaining adequate cerebral perfusion pressure (CPP) is critical to prevent secondary brain injury. In TBI, a higher systolic blood pressure is targeted.

Question 72: A trauma patient presents with a systolic BP of 70 mmHg, HR of 130 bpm, and distended neck veins after a stab wound to the chest. Which injury should the nurse suspect FIRST?

Aortic dissection
Hemothorax
Tension pneumothorax
Cardiac tamponade (Correct answer)

Correct answer: Cardiac tamponade

Cardiac tamponade classically presents with Beck's triad: hypotension, distended neck veins, and muffled heart sounds after penetrating chest trauma.

Question 73: When assessing a trauma patient using the AVPU scale, a patient who responds only to painful stimuli is classified as:

Pain (Correct answer)
Voice
Unresponsive
Alert

Correct answer: Pain

On the AVPU scale, 'P' (Pain) indicates the patient responds only to painful stimulation, roughly correlating with a GCS of 8 or below.

Question 74: During massive transfusion, which electrolyte imbalance is most commonly associated with rapid infusion of packed red blood cells?

Hypomagnesemia
Hypernatremia
Hypocalcemia (Correct answer)
Hyperkalemia

Correct answer: Hypocalcemia

Citrate preservative in PRBCs chelates calcium, causing hypocalcemia during massive transfusion, which can impair cardiac contractility and coagulation.

Question 75: A patient in septic shock requires norepinephrine. Which additional agent is recommended as a second-line vasopressor to reduce norepinephrine dosing?

Phenylephrine
Dopamine
Epinephrine
Vasopressin (Correct answer)

Correct answer: Vasopressin

Vasopressin (0.03-0.04 units/min) is added as a second-line vasopressor to septic shock management, allowing reduction of norepinephrine dose.

Question 76: During initial trauma assessment, which finding in a wound bed is MOST consistent with a high-pressure injection injury requiring urgent surgical consult?

Wound with embedded gravel and moderate contamination
Avulsion injury with partial-thickness skin loss
Small entry wound on the finger with a tense, painful digit out of proportion to appearance (Correct answer)
Jagged laceration with visible tendon exposure

Correct answer: Small entry wound on the finger with a tense, painful digit out of proportion to appearance

High-pressure injection injuries create small entry wounds but massive internal destruction requiring emergent surgical decompression to prevent amputation.

Question 77: A patient with blunt abdominal trauma has an elevated serum lipase. Which injury must be suspected?

Pancreatic injury (Correct answer)
Renal contusion
Splenic rupture
Liver laceration

Correct answer: Pancreatic injury

Elevated serum lipase after abdominal trauma suggests pancreatic injury, which can be subtle and missed on initial CT imaging.

Question 78: Crepitus and 'step-off' deformity on palpation of the posterior calcaneus after a fall from height suggests:

Subtalar dislocation
Lisfranc fracture-dislocation
Achilles tendon rupture
Calcaneal fracture (Correct answer)

Correct answer: Calcaneal fracture

Calcaneal fractures from axial loading present with heel widening, crepitus, and step-off deformity due to flattening of Böhler's angle.

Question 79: When performing the secondary survey in a trauma patient, what does the acronym AMPLE stand for?

Airway, Mechanism, Pulse, Labs, Exposure
Age, Medications, Pressure, Last meal, Evaluation
Allergies, Management, Pain, Level of consciousness, Exam
Allergies, Medications, Past illness, Last meal, Events (Correct answer)

Correct answer: Allergies, Medications, Past illness, Last meal, Events

AMPLE stands for Allergies, Medications, Past illness/pregnancy, Last meal, and Events/environment related to the injury.

Question 80: Circumferential full-thickness burns of the lower extremity require escharotomy primarily to prevent which complication?

Deep vein thrombosis from immobility
Systemic sepsis from eschar colonization
Contracture formation during healing
Compartment syndrome with vascular compromise (Correct answer)

Correct answer: Compartment syndrome with vascular compromise

Circumferential eschar restricts tissue expansion, causing compartment syndrome and limb-threatening vascular compromise that requires escharotomy.

Question 81: A patient presents after a stab wound to the left upper quadrant. Which initial study best identifies diaphragmatic injury?

Abdominal ultrasound
Plain chest X-ray alone
Diagnostic laparoscopy (Correct answer)
FAST exam

Correct answer: Diagnostic laparoscopy

Diagnostic laparoscopy is the gold standard for detecting occult diaphragmatic injuries, as CT and plain films frequently miss small lacerations.

Question 82: A patient is admitted after being trapped in a burning building. They are hoarse, have carbonaceous sputum, and singed nasal hairs. What is the highest priority intervention for this patient?

Preparing for early endotracheal intubation (Correct answer)
Administering 100% oxygen via a non-rebreather mask
Obtaining a carboxyhemoglobin level
Initiating intravenous fluid resuscitation

Correct answer: Preparing for early endotracheal intubation

The presence of hoarseness, carbonaceous sputum, and singed nasal hairs are strong indicators of a significant inhalation injury. The airway can become edematous and obstructed rapidly. Therefore, the highest priority is to secure the airway with early endotracheal intubation before progressive swelling makes it impossible. While oxygen and fluid resuscitation are crucial, they are secondary to securing a patent airway.

Question 83: A pregnant trauma patient at 28 weeks requires a chest X-ray. Which action should the nurse take regarding radiation exposure?

Shield the abdomen/pelvis and proceed — diagnostic benefits outweigh risks (Correct answer)
Perform only ultrasound regardless of clinical need
Delay all imaging until after delivery
Decline the X-ray to protect the fetus entirely

Correct answer: Shield the abdomen/pelvis and proceed — diagnostic benefits outweigh risks

Necessary diagnostic imaging should not be withheld; abdominal shielding reduces fetal exposure, and the radiation dose from standard trauma imaging is well below the threshold for fetal harm.

Question 84: A patient brought to the trauma center after a high-speed motor vehicle collision is hemodynamically unstable with a suspected unstable pelvic fracture. After initiating massive transfusion protocol, what is the most appropriate next step for hemorrhage control?

Obtaining a CT scan of the abdomen and pelvis with contrast.
Application of a pelvic binder or sheet. (Correct answer)
Immediate transfer to the operating room for exploratory laparotomy.
Urgent transfer to interventional radiology for angioembolization.

Correct answer: Application of a pelvic binder or sheet.

In a hemodynamically unstable patient with a suspected pelvic fracture, the immediate priority after starting resuscitation is to stabilize the pelvis mechanically. Applying a pelvic binder or sheet provides temporary stabilization, reduces the pelvic volume, and can help control venous and bony bleeding sources, which are the most common causes of hemorrhage in these injuries. While angioembolization or surgery may be necessary, mechanical stabilization is the crucial first intervention.

Question 85: A 30-year-old patient with an ipsilateral distal radius fracture and elbow dislocation complains of excruciating forearm pain. Analgesia does not relieve the pain. What should the nurse be on the lookout for?

Infection.
Compartment syndrome. (Correct answer)
Fat embolism.

Correct answer: Compartment syndrome.

An early symptom of compartment syndrome, which is typically brought on by bleeding into the tissue, is severe, growing pain that is not eased by analgesia and is localized distal to the injury (in this case, the forearm). Upon examination, the compartment feels tight, and passive muscular stretching may cause pain. Paraesthesia and hypoaesthesia could develop in patients. Finding a pulse below the injury should not lead the nurse to believe that compartment syndrome is ruled out because motor weakness and vascular insufficiency are late signs.

Question 86: An 89-year-old resident of a skilled nursing facility presents with a new onset of confusion and lethargy. Staff report a minor, unwitnessed fall three weeks prior where the patient did not hit their head. This delayed, subacute neurological decline should raise the highest suspicion for which type of injury?

Chronic subdural hematoma (Correct answer)
Intraparenchymal hemorrhage
Epidural hematoma
Diffuse axonal injury

Correct answer: Chronic subdural hematoma

Due to age-related cerebral atrophy, the bridging veins that cross the subdural space are stretched and more susceptible to tearing from even minor trauma. This can cause a slow, insidious bleed, leading to a chronic subdural hematoma that presents with subtle and delayed neurological changes, such as confusion or somnolence, days to weeks after the initial injury.

Question 87: When a trauma patient expresses suicidal ideation with a specific plan, the nurse should:

Reassure the patient that things will improve and continue routine care
Consult social work but delay psychiatric evaluation until the morning
Ask the patient to promise not to act on the plan and document the conversation
Immediately implement safety measures, remove means if possible, notify the provider, and initiate a psychiatric emergency evaluation (Correct answer)

Correct answer: Immediately implement safety measures, remove means if possible, notify the provider, and initiate a psychiatric emergency evaluation

Suicidal ideation with a plan is a psychiatric emergency requiring immediate safety intervention and psychiatric evaluation.

Question 88: Which zone of the neck contains the aortic arch, innominate artery, and proximal common carotid arteries?

Zone IV
Zone III
Zone II
Zone I (Correct answer)

Correct answer: Zone I

Zone I of the neck extends from the clavicles/sternal notch to the cricoid cartilage and contains major thoracic outlet vessels including the aortic arch and innominate artery.

Question 89: A trauma patient with known coagulopathy and hemorrhagic shock has a fibrinogen level of 80 mg/dL. Which product should be prioritized?

Packed red blood cells
Cryoprecipitate (Correct answer)
Fresh frozen plasma
Platelets

Correct answer: Cryoprecipitate

Cryoprecipitate is the most concentrated source of fibrinogen and is indicated when fibrinogen is critically low (below 100-150 mg/dL) in coagulopathic hemorrhage.

Question 90: A patient receives 2L of normal saline for hemorrhagic shock resuscitation. Which metabolic complication is a concern?

Respiratory alkalosis
Hyponatremic encephalopathy
Metabolic alkalosis
Hyperchloremic metabolic acidosis (Correct answer)

Correct answer: Hyperchloremic metabolic acidosis

Large volumes of normal saline deliver a high chloride load, causing hyperchloremic (non-anion gap) metabolic acidosis.

Question 91: A trauma patient's urine output drops to 10 mL/hr despite aggressive fluid resuscitation. What is the minimum acceptable urine output target in adults during resuscitation?

0.5 mL/kg/hr (Correct answer)
1.5 mL/kg/hr
1.0 mL/kg/hr
0.25 mL/kg/hr

Correct answer: 0.5 mL/kg/hr

A urine output of at least 0.5 mL/kg/hr is the accepted minimum target in adults, indicating adequate renal perfusion during resuscitation.

Question 92: Autonomic dysreflexia is a potentially life-threatening complication that occurs primarily in patients with spinal cord injuries at what level or above?

L1
T6 (Correct answer)
C1 only
T10

Correct answer: T6

Autonomic dysreflexia occurs with injuries at T6 or above because the splanchnic sympathetic outflow (T6-L2) can no longer be modulated by descending supraspinal inhibitory signals.

Question 93: A patient presents with a deep, contaminated puncture wound from a farm implement. Their tetanus immunization history is unknown. According to current guidelines, what is the most appropriate prophylaxis?

Tdap vaccine and Tetanus Immune Globulin (TIG) (Correct answer)
Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine only
No immunoprophylaxis is needed if the wound is thoroughly irrigated
Tetanus Immune Globulin (TIG) only

Correct answer: Tdap vaccine and Tetanus Immune Globulin (TIG)

For a patient with a contaminated, tetanus-prone wound and an unknown or incomplete (<3 doses) vaccination history, guidelines recommend administering both the Tdap vaccine for active immunity and Tetanus Immune Globulin (TIG) for immediate passive immunity. They should be given in separate syringes at different anatomical sites.

Question 94: Which clinical finding best distinguishes neurogenic shock from hemorrhagic shock in a trauma patient with spinal cord injury?

Hypotension with tachycardia and cool clammy skin
Hypotension with tachycardia and diaphoresis
Hypotension with bradycardia and warm vasodilated skin (Correct answer)
Hypertension with bradycardia and flushing

Correct answer: Hypotension with bradycardia and warm vasodilated skin

Neurogenic shock results from loss of sympathetic tone, producing hypotension paired with paradoxical bradycardia and peripheral vasodilation, contrasting with the tachycardia of hemorrhagic shock.

Question 95: A morbidly obese trauma patient (BMI 48) requires endotracheal intubation. Which of the following is a primary challenge associated with airway management in this patient population?

Inherent instability of the cervical spine due to excess weight.
Rapid oxygen desaturation during periods of apnea. (Correct answer)
Resistance to standard doses of induction agents.
Increased likelihood of a posterior laryngeal anatomy.

Correct answer: Rapid oxygen desaturation during periods of apnea.

Bariatric patients have a significantly reduced functional residual capacity (FRC) and increased oxygen consumption. This combination means their oxygen reserves are depleted very quickly during apneic periods, such as during intubation, leading to rapid and profound desaturation.

Question 96: A patient with inhalation injury is intubated and mechanically ventilated. Which ventilator strategy is preferred to minimize ventilator-induced lung injury?

Low tidal volume (6 mL/kg IBW) with permissive hypercapnia (Correct answer)
Pressure-controlled ventilation targeting PaCO2 < 35 mmHg
High-frequency oscillatory ventilation as first-line mode
High tidal volume (12–15 mL/kg IBW) with low PEEP

Correct answer: Low tidal volume (6 mL/kg IBW) with permissive hypercapnia

Lung-protective ventilation using low tidal volumes (6 mL/kg IBW) with permissive hypercapnia minimizes barotrauma and volutrauma in inhalation injury patients.

Question 97: When calculating the Revised Trauma Score (RTS), which THREE parameters are used?

GCS, respiratory rate, and systolic BP (Correct answer)
GCS, pupils, and systolic BP
Systolic BP, heart rate, and respiratory rate
GCS, heart rate, and oxygen saturation

Correct answer: GCS, respiratory rate, and systolic BP

The Revised Trauma Score uses Glasgow Coma Scale, respiratory rate, and systolic blood pressure, each coded 0–4.

Question 98: During resuscitation of a trauma patient with hemorrhagic shock, which finding indicates successful resuscitation?

Lactate clearance of >10% per hour (Correct answer)
Persistent tachycardia with improving BP
Normalization of heart rate alone
Rising base deficit worsening to -10

Correct answer: Lactate clearance of >10% per hour

Lactate clearance of greater than 10% per hour indicates improved tissue perfusion and is a reliable marker of successful resuscitation.

Question 99: Which mechanism causes the 'paradoxical bradycardia' sometimes seen in severe hemorrhagic shock (Bezold-Jarisch reflex)?

Vagal stimulation from an empty ventricle causing paradoxical slowing (Correct answer)
Sympathetic overdrive causing AV node suppression
Electrolyte imbalance from rapid fluid shifts
Beta-receptor downregulation from catecholamine excess

Correct answer: Vagal stimulation from an empty ventricle causing paradoxical slowing

The Bezold-Jarisch reflex occurs when a near-empty left ventricle triggers vagal stimulation, paradoxically causing bradycardia in severe hemorrhage.

Question 100: A pediatric trauma patient weighing 20 kg requires a fluid bolus for suspected hemorrhagic shock. The appropriate initial bolus is:

400 mL lactated Ringer's (Correct answer)
200 mL lactated Ringer's
300 mL normal saline
500 mL normal saline

Correct answer: 400 mL lactated Ringer's

Pediatric initial fluid resuscitation is 20 mL/kg of isotonic crystalloid; 20 mL × 20 kg = 400 mL.

Question 101: Which burn depth classification involves destruction of ALL skin layers including subcutaneous tissue, and may appear white, leathery, or charred?

Deep tissue injury
Superficial (first-degree)
Full-thickness (third-degree) (Correct answer)
Partial-thickness superficial (second-degree)

Correct answer: Full-thickness (third-degree)

Full-thickness (third-degree) burns destroy epidermis, dermis, and subcutaneous tissue, presenting as white, leathery, or charred with no pain due to nerve destruction.

Question 102: A patient develops Cushing's triad after TBI. Which set of vital signs best represents this response?

Hypotension, bradycardia, tachypnea
Hypertension, tachycardia, normal respirations
Hypotension, tachycardia, irregular respirations
Hypertension, bradycardia, irregular respirations (Correct answer)

Correct answer: Hypertension, bradycardia, irregular respirations

Cushing's triad is hypertension, bradycardia, and irregular respirations, representing a late sign of severely elevated ICP and impending herniation.

Question 103: An elderly trauma patient is alert and oriented but develops confusion 36 hours after admission. Which condition should be suspected first?

Stroke from paradoxical embolism
Opiate overdose from pain medications
Hypertensive encephalopathy
Hospital-acquired delirium (ICU delirium) (Correct answer)

Correct answer: Hospital-acquired delirium (ICU delirium)

Post-traumatic delirium is extremely common in hospitalized elderly patients and is associated with worse outcomes; it should be the initial diagnostic consideration.

Question 104: Which pressure value defines the threshold for decompressive intervention in compartment syndrome?

Compartment pressure within 30 mmHg of diastolic BP (Correct answer)
Compartment pressure >20 mmHg
Compartment pressure >50 mmHg
Compartment pressure >30 mmHg

Correct answer: Compartment pressure within 30 mmHg of diastolic BP

Fasciotomy is indicated when compartment pressure is within 30 mmHg of diastolic BP (delta pressure ≤30 mmHg), as this compromises perfusion.

Question 105: A patient arrives with blunt anterior neck trauma and a hoarse voice, subcutaneous emphysema, and stridor. Which injury is most suspected?

Esophageal perforation
Carotid artery dissection
Laryngeal fracture (Correct answer)
Thyroid gland hematoma

Correct answer: Laryngeal fracture

Hoarseness, subcutaneous emphysema, and stridor after blunt anterior neck trauma are classic signs of laryngeal fracture requiring urgent airway management.

Question 106: Which intervention is contraindicated in a patient with suspected esophageal perforation from trauma?

NPO status and IV antibiotics
Early surgical consultation
CT scan of the chest
Nasogastric tube insertion by the nurse without further assessment (Correct answer)

Correct answer: Nasogastric tube insertion by the nurse without further assessment

Blind nasogastric tube placement can worsen esophageal perforation; surgical consultation should guide any tube placement.

Question 107: What is the rationale for NOT using iced water or ice packs for initial burn cooling?

Ice causes further tissue damage by direct freezing and hypothermia (Correct answer)
Cold temperatures accelerate bacterial colonization of the wound
Cold application increases pain and patient distress
Ice delays neutrophil migration needed for early healing

Correct answer: Ice causes further tissue damage by direct freezing and hypothermia

Ice and iced water can cause vasoconstriction and hypothermia, worsening tissue damage; cool (not cold) running water at 15–25°C for 20 minutes is recommended.

Question 108: A trauma nurse administers the wrong medication dose to a patient. The nurse's immediate priority after addressing the patient's safety is to:

Inform only the charge nurse verbally and take no further action
Document the correct dose in the medical record to avoid liability
Complete an incident/variance report and notify the treating physician (Correct answer)
Tell the patient nothing to avoid causing anxiety

Correct answer: Complete an incident/variance report and notify the treating physician

After ensuring patient safety, the nurse must notify the physician and complete an incident report to facilitate investigation and prevent recurrence.

Question 109: A burn patient has burns covering the anterior torso and both anterior lower extremities. Using the Rule of Nines, what percentage TBSA is burned?

45%
27%
36% (Correct answer)
18%

Correct answer: 36%

Anterior torso = 18%, each anterior lower extremity = 9% (×2 = 18%); total = 36% TBSA.

Question 110: Which spinal cord syndrome is characterized by disproportionately greater motor weakness in the upper extremities than the lower extremities following a hyperextension mechanism?

Central cord syndrome (Correct answer)
Brown-Séquard syndrome
Posterior cord syndrome
Anterior cord syndrome

Correct answer: Central cord syndrome

Central cord syndrome, most common in older patients with cervical spondylosis after hyperextension, injures the central gray matter and medial corticospinal fibers serving the arms more than the legs.

Question 111: A 40-year-old person with cardiac arrhythmias is given mannitol to lower elevated intracranial pressure brought on by a traumatic brain injury. The arrhythmias are most likely caused by which of the following electrolyte imbalances connected to mannitol administration?

Hypokalemia
Hypernatremia
Hyperkalemia (Correct answer)
Hypermagnesemia

Correct answer: Hyperkalemia

When mannitol is administered to treat cerebral edema, it may lead to hyperkalemia, a fluid and electrolyte imbalance, and cardiac arrhythmias. An osmotic diuretic called mannitol reduces intracranial pressure and brain mass, especially after traumatic brain injury. It also increases potassium levels and salt and water excretion. Urticaria, hypotension, tachycardia, fever, and vomiting are a few other side effects. The blood-brain barrier's cells may be reduced in size with mannitol in order to facilitate the passage of other drugs through it. After injection, cerebral spinal fluid pressure should start to drop within 15 minutes.

Question 112: When there is an abdominal gunshot wound, the trauma nurse should predict that the organ most likely to be damaged is ?

colon
small intestine (Correct answer)
stomach
liver

Correct answer: small intestine

The small intestine (which accounts for half of injuries) is the organ that the trauma nurse should expect to be hurt when a gunshot wound to the abdomen occurs. However, a number of other organs (including the colon, liver, and major veins) could also be hurt depending on the bullet's trajectory and depth of penetration. Close-range high-energy bullet wounds can cause both primary injuries and secondary injuries, such those from broken bones.

Question 113: Which chest injury is characterized by multiple rib fractures in two or more places creating a free-floating segment?

Diaphragmatic rupture
Flail chest (Correct answer)
Open pneumothorax
Pulmonary contusion

Correct answer: Flail chest

Flail chest occurs when multiple contiguous ribs fracture in two or more places, creating a segment that moves independently.

Question 114: In permissive hypotension strategy for penetrating trauma, what is the target systolic blood pressure before hemorrhage control?

60-70 mmHg
100-110 mmHg
80-90 mmHg (Correct answer)
120 mmHg

Correct answer: 80-90 mmHg

Permissive hypotension targets a systolic BP of 80-90 mmHg to maintain minimal perfusion while avoiding dislodgment of clots before surgical hemorrhage control.

Question 115: A trauma patient is noted to have cerebrospinal fluid (CSF) draining from the ear. The nurse should:

Irrigate the ear canal with sterile saline
Place a loose sterile dressing to collect fluid and notify the provider; do not pack the ear (Correct answer)
Reposition the patient so the affected ear is dependent
Pack the ear canal tightly with sterile gauze to stop the leak

Correct answer: Place a loose sterile dressing to collect fluid and notify the provider; do not pack the ear

CSF otorrhea must not be obstructed; the ear should be loosely covered and the provider notified to prevent meningitis risk.

Question 116: A TCRN is caring for a patient with a traumatic brain injury. The cerebral perfusion pressure (CPP) is calculated as:

MAP plus ICP
Systolic BP minus diastolic BP
MAP minus ICP (Correct answer)
ICP minus MAP

Correct answer: MAP minus ICP

CPP = MAP − ICP; the target CPP in TBI management is typically 60-70 mmHg to ensure adequate cerebral blood flow.

Question 117: What is the target systolic blood pressure for a hypotensive patient with a traumatic brain injury (TBI) per ATLS guidelines?

≥130 mmHg
≥70 mmHg
≥90 mmHg (Correct answer)
≥110 mmHg

Correct answer: ≥90 mmHg

Maintaining SBP ≥90 mmHg is critical in TBI to ensure adequate cerebral perfusion pressure and prevent secondary brain injury.

Question 118: A patient with blunt chest trauma has paradoxical chest wall movement. Which intervention takes priority?

Apply a bulky dressing over the flail segment
Administer high-flow oxygen and prepare for intubation (Correct answer)
Place the patient in Trendelenburg position
Obtain a stat chest X-ray before any intervention

Correct answer: Administer high-flow oxygen and prepare for intubation

Flail chest with paradoxical movement causes respiratory failure, so oxygen delivery and airway management take top priority.

Question 119: When managing hemorrhagic shock with a junctional wound (groin/axilla) where direct pressure is ineffective, what device is recommended?

Junctional tourniquet (e.g., JETT or SAM-JT) (Correct answer)
Pressure dressing and elevation
Standard pneumatic tourniquet
Wound packing with hemostatic gauze only

Correct answer: Junctional tourniquet (e.g., JETT or SAM-JT)

Junctional tourniquets like the JETT or SAM-JT are designed to control hemorrhage in anatomical junctions where limb tourniquets cannot be applied.

Question 120: A patient arrives after a fall from height and is in hemorrhagic shock. The massive transfusion protocol (MTP) has been activated. In addition to blood products, which medication should be administered early to inhibit fibrinolysis and stabilize clot formation?

Tranexamic acid (TXA) (Correct answer)
Sodium bicarbonate
Vasopressin
Calcium gluconate

Correct answer: Tranexamic acid (TXA)

Tranexamic acid (TXA) is an antifibrinolytic agent that prevents the breakdown of blood clots. Studies have shown that its administration within three hours of injury in bleeding trauma patients reduces mortality. It is a key adjunct in damage control resuscitation. Calcium is given to treat hypocalcemia from citrate in blood products, bicarbonate treats severe acidosis, and vasopressors are used for refractory hypotension, but TXA specifically targets clot stability.

Question 121: Which imaging modality is the gold standard for evaluating suspected vascular injury in penetrating Zone I neck trauma?

Duplex ultrasound
CT angiography (Correct answer)
Plain radiography
MRI

Correct answer: CT angiography

CT angiography is the gold standard for evaluating vascular injury in neck trauma, providing rapid, non-invasive assessment of the carotid and vertebral arteries.

Question 122: The trauma nurse's role in organ donation notification when a patient is dying includes which responsibility?

Avoiding the topic until the patient is officially declared dead
Making the final decision about organ donation on behalf of the family
Providing compassionate support to the family, ensuring notification of the organ procurement organization (OPO) per hospital protocol (Correct answer)
Discussing donation only if the patient has a donor card on their person

Correct answer: Providing compassionate support to the family, ensuring notification of the organ procurement organization (OPO) per hospital protocol

Timely OPO notification and compassionate family support are the nurse's core responsibilities in the organ donation process.

Question 123: A patient presents with anaphylactic shock with refractory hypotension despite epinephrine. The patient takes lisinopril daily. Why may epinephrine be less effective?

ACE inhibitor use is associated with bradykinin accumulation causing refractory vasodilation (Correct answer)
ACE inhibitors sensitize mast cells to catecholamines
Lisinopril prevents histamine release, masking epinephrine response
Lisinopril blocks beta receptors used by epinephrine

Correct answer: ACE inhibitor use is associated with bradykinin accumulation causing refractory vasodilation

ACE inhibitors block bradykinin breakdown, leading to bradykinin accumulation that causes severe vasodilation refractory to epinephrine in anaphylaxis.

Question 124: A patient with a suspected spinal cord injury at T4 presents with bradycardia and hypotension but warm, flushed skin. This presentation is MOST consistent with:

Septic shock
Hemorrhagic shock
Obstructive shock
Neurogenic shock (Correct answer)

Correct answer: Neurogenic shock

Neurogenic shock results from loss of sympathetic tone after high spinal cord injury, causing hypotension with paradoxical bradycardia and warm, vasodilated skin.

Question 125: A patient presents with paradoxical chest wall movement after blunt chest trauma. This finding indicates:

Massive hemothorax
Tension pneumothorax
Open pneumothorax
Flail chest with underlying pulmonary contusion (Correct answer)

Correct answer: Flail chest with underlying pulmonary contusion

Paradoxical movement (inward during inspiration, outward during expiration) occurs when a flail segment moves opposite to the chest wall, typically with underlying pulmonary contusion.

Question 126: Tranexamic acid (TXA) is MOST effective when given within what time frame after injury?

Within 1 hour
Within 6 hours
Within 3 hours (Correct answer)
Within 30 minutes

Correct answer: Within 3 hours

TXA reduces mortality when given within 3 hours of injury; evidence from the CRASH-2 trial shows no benefit and possible harm when given after 3 hours.

Question 127: A trauma patient with a catastrophic, non-survivable brain injury has been declared brain dead. The patient is a registered organ donor. According to federal regulations and best practices, what is the most appropriate next step regarding organ donation?

Notify the designated Organ Procurement Organization (OPO) of the patient's status. (Correct answer)
Wait for the family to bring up the topic of organ donation first.
The trauma nurse should immediately begin discussing the donation process with the family.
Discontinue all supportive measures as the patient is legally deceased.

Correct answer: Notify the designated Organ Procurement Organization (OPO) of the patient's status.

Federal regulations require hospitals to notify their designated Organ Procurement Organization (OPO) in a timely manner of all deaths and imminent deaths. The OPO is responsible for determining medical suitability and, through its specially trained staff, approaching the family to discuss donation. This uncouples the donation request from the clinical team and ensures a standardized, sensitive approach. Supportive measures must be continued to maintain organ viability pending the donation process.

Question 128: Which finding best distinguishes obstructive shock from hypovolemic shock on assessment?

Tachycardia and hypotension
Elevated JVD with hypotension (Correct answer)
Narrowed pulse pressure
Cool clammy skin

Correct answer: Elevated JVD with hypotension

Elevated jugular venous distension (JVD) with hypotension indicates obstructive shock (e.g., tension pneumothorax, cardiac tamponade), not hypovolemic shock.

Question 129: Which document designates a person to make healthcare decisions on behalf of a patient who becomes incapacitated?

POLST form
Living will
Durable power of attorney for healthcare (Correct answer)
Do-not-resuscitate order

Correct answer: Durable power of attorney for healthcare

A durable power of attorney for healthcare designates a specific person (healthcare proxy) to make medical decisions if the patient cannot do so.

Question 130: A patient with a posterior hip dislocation is being reduced. Which post-reduction assessment is MOST critical?

Sciatic nerve function assessment (Correct answer)
Skin integrity over the greater trochanter
Hip flexion range of motion
Femoral artery pulse check

Correct answer: Sciatic nerve function assessment

The sciatic nerve is at risk with posterior hip dislocation; post-reduction assessment of sciatic nerve function (foot dorsiflexion and plantar sensation) is essential.

Question 131: Which position is recommended for patients with TBI to minimize ICP elevation?

Head of bed elevated 30 degrees with head midline (Correct answer)
Prone position
Supine flat with bilateral cervical rolls
Trendelenburg position

Correct answer: Head of bed elevated 30 degrees with head midline

HOB 30° with neutral head alignment promotes cerebral venous drainage without compromising cerebral perfusion pressure.

Question 132: A morbidly obese trauma patient (BMI 48) requires endotracheal intubation. Which airway challenge is most likely compared to a non-obese patient?

Rapid oxygen desaturation due to reduced functional residual capacity (Correct answer)
Lower risk of aspiration due to delayed gastric emptying
Smaller glottic opening requiring a smaller ETT
Hypersensitivity to sedative medications

Correct answer: Rapid oxygen desaturation due to reduced functional residual capacity

Morbidly obese patients have significantly reduced FRC and increased oxygen consumption, leading to rapid desaturation during apneic periods even with pre-oxygenation.

Question 133: A trauma patient develops neurogenic shock after a cervical spinal cord injury. What hemodynamic pattern differentiates neurogenic shock from hemorrhagic shock?

Hypotension with tachycardia and warm skin
Hypotension with normal HR and diaphoresis
Hypotension with tachycardia and cool skin
Hypotension with bradycardia and warm skin (Correct answer)

Correct answer: Hypotension with bradycardia and warm skin

Neurogenic shock presents with hypotension, bradycardia, and warm/flushed skin due to loss of sympathetic tone — unlike hemorrhagic shock which causes tachycardia and vasoconstriction.

Question 134: A trauma nurse disagrees with a physician's treatment plan for ethical reasons. The most appropriate course of action is to:

Refuse all further care for the patient
Independently change the treatment plan without notifying the physician
Follow the order silently to avoid conflict
Express concerns to the physician, document the discussion, and use the ethics committee if unresolved (Correct answer)

Correct answer: Express concerns to the physician, document the discussion, and use the ethics committee if unresolved

Ethical disagreements should be addressed through direct professional communication and escalation to ethics resources when needed, while continuing safe patient care.

Question 135: A 45-year-old male weighing 70 kg was rescued from a house fire and has full-thickness burns to his entire chest and abdomen, and the entire circumference of his right arm. Using the Rule of Nines, what is the total volume of Lactated Ringer's solution to be administered in the first 8 hours of fluid resuscitation according to the Parkland formula?

15,120 mL
7,560 mL
3,780 mL (Correct answer)
5,040 mL

Correct answer: 3,780 mL

First, calculate the Total Body Surface Area (TBSA) burned using the Rule of Nines: Chest (9%) + Abdomen (9%) + Entire Right Arm (9%) = 27% TBSA. Next, use the Parkland formula: 4 mL x Body Weight (kg) x TBSA (%). So, 4 mL x 70 kg x 27% = 7,560 mL. This is the total volume for the first 24 hours. The formula specifies that half of this total volume must be administered in the first 8 hours post-burn. Therefore, 7,560 mL / 2 = 3,780 mL.

Question 136: Which element is NOT required to establish nursing malpractice in a court of law?

Breach of the standard of care
Causation and damages
Duty owed to the patient
Malicious intent by the nurse (Correct answer)

Correct answer: Malicious intent by the nurse

Malpractice requires duty, breach, causation, and damages — malicious intent is not a required element; negligence is sufficient.

Question 137: Permissive hypotension in a penetrating trauma patient WITHOUT head injury targets a systolic BP of approximately:

90–100 mmHg
50–60 mmHg
110–120 mmHg
70–80 mmHg (Correct answer)

Correct answer: 70–80 mmHg

Permissive hypotension targets a systolic BP of 70–80 mmHg in penetrating trauma without TBI to reduce clot disruption while maintaining organ perfusion until surgical hemorrhage control.

Question 138: A patient presents with inability to fully extend the knee after a dashboard impact. The patella is palpable superiorly. What is the most likely injury?

Tibial plateau fracture
Quadriceps tendon rupture
Patellar fracture with displacement
Patellar tendon rupture (Correct answer)

Correct answer: Patellar tendon rupture

Patellar tendon rupture results in proximal migration of the patella (patella alta) and inability to actively extend the knee.

Question 139: Which sign is associated with basilar skull fracture indicating blood tracking into the mastoid area?

Cullen's sign
Battle's sign (Correct answer)
Kehr's sign
Grey Turner's sign

Correct answer: Battle's sign

Battle's sign is ecchymosis over the mastoid process (behind the ear) and is a delayed clinical sign of basilar skull fracture.

Question 140: Current guidelines recommend maintaining a mean arterial pressure (MAP) of at least _____ for the first 7 days after acute spinal cord injury to optimize cord perfusion:

85 mmHg (Correct answer)
95 mmHg
75 mmHg
65 mmHg

Correct answer: 85 mmHg

Guidelines recommend MAP ≥ 85 mmHg for 7 days post-acute SCI to support spinal cord perfusion pressure and limit secondary injury, a higher target than general ICU goals.

Question 141: Which method for estimating the Total Body Surface Area (TBSA) of a burn is considered the most accurate for pediatric patients because it accounts for the developmental differences in body proportions?

Rule of Nines
Palmar method
Rule of Fives
Lund-Browder chart (Correct answer)

Correct answer: Lund-Browder chart

The Lund-Browder chart is the most accurate method for estimating TBSA in children because it adjusts the percentage assigned to different body parts based on age. Children have proportionally larger heads and smaller legs than adults, a fact that the standard Rule of Nines does not accurately reflect.

Question 142: Which ECG finding is most associated with myocardial contusion following blunt chest trauma?

Prolonged PR interval only
Peaked T waves in V1-V2
New right bundle branch block or ST-segment changes (Correct answer)
Left axis deviation

Correct answer: New right bundle branch block or ST-segment changes

Myocardial contusion most commonly manifests as new bundle branch block or ST changes on ECG, indicating direct cardiac injury.

Question 143: Which vasopressor has both alpha-1 and beta-1 agonist activity, making it first-line for most types of shock requiring vasopressor support?

Dobutamine
Vasopressin
Phenylephrine
Norepinephrine (Correct answer)

Correct answer: Norepinephrine

Norepinephrine's combined alpha-1 (vasoconstriction) and beta-1 (inotropy) activity makes it the first-line vasopressor for most shock states including septic and distributive shock.

Question 144: A trauma patient with a pelvis fracture and suspected urethral injury requires urinary catheterization. The CORRECT approach is:

Consult urology before any catheterization attempt; a suprapubic catheter may be required (Correct answer)
Insert a three-way catheter to allow irrigation if blood is encountered
Delay catheterization until after pelvic CT confirms bladder integrity
Attempt gentle Foley insertion with a smaller catheter size

Correct answer: Consult urology before any catheterization attempt; a suprapubic catheter may be required

Blood at the urethral meatus or scrotal hematoma suggests urethral injury; blind catheterization can convert a partial tear to a complete rupture, requiring urology and possible suprapubic catheter.

Question 145: A nurse is assessing a patient's pain 2 hours after dressing change for partial-thickness burns. The patient rates pain 8/10 and is tachycardic. Which analgesic approach is most appropriate for procedural burn pain?

IV opioids titrated to effect before and during procedures (Correct answer)
Topical lidocaine applied to wound surface
Scheduled oral acetaminophen alone
NSAIDs as primary analgesic to reduce inflammation

Correct answer: IV opioids titrated to effect before and during procedures

Procedural burn pain requires preemptive IV opioid analgesics titrated to effect, often combined with anxiolytics, as topical agents are insufficient and oral medications have delayed onset.

Question 146: How much mL of fluid should be given during the first eight hours if a burn patient's fluid resuscitation needs have been determined as 12,000 mL/24 hours using the burn/Baxter formula (4 mL of LR X kg body weight X TBSA burned)?

4000 mL.
6000 mL. (Correct answer)
8000 mL.
3000 mL.

Correct answer: 6000 mL.

According to the burn/Baxter formula (4 mL of LR X kg body weight X TBSA burnt), a burn patient's fluid resuscitation needs are estimated to be 12,000 mL/24 hours. Of that amount, 6000 mL (50% of the total) should be given within the first 8 hours and the remaining 6000 mL over the following 16 hours. Burns that have burned 20% or more of the total body surface area (TBSA) call for fluid resuscitation. Instead of using NS, lactated Ringers IV solution is utilized, which might cause hypernatremia and hyperchloremia.

Question 147: Which acid-base disturbance is most commonly found in the early phase of hemorrhagic shock?

Metabolic acidosis (Correct answer)
Metabolic alkalosis
Mixed respiratory and metabolic alkalosis
Respiratory alkalosis

Correct answer: Metabolic acidosis

Hemorrhagic shock causes tissue hypoperfusion leading to anaerobic metabolism and lactic acid production, resulting in metabolic acidosis.

Question 148: A 10-year-old is admitted after blunt abdominal trauma. The CT shows a grade III splenic laceration. The child is hemodynamically stable. What is the preferred management strategy?

Angioembolization only
Exploratory laparotomy to assess full extent
Non-operative management with close monitoring (Correct answer)
Immediate splenectomy to prevent delayed rupture

Correct answer: Non-operative management with close monitoring

Hemodynamically stable pediatric patients with splenic lacerations are managed non-operatively to preserve splenic immune function whenever possible.

Question 149: Of the following, which is a strict no-no for nasotracheal intubation?

Apnea. (Correct answer)
Facial trauma.
Skull fracture.
Cervical spine injury

Correct answer: Apnea.

Nasotracheal intubation is completely contraindicated in cases of apnea. The main warning signs are a clinched jaw but with an intact gag reflex and acute respiratory distress due to a suspected or verified cervical spine injury. Depending on where the fractures are and how severe they are, facial and skull fractures may occasionally be contraindicated. The nares must be large enough to accommodate sizes 7 to 8 endotracheal tubes. Prior to inserting the tube, an anti-decongestant, such as phenylephrine 0.5 mg, is typically given to the nose.

Question 150: A patient with a closed tibial fracture after a motorcycle crash requires escalating doses of opioid analgesia. Which early clinical finding is most indicative of developing acute compartment syndrome?

Absence of a distal pulse
Inability to move the toes (paralysis)
A cool, pale extremity
Pain that is out of proportion to the injury (Correct answer)

Correct answer: Pain that is out of proportion to the injury

Pain out of proportion to the injury, especially pain with passive stretching of the muscles in the affected compartment, is the earliest and most sensitive sign of acute compartment syndrome. Pulselessness, paralysis, and pallor are all considered very late and ominous signs, indicating significant vascular compromise and nerve damage have already occurred.

Question 151: A patient is diagnosed with a Le Fort I fracture following an assault. The primary goal in the surgical management of this specific fracture is to restore:

Zygomatic projection
Functional dental occlusion (Correct answer)
Naso-orbital-ethmoid complex
Craniofacial height

Correct answer: Functional dental occlusion

A Le Fort I fracture is a horizontal fracture of the maxilla that separates the tooth-bearing portion of the upper jaw from the rest of the midface. The primary goal of treatment is to restore the patient's pre-injury dental occlusion (how the teeth fit together) and ensure proper masticatory function. [14, 29] This is typically achieved through open reduction and internal fixation, often with the use of intermaxillary fixation to guide the reduction.

Question 152: Which class of hemorrhagic shock is characterized by 30-40% blood volume loss, confusion, and systolic BP of 90 mmHg?

Class III (Correct answer)
Class IV
Class I
Class II

Correct answer: Class III

Class III hemorrhage involves 30-40% blood volume loss (1,500-2,000 mL) with confusion, tachycardia, and systolic BP around 90 mmHg.

Question 153: Which parameter best guides fluid resuscitation adequacy in a major burn patient?

Mean arterial pressure > 70 mmHg
Urine output of 0.5–1 mL/kg/hr (Correct answer)
Heart rate < 100 beats/min
Central venous pressure of 8–12 mmHg

Correct answer: Urine output of 0.5–1 mL/kg/hr

Urine output of 0.5–1 mL/kg/hr is the most reliable indicator of adequate end-organ perfusion and guides burn resuscitation.

Question 154: Which nursing action best demonstrates adherence to the TCRN standard of care in a mass casualty incident?

Providing maximal care to the first patient who arrives regardless of severity
Deferring all triage decisions to the emergency physician
Treating patients in the order they are registered
Implementing START triage to allocate resources based on survivability (Correct answer)

Correct answer: Implementing START triage to allocate resources based on survivability

START (Simple Triage and Rapid Treatment) triage is the evidence-based system used in MCIs to maximize survival by allocating resources based on injury severity and survivability.

Question 155: A patient in distributive shock has warm, flushed skin and bounding pulses. What is the underlying hemodynamic mechanism?

Decreased systemic vascular resistance (Correct answer)
Increased afterload
Decreased cardiac contractility
Decreased preload

Correct answer: Decreased systemic vascular resistance

Distributive shock is characterized by pathological vasodilation causing decreased systemic vascular resistance, leading to warm flushed skin and bounding pulses.

Question 156: What is the American Association for the Surgery of Trauma (AAST) grade of a splenic injury with vascular injury or active bleeding confined within the splenic capsule?

Grade IV (Correct answer)
Grade V
Grade III
Grade II

Correct answer: Grade IV

Grade IV splenic injuries involve vascular injury or active bleeding confined within the splenic capsule, representing a high-grade injury that often requires intervention.

Question 157: A trauma patient in hemorrhagic shock is receiving massive transfusion. The TCRN should monitor for which complication of massive blood transfusion?

Hyperkalemia, hypocalcemia, and hypothermia (Correct answer)
Thrombocytosis and hypermagnesemia
Metabolic alkalosis and hypernatremia
Hypokalemia, hypercalcemia, and hyperthermia

Correct answer: Hyperkalemia, hypocalcemia, and hypothermia

Massive transfusion causes hypothermia from cold blood products, hypocalcemia from citrate binding calcium, and hyperkalemia from hemolysis of stored RBCs.

Question 158: A patient in neurogenic shock following a C5 spinal cord injury has BP 82/50 and HR 52. After fluids, BP remains low. What vasopressor is preferred?

Phenylephrine
Dopamine (Correct answer)
Norepinephrine
Vasopressin

Correct answer: Dopamine

Dopamine is preferred in neurogenic shock when bradycardia accompanies hypotension because it increases both heart rate and blood pressure.

Question 159: A patient with severe TBI has an ICP of 28 mmHg despite initial interventions. Which second-tier intervention is most appropriate?

Reducing IV fluid to restrict cerebral edema
Increasing the head of bed to 45 degrees
Decompressive craniectomy or barbiturate coma (Correct answer)
Administering high-dose corticosteroids

Correct answer: Decompressive craniectomy or barbiturate coma

Second-tier interventions for refractory ICP elevation include decompressive craniectomy or barbiturate (pentobarbital) coma when first-tier measures have failed.

Question 160: A geriatric trauma patient takes beta-blockers daily. Which assessment finding may be masked by this medication?

Hypotension
Tachycardia (Correct answer)
Altered mental status
Decreased respiratory rate

Correct answer: Tachycardia

Beta-blockers blunt the compensatory tachycardia response to hemorrhage, making heart rate an unreliable indicator of shock in these patients.

Question 161: A motorcyclist has a degloving injury of the lower leg. The degloved skin flap is pale and cool. The nurse's PRIORITY action is:

Reapply the skin flap and wrap tightly to restore circulation
Apply a tourniquet proximal to the injury to control bleeding
Wrap the skin flap in saline-moistened gauze and notify the surgeon immediately (Correct answer)
Discard the avulsed skin as it is non-viable

Correct answer: Wrap the skin flap in saline-moistened gauze and notify the surgeon immediately

Degloved skin, even if pale, should be preserved in moist sterile gauze for potential grafting while awaiting urgent surgical evaluation.

Question 162: Which splint position is correct for a suspected scaphoid fracture in the ED?

Thumb spica splint with wrist in neutral position (Correct answer)
Sugar-tong splint immobilizing elbow to fingers
Volar splint with wrist in 20-degree flexion
Ulnar gutter splint with wrist in neutral

Correct answer: Thumb spica splint with wrist in neutral position

Scaphoid fractures require a thumb spica splint to immobilize the thumb ray and wrist, protecting the avascular scaphoid from displacement.

Question 163: The cerebral perfusion pressure (CPP) is calculated as:

MAP – CVP
SBP – ICP
MAP + ICP
MAP – ICP (Correct answer)

Correct answer: MAP – ICP

CPP = MAP – ICP; maintaining CPP between 60–70 mmHg is the target in severe TBI management to prevent secondary ischemic injury.

Question 164: A patient involved in a high-speed motor vehicle collision has significant mid-face trauma, including mobility of the entire maxilla and zygomatic bones, resulting in craniofacial disjunction. Which Le Fort fracture classification does this presentation represent?

Le Fort IV
Le Fort III (Correct answer)
Le Fort II
Le Fort I

Correct answer: Le Fort III

A Le Fort III fracture, also known as craniofacial disjunction, is the most severe type of Le Fort fracture. It involves a transverse fracture line that passes through the nasofrontal suture, maxillo-frontal suture, orbital wall, and zygomatic arch, effectively separating the entire facial skeleton from the cranial base. [17, 23, 27] Le Fort I is a horizontal maxillary fracture, and Le Fort II is a pyramidal fracture.

Question 165: A competent adult trauma patient refuses a blood transfusion on religious grounds. The nurse should:

Contact the patient's family to override the refusal
Obtain a court order to override the patient's wishes
Document the refusal, notify the physician, and respect the patient's autonomous decision (Correct answer)
Administer the blood transfusion to save the patient's life

Correct answer: Document the refusal, notify the physician, and respect the patient's autonomous decision

Competent adults have the legal and ethical right to refuse any medical treatment, including life-saving interventions, and this must be respected and documented.

Question 166: A severely injured trauma patient is developing the 'trauma triad of death.' Which of the following components is NOT part of this lethal triad?

Coagulopathy
Acidosis
Hypocalcemia (Correct answer)
Hypothermia

Correct answer: Hypocalcemia

The classic 'trauma triad of death' is a vicious cycle consisting of hypothermia, metabolic acidosis, and coagulopathy. Each component exacerbates the others, leading to a rapid physiological decline. While hypocalcemia is a critical concern in massive transfusion (often called the 'trauma diamond of death' when included), it is not part of the original triad.

Question 167: A trauma patient is receiving a massive transfusion protocol (MTP). To mitigate the 'trauma triad of death,' which balanced ratio of blood products is most commonly recommended?

1 unit PRBCs : 1 unit FFP : 2 units platelets
2 units PRBCs : 1 unit FFP : 1 unit platelets
1 unit packed red blood cells (PRBCs) : 2 units fresh frozen plasma (FFP) : 1 unit platelets
1 unit PRBCs : 1 unit FFP : 1 unit platelets (Correct answer)

Correct answer: 1 unit PRBCs : 1 unit FFP : 1 unit platelets

Current evidence and massive transfusion protocols (MTPs) advocate for a balanced resuscitation approach to mimic whole blood and combat coagulopathy. The most widely accepted ratio is 1:1:1, consisting of one unit of packed red blood cells, one unit of fresh frozen plasma, and one unit of apheresis platelets (or a 6-pack of pooled platelets).

Question 168: A pregnant trauma patient at 24 weeks gestation has fetal heart tones of 90 bpm. What does this finding indicate?

Artifact from maternal tachycardia
Normal fetal heart rate for this gestational age
Normal variation in the second trimester
Fetal bradycardia indicating fetal distress or hypoxia (Correct answer)

Correct answer: Fetal bradycardia indicating fetal distress or hypoxia

Normal fetal heart rate is 110-160 bpm; bradycardia below 110 bpm indicates fetal distress and requires urgent obstetric evaluation.

Question 169: A trauma patient is a registered organ donor. The patient is declared brain dead. The nurse's role includes:

Notifying the organ procurement organization (OPO) and maintaining physiologic stability of the donor (Correct answer)
Obtaining family consent before notifying the OPO
Documenting the donor status but taking no further action until the family decides
Immediately withdrawing all supportive care

Correct answer: Notifying the organ procurement organization (OPO) and maintaining physiologic stability of the donor

Federal law requires hospitals to notify the OPO of all potential donors, and physiologic support must be maintained to preserve organ viability.

Question 170: Which intervention best supports a trauma patient experiencing acute psychological distress in the emergency department?

Provide calm, brief explanations of procedures, maintain a therapeutic presence, and involve support persons when possible (Correct answer)
Discourage the patient from talking about the traumatic event to avoid re-traumatization
Administer sedatives immediately to prevent further agitation
Leave the patient alone in a quiet room to self-regulate

Correct answer: Provide calm, brief explanations of procedures, maintain a therapeutic presence, and involve support persons when possible

Consistent presence, clear communication, and family support reduce anxiety and foster trust during acute trauma care.

Question 171: A patient in cardiogenic shock post-trauma has a pulmonary artery occlusion pressure (PAOP) of 22 mmHg and cardiac index of 1.8 L/min/m². Which intervention is most appropriate?

Norepinephrine infusion
Blood transfusion
Dobutamine infusion (Correct answer)
Aggressive IV fluid bolus

Correct answer: Dobutamine infusion

Elevated PAOP with low cardiac index in cardiogenic shock indicates heart failure; dobutamine increases contractility without significantly increasing preload.

Question 172: A patient with traumatic subarachnoid hemorrhage is at highest risk for which delayed complication between days 3 and 14 post-injury?

Cerebral vasospasm causing delayed ischemia (Correct answer)
Coagulopathy from massive transfusion
Rebleeding from the aneurysm
Hydrocephalus requiring immediate VP shunt

Correct answer: Cerebral vasospasm causing delayed ischemia

Cerebral vasospasm peaks between days 3–14 after traumatic SAH, causing delayed neurological deficits from ischemia in vessels exposed to subarachnoid blood.

Question 173: A patient arrives at a rural community hospital with a severe, unstable pelvic fracture after a farming accident and is in hemorrhagic shock. The hospital lacks an interventional radiologist and trauma surgeon. According to the Emergency Medical Treatment and Active Labor Act (EMTALA), what is the hospital's primary obligation before transferring the patient to a Level I trauma center?

Obtain written consent for transfer from the patient or family.
Provide stabilizing treatment to the best of its ability and resources. (Correct answer)
Contact the hospital's administrator to authorize the transfer costs.
Immediately transfer the patient to the higher level of care.

Correct answer: Provide stabilizing treatment to the best of its ability and resources.

EMTALA requires that if an emergency medical condition exists, the hospital must provide stabilizing treatment within its capabilities before transferring a patient. This includes initiating resuscitation, controlling external hemorrhage, and providing ongoing care to minimize risks during transport. While consent is necessary, the primary obligation is to stabilize first. A transfer cannot occur until the benefits of transfer outweigh the risks, and the transferring facility has done all it can to stabilize the patient.

Question 174: A patient with a C5 spinal cord injury would be expected to retain which motor function?

Diaphragmatic breathing only
Elbow flexion (Correct answer)
Wrist extension
Hand grip

Correct answer: Elbow flexion

C5 innervates the biceps, allowing elbow flexion; wrist extension requires C6, hand grip requires C7–C8.

Question 175: Which blood product ratio is recommended in damage control resuscitation for hemorrhagic shock?

1:1:1 (PRBCs:FFP:platelets) (Correct answer)
6:1:1 (PRBCs:FFP:platelets)
2:1:0 (PRBCs:FFP)
4:1:1 (PRBCs:FFP:platelets)

Correct answer: 1:1:1 (PRBCs:FFP:platelets)

Damage control resuscitation targets a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets to approximate whole blood.

Question 176: Which professional resource is most appropriate for a trauma nurse experiencing signs of secondary traumatic stress?

Continue working additional shifts to build resilience through exposure
Self-medicate with over-the-counter sleep aids until symptoms resolve
Request transfer to a non-trauma unit without discussing symptoms with anyone
Access the hospital's employee assistance program (EAP) and seek peer support or professional counseling (Correct answer)

Correct answer: Access the hospital's employee assistance program (EAP) and seek peer support or professional counseling

EAP services and peer support programs are specifically designed to help healthcare workers manage secondary traumatic stress and compassion fatigue.

Question 177: A trauma patient's arterial blood gas shows: pH 7.28, PaCO2 38, HCO3 16, PaO2 92 on 4L NC. This pattern is MOST consistent with:

Metabolic alkalosis
Metabolic acidosis (Correct answer)
Respiratory acidosis
Respiratory alkalosis

Correct answer: Metabolic acidosis

A low pH with low bicarbonate and a normal PaCO2 indicates metabolic acidosis, which in trauma is commonly caused by lactic acidosis from poor perfusion.

TCRN Certification Exam

The TCRN (Trauma Certified Registered Nurse) exam, administered by BCEN, validates the specialized knowledge and skills of nurses caring for trauma patients across the continuum of care.

175

Questions

180 min

Time Limit

64%

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