TCRN Certification Exam — Questions and Answers

Question 1: Which assessment finding is MOST consistent with a tension pneumothorax?

Tracheal deviation away from the affected side with absent breath sounds (Correct answer)
Tracheal deviation toward the affected side with crackles
Symmetric chest rise with SpO2 of 88%
Bilateral breath sounds with dullness to percussion

Correct answer: Tracheal deviation away from the affected side with absent breath sounds

Tension pneumothorax causes tracheal deviation away from the affected (collapsed) side due to mediastinal shift, along with absent breath sounds.

Question 2: Which intervention is the HIGHEST priority for a trauma patient presenting with an open (sucking) chest wound?

Immediate chest tube insertion at the bedside
Portable chest X-ray to assess pneumothorax size
Apply a three-sided occlusive dressing to seal the wound (Correct answer)
Intubation and mechanical ventilation

Correct answer: Apply a three-sided occlusive dressing to seal the wound

A three-sided (vented) occlusive dressing seals the wound on inspiration while allowing air to escape on expiration, preventing tension pneumothorax development.

Question 3: 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?

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

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

Phenylephrine
Norepinephrine (Correct answer)
Vasopressin
Dobutamine

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

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

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

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

Correct answer: Metabolic acidosis

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

Question 7: A 7-year-old child is brought to the trauma center after being struck by a car. Assessment reveals a fractured right femur, right-sided pulmonary contusions, and a left-sided epidural hematoma. This classic pattern of injuries in a pediatric pedestrian is known as:

Waddell's Triad (Correct answer)
Pediatric Impact Triad
Beck's Triad
Cushing's Triad

Correct answer: Waddell's Triad

Waddell's Triad describes a common injury pattern in pediatric pedestrians struck by vehicles. It consists of: 1) ipsilateral (same side) femur/tibial fracture from the initial bumper impact, 2) ipsilateral thoracic or abdominal injuries from the fender/hood, and 3) a contralateral (opposite side) head injury as the child is thrown to the ground.

Question 8: 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 9: 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.
Fat embolism.
Compartment syndrome. (Correct answer)

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 10: When applying a wound vacuum-assisted closure (VAC) device, which wound characteristic is a CONTRAINDICATION?

Untreated osteomyelitis in the wound bed (Correct answer)
Post-fasciotomy wound with exposed muscle
Wound with moderate exudate
Wound with greater than 50% granulation tissue

Correct answer: Untreated osteomyelitis in the wound bed

Active untreated osteomyelitis is a contraindication to VAC therapy as negative pressure may accelerate spread of bone infection.

Question 11: 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?

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

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 12: A patient with 30% TBSA burns develops fever, tachycardia, and wound purulence on day 5. Which organism is the most common cause of early burn wound infection?

Candida albicans
Klebsiella pneumoniae
Pseudomonas aeruginosa
Staphylococcus aureus (Correct answer)

Correct answer: Staphylococcus aureus

Staphylococcus aureus (including MRSA) predominates in early burn wound infections during the first week, while Pseudomonas aeruginosa becomes more common later.

Question 13: Which of the following is a Class I indication for ICP monitoring according to Brain Trauma Foundation guidelines?

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

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 14: Which intervention BEST prevents pressure injury development in an intubated, sedated trauma patient?

Repositioning every 4 hours to minimize disruption of healing tissue
Using a standard hospital mattress with a sheepskin overlay
Repositioning every 2 hours with documentation of skin assessment (Correct answer)
Applying prophylactic foam dressings to bony prominences only when erythema appears

Correct answer: Repositioning every 2 hours with documentation of skin assessment

Scheduled repositioning every 2 hours remains the gold-standard pressure injury prevention strategy, combined with skin assessment documentation.

Question 15: A pregnant patient at 36 weeks presents after blunt abdominal trauma. Continuous fetal monitoring shows repeated late decelerations. What does this pattern indicate?

Uteroplacental insufficiency and fetal hypoxia (Correct answer)
Cord compression — normal in late pregnancy
Fetal movement artifact
Head compression during Braxton Hicks contractions

Correct answer: Uteroplacental insufficiency and fetal hypoxia

Late decelerations (occurring after the peak of a contraction) are associated with uteroplacental insufficiency and indicate fetal hypoxia requiring urgent intervention.

Question 16: A child with burns to the entire right leg is evaluated using the Lund and Browder chart. How does this differ from adult calculation for the same area?

Children's legs account for a larger percentage of TBSA than adults
Children's head and legs are calculated identically to adults
Children's legs account for a smaller percentage of TBSA than adults (Correct answer)
The Lund and Browder chart applies the same percentages as the Rule of Nines

Correct answer: Children's legs account for a smaller percentage of TBSA than adults

In children, the head is proportionally larger and each leg proportionally smaller than in adults; the Lund and Browder chart accounts for these age-based anatomical differences.

Question 17: Secondary brain injury after TBI is primarily caused by which mechanism?

Hypoxia, hypotension, cerebral edema, and elevated ICP occurring after the primary injury (Correct answer)
The initial kinetic energy transfer from impact
Genetic predisposition to neuronal death
Inflammatory response that only begins 72 hours post-injury

Correct answer: Hypoxia, hypotension, cerebral edema, and elevated ICP occurring after the primary injury

Secondary brain injury results from systemic and intracranial processes after the initial insult—all of which are potentially preventable.

Question 18: 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 application increases pain and patient distress
Ice delays neutrophil migration needed for early healing
Cold temperatures accelerate bacterial colonization of the wound

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

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

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

Respiratory alkalosis
Disseminated intravascular coagulation
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 21: A trauma patient with a known history of alcohol use disorder (AUD) is admitted and becomes agitated with tremors and diaphoresis 24 hours later. What is the priority intervention?

Naloxone administration
CT head for intracranial pathology as first step
Restraints and haloperidol for agitation
IV thiamine followed by benzodiazepine-based CIWA protocol (Correct answer)

Correct answer: IV thiamine followed by benzodiazepine-based CIWA protocol

Alcohol withdrawal can be life-threatening; IV thiamine prevents Wernicke's encephalopathy and benzodiazepines (guided by CIWA scoring) are first-line treatment for withdrawal symptoms.

Question 22: In damage control resuscitation for massive hemorrhage, what ratio of packed red blood cells to fresh frozen plasma to platelets is recommended?

2:1:0
1:1:1 (Correct answer)
4:1:1
6:4:1

Correct answer: 1:1:1

A 1:1:1 ratio of pRBC:FFP:platelets approximates whole blood and is recommended in damage control resuscitation to prevent coagulopathy.

Question 23: Which of the following is a PRIMARY survey finding that requires IMMEDIATE intervention?

Suspected pelvic fracture on palpation
Positive FAST exam with stable vitals
Open pneumothorax (sucking chest wound) (Correct answer)
Open femur fracture with deformity

Correct answer: Open pneumothorax (sucking chest wound)

An open pneumothorax allows air to enter the pleural space with each breath, rapidly causing respiratory failure and must be immediately sealed with an occlusive dressing.

Question 24: A burn patient on day 3 develops hypotension, fever of 39.8°C, confusion, and a white blood cell count of 18,000. Which condition must be differentiated from the normal post-burn inflammatory response?

Sepsis from burn wound or line infection (Correct answer)
Burn shock due to inadequate resuscitation
Abdominal compartment syndrome
Systemic inflammatory response syndrome (SIRS) from burns alone

Correct answer: Sepsis from burn wound or line infection

While SIRS is expected after major burns, the addition of a suspected source, organ dysfunction, and clinical deterioration requires urgent evaluation for sepsis and appropriate cultures.

Question 25: Which fluid is the PREFERRED initial resuscitation fluid for hemorrhagic shock according to current ATLS guidelines?

Warm lactated Ringer's solution (Correct answer)
Albumin 5%
0.9% normal saline
5% dextrose in water

Correct answer: Warm lactated Ringer's solution

Warm lactated Ringer's solution is preferred over normal saline for resuscitation due to its balanced electrolyte composition and reduced risk of hyperchloremic acidosis.

Question 26: 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)
Acalculous cholecystitis
Neurogenic shock
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 27: A patient with a traumatic amputation of the right hand arrives in the trauma bay. After controlling hemorrhage, what is the CORRECT method for preserving the amputated part?

Soak the part in normal saline and keep at room temperature
Place the part directly in ice water
Wrap in moist sterile gauze, place in a sealed bag, then place on ice (Correct answer)
Wrap in dry sterile gauze and place in a sealed bag on ice

Correct answer: Wrap in moist sterile gauze, place in a sealed bag, then place on ice

The amputated part should be wrapped in moist sterile gauze, placed in a sealed plastic bag, and then placed on ice to preserve tissue viability without causing frostbite from direct ice contact.

Question 28: Which parameter is the most sensitive early indicator of hemorrhagic shock in a healthy young trauma patient?

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

Correct answer: Tachycardia

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

Question 29: The patient's temperature should typically be decreased and maintained at? with targeted temperature management (TTM), also known as therapeutic hypothermia.

28 to 30° C.
30 to 32° C.
32 to 36° C. (Correct answer)
24 to 28° C.

Correct answer: 32 to 36° C.

The patient's temperature should typically be decreased and maintained at 32 to 36° C with targeted temperature management (TTM), also known as therapeutic hypothermia. (Normal temperature is around 37° C). TTM is normally kept for 24 hours or so. In cases of sepsis, recent surgery (within two weeks), coagulopathy, or pre-existing coma, hypothermia is not advised. Ice packs, cooling blankets, helmets, and cool infusions or instillations can all be used to cool someone down.

Question 30: 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?

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

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 31: A TCRN discovers a colleague charted a procedure that was never performed. The most appropriate first action is to:

Confront the colleague publicly on the unit
Report the finding through the facility's chain of command or risk management (Correct answer)
Ignore it since it did not harm the patient
Correct the chart entry yourself without notifying anyone

Correct answer: Report the finding through the facility's chain of command or risk management

Falsified documentation is fraudulent and must be reported through proper channels such as the chain of command or risk management.

Question 32: Tranexamic acid (TXA) is MOST effective when given within what time frame after injury?

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

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 33: A patient with a subdural hematoma has a lucid interval followed by rapid neurological deterioration. This presentation is more classic for which type of hematoma?

Epidural hematoma (Correct answer)
Acute subdural hematoma
Subarachnoid hemorrhage
Chronic subdural hematoma

Correct answer: Epidural hematoma

Epidural hematomas classically present with a lucid interval followed by rapid deterioration due to arterial bleeding (typically middle meningeal artery) expanding between the dura and skull.

Question 34: During resuscitation of a trauma patient with hemorrhagic shock, which finding indicates successful resuscitation?

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

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 35: A patient with a basilar skull fracture may exhibit which classic finding?

Battle's sign or raccoon eyes with possible CSF rhinorrhea or otorrhea (Correct answer)
Babinski reflex bilaterally
Lhermitte's sign
Absent corneal reflexes only

Correct answer: Battle's sign or raccoon eyes with possible CSF rhinorrhea or otorrhea

Basilar skull fractures classically produce periorbital or mastoid ecchymosis (raccoon eyes/Battle's sign) and possible CSF leaks.

Question 36: A trauma patient with sickle cell disease is admitted with long bone fractures. Which additional complication should the nurse monitor for that non-sickle cell patients do not face?

Vaso-occlusive crisis triggered by hypoxia, dehydration, and stress (Correct answer)
Excessive blood transfusion requirements from hemolysis only
Fat embolism syndrome exclusively
Hypercalcemia from bone breakdown

Correct answer: Vaso-occlusive crisis triggered by hypoxia, dehydration, and stress

Trauma-induced hypoxia, dehydration, acidosis, and physiologic stress can trigger vaso-occlusive crisis in sickle cell patients, adding significant morbidity beyond the primary injury.

Question 37: 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?

Norepinephrine
Dopamine (Correct answer)
Phenylephrine
Vasopressin

Correct answer: Dopamine

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

Question 38: A patient with suspected aortic disruption is most likely to have which mechanism of injury?

Low-speed rear-end collision
Direct blow to the sternum during CPR
High-speed deceleration injury such as a motor vehicle crash or fall from height (Correct answer)
Penetrating stab wound to the abdomen

Correct answer: High-speed deceleration injury such as a motor vehicle crash or fall from height

Traumatic aortic disruption typically results from rapid deceleration forces that shear the aorta at fixed anatomic points.

Question 39: Which clinical finding best distinguishes neurogenic shock from hemorrhagic shock in a trauma patient with spinal cord injury?

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

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 40: Diffuse axonal injury (DAI) is best diagnosed by which imaging modality?

MRI of the brain (Correct answer)
Plain skull X-ray
CT scan of the head without contrast
Cerebral angiography

Correct answer: MRI of the brain

MRI is far superior to CT for detecting the small axonal shearing injuries characteristic of DAI, especially in white matter.

Question 41: In the primary survey, the 'E' in ABCDE stands for Exposure. What is the KEY nursing consideration during this step?

Exposing only the injured extremity to preserve modesty
Removing clothing only if the patient consents
Fully undressing the patient while preventing hypothermia (Correct answer)
Exposing only after IV access is established

Correct answer: Fully undressing the patient while preventing hypothermia

Full exposure allows identification of all injuries, but active warming measures must immediately prevent hypothermia, which worsens coagulopathy.

Question 42: Which organ is most commonly injured in blunt abdominal trauma in adults?

Liver
Small bowel
Spleen (Correct answer)
Pancreas

Correct answer: Spleen

The spleen is the most commonly injured solid organ in blunt abdominal trauma due to its fragility and highly vascular nature.

Question 43: 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)
500 mL of normal saline
200 mL of normal saline
1,000 mL of lactated Ringer's

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

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

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 45: 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?

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

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

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

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 48: A patient with a pelvic fracture from a crush injury has ongoing hemodynamic instability despite resuscitation. Which intervention should the trauma nurse anticipate FIRST?

Angioembolization
External fixation in the OR
Emergent laparotomy
Application of a pelvic binder (Correct answer)

Correct answer: Application of a pelvic binder

A pelvic binder is the immediate intervention to reduce pelvic volume and tamponade venous bleeding before more definitive treatment.

Question 49: Which type of intracranial hematoma is associated with a lucid interval followed by rapid deterioration?

Intracerebral hemorrhage
Epidural hematoma (Correct answer)
Diffuse axonal injury
Subdural hematoma

Correct answer: Epidural hematoma

Epidural hematoma, classically from middle meningeal artery rupture, produces a lucid interval before rapid neurological decline.

Question 50: Which splint position is correct for a suspected scaphoid fracture in the ED?

Ulnar gutter splint with wrist in neutral
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

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 51: Post-traumatic seizures in TBI patients are classified as immediate (within 24 hours), early (1–7 days), or late (>7 days). Which type is associated with the highest risk of developing epilepsy?

All types carry equal risk
Early seizures
Immediate seizures
Late seizures (Correct answer)

Correct answer: Late seizures

Late post-traumatic seizures, occurring more than 7 days after injury, indicate permanent epileptogenic changes and are strongly associated with ongoing epilepsy.

Question 52: Which sign indicates that a burn patient's inhalation injury has progressed to involve the lower airway?

Stridor and hoarseness on presentation
Soot in the oropharynx
Wheezing and bronchospasm on auscultation (Correct answer)
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 53: 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 54: A patient in septic shock requires norepinephrine. Which additional agent is recommended as a second-line vasopressor to reduce norepinephrine dosing?

Epinephrine
Phenylephrine
Vasopressin (Correct answer)
Dopamine

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 55: Which assessment finding in a trauma patient indicates neurogenic shock rather than hypovolemic shock?

Tachycardia with cool, clammy skin
Bradycardia with warm, flushed skin (Correct answer)
Bradycardia with pale, mottled skin
Tachycardia with diaphoresis

Correct answer: Bradycardia with warm, flushed skin

Neurogenic shock causes loss of sympathetic tone, resulting in paradoxical bradycardia and vasodilation (warm, flushed skin), unlike the compensatory tachycardia and vasoconstriction of hypovolemic shock.

Question 56: A pregnant trauma patient at 28 weeks requires a chest X-ray. Which action should the nurse take regarding radiation exposure?

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

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 57: 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?

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

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 58: Which finding on secondary survey MOST indicates a diaphyseal femur fracture with significant hemorrhage?

Shortened leg with external rotation
Ecchymosis limited to the thigh
Crepitus at the fracture site only
Thigh circumference 5 cm larger than the contralateral side with hemodynamic instability (Correct answer)

Correct answer: Thigh circumference 5 cm larger than the contralateral side with hemodynamic instability

A femur fracture can sequester 1-2 liters of blood; significant thigh swelling (increased circumference) combined with hemodynamic instability confirms substantial hemorrhage.

Question 59: A patient sustains burns to the anterior trunk, both arms, and the head. Using the Rule of Nines, what is the estimated TBSA burned?

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

Correct answer: 45%

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

Question 60: The central venous pressure (CVP) of an adult patient is being monitored, and the pressure is decreasing. Which method is used to confirm hypovolemia?

Decrease rate of IV fluids and observe for further decrease in pressure.
Rapid fluid infusion of 250 to 500 mL and then evaluation in 10 minutes. (Correct answer)
Repeat readings every 5 minutes X 5 to determine further decrease in pressure.
Increase rate of fluids 2 X current rate and evaluate for increase in pressure.

Correct answer: Rapid fluid infusion of 250 to 500 mL and then evaluation in 10 minutes.

A fast fluid infusion of 250 to 500 mL may be administered because hypovolemia is the most frequent cause of a decline in CVP. If the pressure begins to drop again after ten minutes, hypovolemia is likely the cause. Always utilize serial readings to confirm an increase or reduction. The right atrium, right ventricle, and blood flow back into the heart are all evaluated using the CVP, which is the pressure in the superior vena cava close to the right atrium. Depending on the method of measurement, the normal ranges for CVP are 0 to 8 cm H2O or 2 to 6 mm Hg.

Question 61: A patient presents with paradoxical chest wall movement after blunt chest trauma. This finding indicates:

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

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

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 63: A trauma nurse is assessing a patient with a penetrating neck injury located in Zone II. Which of the following is considered a 'hard sign' of significant vascular or airway injury, mandating immediate surgical exploration?

Non-expanding hematoma
Pulsatile external bleeding (Correct answer)
Dysphonia
Subcutaneous emphysema

Correct answer: Pulsatile external bleeding

Hard signs of penetrating neck trauma indicate a high probability of significant injury and often require immediate surgical intervention. These signs include active, pulsatile bleeding, an expanding hematoma, shock, diminished carotid pulse, bruit or thrill, and signs of airway obstruction like stridor. [7, 18] Dysphonia, non-expanding hematoma, and subcutaneous emphysema are considered 'soft signs,' which warrant further diagnostic evaluation but not necessarily immediate surgery.

Question 64: During assessment of a neck trauma patient, you note tracheal deviation, absent breath sounds on the left, and distended neck veins. What is the priority intervention?

Chest X-ray confirmation
Needle decompression of the left chest (Correct answer)
Pericardiocentesis
Immediate intubation

Correct answer: Needle decompression of the left chest

Tension pneumothorax presents with tracheal deviation away from the affected side, absent breath sounds, and JVD, requiring immediate needle decompression.

Question 65: In the acute trauma setting, which imaging modality is MOST appropriate for initial evaluation of suspected thoracic vertebral injury in a hemodynamically unstable patient?

Myelography to assess cord compression
CT scan of the chest and thoracic spine (Correct answer)
MRI of the thoracic spine with contrast
Plain anteroposterior and lateral X-rays of the thoracic spine

Correct answer: CT scan of the chest and thoracic spine

CT is preferred for acute spinal trauma evaluation because it is faster, more sensitive for bony injury, and readily available alongside standard trauma imaging protocols.

Question 66: 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?

Nasotracheal intubation
Placement of a supraglottic airway device
Rapid sequence intubation (RSI)
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 67: In permissive hypotension strategy for penetrating trauma, what is the target systolic blood pressure before hemorrhage control?

120 mmHg
80-90 mmHg (Correct answer)
60-70 mmHg
100-110 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 68: A trauma patient receives 10 units of PRBCs during massive transfusion. Which complication is specifically associated with this volume of transfusion?

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

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

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

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 70: When assessing pupils in a TBI patient, which finding indicates the most critical concern?

Bilateral 4 mm pupils that react sluggishly
Both pupils 3 mm and reactive
Anisocoria of 0.5 mm present since childhood
One fixed, dilated pupil on the side of a known hematoma (Correct answer)

Correct answer: One fixed, dilated pupil on the side of a known hematoma

Ipsilateral fixed, dilated pupil indicates uncal herniation with CN III compression, a neurosurgical emergency.

Question 71: When checking intracranial pressure in an adult, the trauma nurse must be informed of what the usual range is?

5 to 10 mm Hg.
20 to 25 mm Hg.
15 to 20 mm Hg.
10 to 15 mm Hg. (Correct answer)

Correct answer: 10 to 15 mm Hg.

The trauma nurse must be aware that the typical range for intracranial pressure in adults is 10 to 15 mm Hg when doing so. When there is internal bleeding in the brain, the brain initially tries to reduce the volume of CSF by increasing absorption and decreasing blood flow, but when the brain is unable to do so, the ICP starts to rise very quickly, which can sometimes cause brain shift and herniation syndromes as well as compression of the tissue. If the disease is not corrected right away, death might occur in a matter of hours.

Question 72: What is the target systolic blood pressure for a hypotensive patient with a traumatic brain injury (TBI) per ATLS guidelines?

≥70 mmHg
≥90 mmHg (Correct answer)
≥110 mmHg
≥130 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 73: 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 an unstable pelvic fracture
Patients with extremity amputation and active bleeding
Patients with a suspected traumatic brain injury (TBI) (Correct answer)
Patients with penetrating abdominal trauma

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 74: 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?

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

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 75: 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 — safe to observe
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

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 76: A trauma patient with a suspected C-spine injury requires intubation. Which method is MOST appropriate for maintaining cervical spine stabilization?

Rapid sequence intubation with in-line stabilization (Correct answer)
Blind orotracheal intubation
Nasotracheal intubation without sedation
Cricothyrotomy as first choice

Correct answer: Rapid sequence intubation with in-line stabilization

Rapid sequence intubation with manual in-line cervical spine stabilization is the preferred method for intubating trauma patients with suspected C-spine injuries.

Question 77: A patient with a posterior hip dislocation is being reduced. Which post-reduction assessment is MOST critical?

Hip flexion range of motion
Skin integrity over the greater trochanter
Sciatic nerve function assessment (Correct answer)
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 78: A patient with a C5 spinal cord injury would be expected to retain which motor function?

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

Correct answer: Elbow flexion

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

Question 79: Spinal shock is defined as which of the following phenomena following acute spinal cord injury?

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

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 80: Which statement about the Health Insurance Portability and Accountability Act (HIPAA) is correct?

HIPAA applies only to electronic health records
HIPAA prohibits all sharing of patient information within the care team
HIPAA requires patient consent before emergency treatment can begin
HIPAA permits sharing patient information among the treatment team without additional authorization (Correct answer)

Correct answer: HIPAA permits sharing patient information among the treatment team without additional authorization

HIPAA's treatment exception allows providers directly involved in care to share information necessary for treatment without additional patient authorization.

Question 81: Which class of hemorrhagic shock is characterized by 30-40% blood volume loss, confusion, and systolic BP of 90 mmHg?

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

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

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

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

Acidosis
Hypothermia
Coagulopathy
Hypocalcemia (Correct answer)

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 84: Using the ASIA Impairment Scale, a patient with incomplete SCI whose key muscles below the injury level have a motor grade less than 3 in the majority is classified as:

ASIA A — complete injury
ASIA B — sensory incomplete only
ASIA C — motor incomplete, most muscles grade < 3 (Correct answer)
ASIA D — motor incomplete, most muscles grade ≥ 3

Correct answer: ASIA C — motor incomplete, most muscles grade < 3

ASIA C denotes incomplete injury with preserved motor function below the level but with most key muscles graded below 3 (antigravity strength).

Question 85: A patient receives 2L of normal saline for hemorrhagic shock resuscitation. Which metabolic complication is a concern?

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

Correct answer: Hyperchloremic metabolic acidosis

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

Question 86: 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)
Electrolyte imbalance from rapid fluid shifts
Sympathetic overdrive causing AV node suppression
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 87: A geriatric trauma patient takes beta-blockers daily. Which assessment finding may be masked by this medication?

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

Correct answer: Tachycardia

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

Question 88: An 84-year-old patient is admitted after a fall, presenting with a fractured hip. The nurse notes several large bruises on the patient's back in various stages of healing and that the patient appears fearful when their caregiver is in the room. What is the nurse's primary legal responsibility in this situation?

Ask the caregiver to explain the origin of the bruises.
Document the findings and monitor for further signs of abuse.
Ask the patient if they feel safe at home with the caregiver present.
Report the suspicion of elder abuse to Adult Protective Services. (Correct answer)

Correct answer: Report the suspicion of elder abuse to Adult Protective Services.

Nurses are legally mandated reporters. When there is a reasonable suspicion of elder abuse or neglect, the nurse has a legal duty to report it to the designated state authority, typically Adult Protective Services. The report is based on suspicion; proof is not required. Confronting the caregiver or waiting for more evidence can delay intervention and potentially endanger the patient.

Question 89: The cerebral perfusion pressure (CPP) is calculated as:

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

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

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

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 91: 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
Deep vein thrombosis and pulmonary embolism (Correct answer)
Heterotopic ossification
Adjustment disorder and depression

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 92: A patient sustains handlebar trauma to the abdomen. Which injury should be highest on the differential?

Duodenal injury (Correct answer)
Mesenteric avulsion
Liver laceration
Bladder rupture

Correct answer: Duodenal injury

Handlebar injuries cause focal compression to the upper abdomen, making duodenal hematomas or perforations a classic associated injury.

Question 93: A pregnant trauma patient at 24 weeks gestation has fetal heart tones of 90 bpm. What does this finding indicate?

Normal fetal heart rate for this gestational age
Normal variation in the second trimester
Artifact from maternal tachycardia
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 94: A trauma patient with suspected hemorrhagic shock has a lactate of 6.2 mmol/L. What does this value primarily indicate?

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

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

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

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 96: Which factor is the strongest risk indicator for completed suicide in a trauma patient?

A previous suicide attempt (Correct answer)
Chronic low back pain
Mild depression without prior history
Social isolation without prior attempt

Correct answer: A previous suicide attempt

A prior suicide attempt is the single strongest predictor of future completed suicide.

Question 97: When assessing a wound for infection, which finding is MOST concerning for systemic sepsis requiring immediate action?

Wound dehiscence with exposed subcutaneous tissue
Localized erythema within 1 cm of wound edges
New purulent drainage with fever 38.8°C, HR 118, and WBC 18,000 (Correct answer)
Serosanguineous drainage with mild periwound warmth

Correct answer: New purulent drainage with fever 38.8°C, HR 118, and WBC 18,000

Systemic signs — fever, tachycardia, and leukocytosis — combined with purulent drainage indicate sepsis from wound infection requiring immediate intervention.

Question 98: A 28-year-old pregnant patient at 32 weeks gestation is in the trauma bay after a motor vehicle collision. In what position should she be placed to optimize hemodynamics?

Supine with legs elevated
Left lateral decubitus or 15-30 degree left tilt (Correct answer)
Semi-Fowler's at 45 degrees
Right lateral decubitus

Correct answer: Left lateral decubitus or 15-30 degree left tilt

Left lateral tilt or full left lateral decubitus relieves aortocaval compression by the gravid uterus, improving cardiac output and uteroplacental perfusion.

Question 99: 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)
length of time since injury.
loss of blood

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

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

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 101: Under which circumstance may a trauma nurse legally restrain a patient without a physician's order?

Immediately when the patient poses an imminent danger to self or others, with a physician order obtained promptly after (Correct answer)
Only after two nurses agree the restraint is needed
Never — physician order must precede any restraint
Whenever the patient is confused or agitated

Correct answer: Immediately when the patient poses an imminent danger to self or others, with a physician order obtained promptly after

Emergency restraint is permissible when there is immediate danger, but a physician order must be obtained as soon as possible after application.

Question 102: An unconscious trauma patient has a suspected cervical spine injury. Which airway method is PREFERRED?

Cricothyrotomy as the first choice
Blind nasotracheal intubation
Nasopharyngeal airway with jaw thrust only
Rapid sequence intubation (RSI) with in-line stabilization (Correct answer)

Correct answer: Rapid sequence intubation (RSI) with in-line stabilization

RSI with manual in-line cervical stabilization is the preferred method as it protects the airway while minimizing cervical movement.

Question 103: A patient with a traumatic brain injury has a sudden drop in GCS from 13 to 7 with ipsilateral pupil dilation. This is MOST consistent with:

Epidural hematoma (Correct answer)
Cerebral contusion
Subdural hematoma
Diffuse axonal injury

Correct answer: Epidural hematoma

Epidural hematoma classically presents with a lucid interval followed by rapid neurological deterioration and ipsilateral (uncal herniation) pupil dilation from arterial bleeding.

Question 104: Which finding suggests an intraperitoneal bladder rupture rather than an extraperitoneal rupture on cystogram?

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

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 105: 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 I
Le Fort III (Correct answer)
Le Fort II

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 106: 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
5,600 mL (Correct answer)
8,400 mL

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

Subtalar dislocation
Achilles tendon rupture
Lisfranc fracture-dislocation
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 108: Permissive hypotension in a penetrating trauma patient WITHOUT head injury targets a systolic BP of approximately:

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

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 109: A patient transferred from an outside hospital with 50% TBSA burns has received 3 liters of NS. On arrival, the patient is in burn shock. What is the most appropriate fluid adjustment?

Administer 2L boluses of LR until hemodynamic stability
Continue normal saline at the same rate and reassess in 1 hour
Switch to colloid (albumin) as first-line resuscitation fluid
Recalculate Parkland formula from time of injury and adjust LR rate accordingly (Correct answer)

Correct answer: Recalculate Parkland formula from time of injury and adjust LR rate accordingly

The Parkland formula should be recalculated from the time of injury, credit given for fluids already received, and the remaining volume adjusted using lactated Ringer's.

Question 110: Which intervention is the priority when a spinal cord injury patient develops autonomic dysreflexia with BP 220/130 mmHg?

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

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 111: A burn patient develops myoglobinuria after electrical injury. What is the minimum target urine output to prevent acute kidney injury?

0.25 mL/kg/hr
3–5 mL/kg/hr
1–2 mL/kg/hr (Correct answer)
0.5 mL/kg/hr

Correct answer: 1–2 mL/kg/hr

With myoglobinuria, urine output should be increased to 1–2 mL/kg/hr (with IV fluids and possible sodium bicarbonate to alkalinize urine) to flush myoglobin and prevent tubular obstruction.

Question 112: 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 3 — inappropriate words
Score of 4 — confused (Correct answer)
Score of 2 — incomprehensible sounds

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 113: A trauma patient with a pelvic fracture and hemodynamic instability has a pelvic binder applied but remains unstable. After ruling out other sources of hemorrhage, which procedure provides definitive hemorrhage control when angiography is not immediately available?

Bilateral femoral artery ligation
External pelvic fixation alone
Pelvic preperitoneal packing (Correct answer)
Peritoneal lavage

Correct answer: Pelvic preperitoneal packing

Preperitoneal pelvic packing directly compresses the pelvic venous plexus and is the recommended damage-control procedure when angioembolization is unavailable or fails.

Question 114: A trauma nurse administers the wrong medication dose to a patient. The nurse's immediate priority after addressing the patient's safety is to:

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

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

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

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 116: During chest tube insertion for hemothorax, the nurse notes 1,500 mL of blood drains immediately. What is the priority action?

Increase IV fluid rate to compensate for blood loss
Document findings and reassess in 30 minutes
Notify the surgeon immediately for possible operative intervention (Correct answer)
Clamp the chest tube to slow blood loss

Correct answer: Notify the surgeon immediately for possible operative intervention

Immediate drainage of ≥1,000–1,500 mL indicates massive hemothorax requiring surgical evaluation for operative control.

Question 117: A trauma patient is on a ventilator and the nurse notes rising peak airway pressures with decreased breath sounds on the left. The MOST immediate action is to:

Suction the endotracheal tube
Perform immediate needle decompression on the left (Correct answer)
Increase the PEEP setting
Obtain a chest X-ray

Correct answer: Perform immediate needle decompression on the left

Rising peak airway pressures with absent unilateral breath sounds in a ventilated trauma patient indicates tension pneumothorax requiring emergent needle decompression without delay for imaging.

Question 118: Which ECG finding is most associated with myocardial contusion following blunt chest trauma?

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

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 119: A patient with a femur fracture develops sudden hypotension, tachycardia, and decreased breath sounds on the left. Which complication is most likely?

Pulmonary embolism
Hemorrhagic shock from femur fracture
Fat embolism syndrome
Tension pneumothorax (Correct answer)

Correct answer: Tension pneumothorax

Sudden hemodynamic collapse with decreased unilateral breath sounds after trauma suggests tension pneumothorax, requiring immediate needle decompression.

Question 120: Cushing's triad, the late sign of increased ICP, includes which three findings?

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

Correct answer: Bradycardia, hypertension, and irregular respirations

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

Question 121: A burn patient develops hoarseness, stridor, and oropharyngeal edema 2 hours after a house fire. What is the priority intervention?

Obtain ABG and reassess in 30 minutes
Apply a non-rebreather mask at 15 L/min
Perform early endotracheal intubation (Correct answer)
Administer nebulized racemic epinephrine

Correct answer: Perform early endotracheal intubation

Progressive upper airway edema from inhalation injury mandates early endotracheal intubation before complete obstruction renders intubation impossible.

Question 122: A patient with a complete C7 spinal cord injury asks what level of independence to expect. The nurse's BEST response is that C7 complete SCI patients typically can:

Ambulate with leg braces and forearm crutches
Require 24-hour attendant care for all activities of daily living
Transfer independently and propel a manual wheelchair without assistance (Correct answer)
Have full hand function with weakness limited to the legs

Correct answer: Transfer independently and propel a manual wheelchair without assistance

C7 preserves triceps function (elbow extension), enabling independent transfers, manual wheelchair propulsion, and many ADLs with adaptive equipment.

Question 123: A patient with a C5 spinal cord injury reports increased spasticity and a new pressure injury over the sacrum. Which nursing intervention is PRIORITY?

Reposition the patient and apply a hydrocolloid dressing immediately
Assess for and relieve the noxious stimulus causing autonomic dysreflexia trigger (Correct answer)
Administer antispasmodic medication as ordered
Notify the physician for a new pressure injury staging

Correct answer: Assess for and relieve the noxious stimulus causing autonomic dysreflexia trigger

In SCI at or above T6, a pressure injury can trigger autonomic dysreflexia, a life-threatening hypertensive emergency requiring immediate stimulus removal.

Question 124: 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)
High tidal volume (12–15 mL/kg IBW) with low PEEP
Pressure-controlled ventilation targeting PaCO2 < 35 mmHg
High-frequency oscillatory ventilation as first-line mode

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 125: A patient with full-thickness circumferential burns to both lower extremities develops absent pedal pulses bilaterally. The PRIORITY intervention is:

Prepare the patient for bilateral lower extremity escharotomy (Correct answer)
Apply topical vasodilator and warm blankets
Elevate both lower extremities above heart level
Increase IV fluid rate to improve perfusion pressure

Correct answer: Prepare the patient for bilateral lower extremity escharotomy

Circumferential full-thickness burns restrict blood flow as edema develops; escharotomy releases the constricting eschar to restore distal perfusion.

Question 126: At which level of complete cervical spinal cord injury would a patient most likely require permanent mechanical ventilation?

C3 (Correct answer)
C6
T1
C5

Correct answer: C3

Injuries at C3 and above disrupt the phrenic nerve origin (C3-C5), eliminating diaphragmatic function and requiring permanent ventilatory support.

Question 127: 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?

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

Correct answer: Dobutamine infusion

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

Question 128: Which blood product ratio is recommended in damage control resuscitation for hemorrhagic shock?

2:1:0 (PRBCs:FFP)
6:1:1 (PRBCs:FFP:platelets)
1:1:1 (PRBCs:FFP:platelets) (Correct answer)
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 129: A trauma patient has blood at the urethral meatus, perineal bruising, and a high-riding prostate on rectal exam. Which intervention should the nurse AVOID?

Surgical consultation
IV fluid resuscitation
Pelvic X-ray
Foley catheter insertion (Correct answer)

Correct answer: Foley catheter insertion

Foley catheter insertion is contraindicated when urethral injury is suspected; a urethrogram must be performed first to rule out urethral disruption.

Question 130: Which scenario represents a conflict of interest that a trauma nurse must disclose or avoid?

Seeking consultation from a specialist for a complex patient case
Accepting gifts from a medical device company while making product recommendations to the unit (Correct answer)
Attending a hospital-sponsored continuing education event
Reporting a near-miss incident anonymously through the hospital system

Correct answer: Accepting gifts from a medical device company while making product recommendations to the unit

Accepting gifts from industry while influencing product decisions creates a conflict of interest that must be disclosed or avoided to maintain professional integrity.

Question 131: Grief following traumatic death of a patient is a normal response for trauma nurses. Which statement about nurse grief is true?

Nurses who grieve patient deaths are not suited for trauma nursing
Nurse grief should always be expressed openly in front of patients
Grief in nurses only becomes problematic if it lasts more than 24 hours
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 132: Which of the following findings is most consistent with spinal cord injury without radiographic abnormality (SCIWORA) in a pediatric patient?

Normal CT and MRI with neurological deficits (Correct answer)
Compression fracture at T12 on X-ray
C-spine fracture visible on CT scan
Odontoid fracture without neurological symptoms

Correct answer: Normal CT and MRI with neurological deficits

SCIWORA is defined by neurological deficits with normal CT and MRI, and occurs more commonly in children due to ligamentous laxity.

Question 133: In pediatric trauma, which behavioral finding should alert the trauma nurse to possible child abuse?

Injuries inconsistent with the developmental stage or the history provided by caregivers (Correct answer)
Bruising over the shins in a child who just learned to walk
Single fracture of the clavicle from a fall
Fearfulness during physical exam only

Correct answer: Injuries inconsistent with the developmental stage or the history provided by caregivers

Injuries that don't match the caregiver's explanation or the child's developmental ability are the most important red flags for non-accidental trauma.

Question 134: A patient with a C5 spinal cord injury is most likely to experience which respiratory complication?

Diaphragmatic breathing only with impaired intercostal and accessory muscle function, requiring close monitoring (Correct answer)
Paradoxical breathing from intercostal spasticity
Complete apnea requiring immediate intubation regardless of other findings
No respiratory compromise because diaphragm function is preserved

Correct answer: Diaphragmatic breathing only with impaired intercostal and accessory muscle function, requiring close monitoring

C5 injuries spare the diaphragm (C3-C5) but impair intercostal and accessory muscles, leaving patients at high risk for respiratory fatigue.

Question 135: Which of the following patients is least likely to require monitoring of intracranial pressure?

Four-year old with extensive subarachnoid hemorrhage.
Sixteen-year-old with acute head injury and unable to follow commands.
Forty-five-year-old head injury patient with BP of 80/40 and unilateral posturing.
Fifty-year old female with head injury, Glasgow coma score of 14, and BP of 95/60. (Correct answer)

Correct answer: Fifty-year old female with head injury, Glasgow coma score of 14, and BP of 95/60.

Most patients with mild to severe head injuries and a Glasgow coma score of 13 to 15 do not need ICP monitoring. If a person is >40, postures, and has hypotension (90 systolic), they usually need to be monitored if they have suffered a significant head injury (even with a normal CT scan). With subarachnoid and intraventricular hemorrhage, cerebrovascular accident, brain tumors, brain abscesses/infections, and hydrocephalus, ICP monitoring may be necessary. ICP threshold values range from 20 to 25 mm HG for adults and 20 mm HG for children.

Question 136: A patient in distributive shock has warm, flushed skin and bounding pulses. What is the underlying hemodynamic mechanism?

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

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 137: A patient arrives after being thrown from a motorcycle with an open femur fracture. After airway and hemorrhage control, the PRIORITY wound intervention is:

Immediate operative debridement in the trauma bay
Wound culture before any irrigation
Application of antibiotic-soaked gauze and splinting
Irrigation with normal saline and sterile dressing application (Correct answer)

Correct answer: Irrigation with normal saline and sterile dressing application

Initial management of open fractures includes copious irrigation and sterile dressing to reduce contamination prior to definitive operative care.

Question 138: A trauma patient develops worsening hypoxia 24 hours after admission despite supplemental oxygen. Chest X-ray shows bilateral opacities. Which condition is most likely?

Diaphragmatic hernia
Acute respiratory distress syndrome (ARDS) (Correct answer)
Spontaneous pneumothorax
Pulmonary embolism

Correct answer: Acute respiratory distress syndrome (ARDS)

ARDS following trauma presents with bilateral infiltrates and refractory hypoxia, typically peaking 24–72 hours after injury.

Question 139: 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 140: A trauma patient in police custody is being evaluated. Regarding release of medical information to law enforcement, the nurse should:

Release only the minimum necessary information as required by law or court order (Correct answer)
Allow officers unrestricted access to the patient's chart
Provide complete records to law enforcement upon request
Refuse all disclosure regardless of legal requirements

Correct answer: Release only the minimum necessary information as required by law or court order

HIPAA allows disclosure to law enforcement only in specific circumstances and requires release of only the minimum necessary information.

Question 141: Which finding best distinguishes obstructive shock from hypovolemic shock on assessment?

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

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

Hypocalcemia (Correct answer)
Hyperkalemia
Hypomagnesemia
Hypernatremia

Correct answer: Hypocalcemia

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

Question 143: During the secondary survey of a blunt trauma patient, you note a perineal hematoma and scrotal ecchymosis. Which injury should be suspected?

Urethral disruption or perineal vascular injury (Correct answer)
Intraperitoneal bladder rupture
Rectal tear alone
Femoral artery injury

Correct answer: Urethral disruption or perineal vascular injury

Perineal and scrotal ecchymosis after trauma suggests urethral disruption or significant perineal vascular injury requiring urologic evaluation before catheterization.

Question 144: 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:

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

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

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

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

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 147: A patient sustains a complete C5 spinal cord injury. Which functional finding would the nurse expect on assessment?

Full hand function with paralysis limited to the lower extremities
Loss of shoulder shrug with intact elbow flexion
Intact elbow flexion but inability to extend the wrist (Correct answer)
Complete loss of all upper extremity function with intact diaphragm

Correct answer: Intact elbow flexion but inability to extend the wrist

C5 preserves elbow flexion (biceps, C5-C6) but a complete C5 injury eliminates C6-innervated wrist extension, creating this characteristic pattern.

Question 148: Which coagulopathy triad is associated with worsening hemorrhagic shock and increased mortality in trauma?

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

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 149: A trauma patient has breath sounds on the right but gastric sounds audible over the left chest. Which injury does this suggest?

Tracheal tear
Left diaphragmatic rupture with herniation of abdominal contents (Correct answer)
Left pneumothorax
Left hemothorax

Correct answer: Left diaphragmatic rupture with herniation of abdominal contents

Bowel sounds auscultated in the chest cavity indicate diaphragmatic rupture with herniation of abdominal organs into the thorax.

Question 150: 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 151: A restrained driver involved in a high-speed MVC complains of severe neck pain and bilateral upper extremity weakness. Which spinal cord injury syndrome is most likely?

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

Correct answer: Central cord syndrome

Central cord syndrome causes greater weakness in the upper extremities than lower extremities and is the most common incomplete spinal cord injury, often from hyperextension.

Question 152: 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?

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

Correct answer: Pericardiocentesis

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

Question 153: A restrained driver involved in a high-speed MVC presents with GCS of 14 and a widened mediastinum on chest X-ray. Which injury must be immediately considered?

Pulmonary contusion
Esophageal rupture
Diaphragmatic tear
Traumatic aortic injury (Correct answer)

Correct answer: Traumatic aortic injury

A widened mediastinum on chest X-ray in a high-deceleration mechanism is a classic indicator of traumatic aortic injury until proven otherwise.

Question 154: A patient with a substance use disorder is admitted after trauma. Which approach best reflects trauma-informed, non-stigmatizing care?

Document 'drug-seeking behavior' in the chart to alert future providers
Discharge as soon as medically stable without referral
Withhold pain medication to avoid worsening addiction
Treat withdrawal and pain proactively, use respectful language, and involve addiction medicine consultants as appropriate (Correct answer)

Correct answer: Treat withdrawal and pain proactively, use respectful language, and involve addiction medicine consultants as appropriate

Trauma-informed care recognizes substance use disorder as a chronic illness; proactive treatment and specialist involvement reduce harm.

Question 155: 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?

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

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 156: Which type of liver injury is characterized by hepatic avulsion from the retrohepatic vena cava and is typically fatal?

Grade II subcapsular hematoma
Grade IV liver laceration
Grade III liver laceration
Grade VI (juxtahepatic venous injury) (Correct answer)

Correct answer: Grade VI (juxtahepatic venous injury)

Grade VI liver injuries (formerly described as hepatic avulsion) involve the retrohepatic vena cava or major hepatic veins and carry an extremely high mortality rate.

Question 157: A patient with a pelvic fracture has gross hematuria. A CT cystogram reveals extravasation of contrast into the peritoneal cavity. Which of the following is the most definitive management for this type of injury?

Placement of a suprapubic catheter.
Surgical exploration and repair. (Correct answer)
Serial abdominal examinations and bed rest.
Prolonged Foley catheter drainage for 10-14 days.

Correct answer: Surgical exploration and repair.

The finding of contrast in the peritoneal cavity on a cystogram confirms an intraperitoneal bladder rupture. This type of injury requires surgical exploration and repair to prevent complications such as urinary ascites, peritonitis, and sepsis. Conservative management with catheter drainage alone is typically reserved for uncomplicated extraperitoneal bladder ruptures.

Question 158: 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?

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

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 159: Which intervention is indicated for a patient with suspected hydrofluoric acid (HF) burns to the hand with systemic symptoms?

Intravenous calcium gluconate infusion (Correct answer)
Immediate surgical debridement of affected tissue
Silver sulfadiazine dressing and wound elevation
Sodium bicarbonate soaks to neutralize the acid

Correct answer: Intravenous calcium gluconate infusion

HF penetrates tissue and binds calcium, causing life-threatening hypocalcemia and dysrhythmias; systemic involvement requires IV calcium gluconate in addition to topical calcium gel.

Question 160: 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?

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

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

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

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 162: Which physical exam finding is a late sign of intra-abdominal hemorrhage after blunt trauma?

Abdominal rigidity and peritoneal signs (Correct answer)
Tachycardia
Mild abdominal tenderness
Seat-belt abrasion

Correct answer: Abdominal rigidity and peritoneal signs

Abdominal rigidity and peritoneal signs indicate significant bleeding or bowel contamination and represent a late, serious finding requiring urgent surgical intervention.

Question 163: Which topical antimicrobial agent is contraindicated in patients with sulfonamide allergy?

Mafenide acetate (Sulfamylon)
Bacitracin ointment
Silver nitrate solution
Silver sulfadiazine (Silvadene) (Correct answer)

Correct answer: Silver sulfadiazine (Silvadene)

Silver sulfadiazine (Silvadene) is a sulfonamide compound and is contraindicated in patients with sulfa allergy due to risk of allergic reaction.

Question 164: A trauma patient arrives with a GCS of 8. What is the PRIORITY nursing intervention?

Apply cervical collar
Prepare for definitive airway management (Correct answer)
Obtain IV access
Administer supplemental oxygen via non-rebreather mask

Correct answer: Prepare for definitive airway management

A GCS ≤8 indicates inability to protect the airway, making definitive airway management (intubation) the priority intervention.

Question 165: A child's endotracheal tube size is being estimated using the Broselow tape. The tape reads 'red zone.' What other information does the Broselow tape provide beyond ETT size?

Only equipment sizes
Weight-based medication doses and equipment sizes simultaneously (Correct answer)
Heart rate and blood pressure norms only
Only medication doses

Correct answer: Weight-based medication doses and equipment sizes simultaneously

The Broselow tape provides weight-based estimates for both medication doses and equipment sizes (ETT, BP cuff, laryngoscope blade) simultaneously.

Question 166: Which finding on point-of-care ultrasound (POCUS/FAST exam) indicates a hemodynamically significant pericardial effusion causing obstructive shock?

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

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 167: Which of the following interventions is the priority for a hemodynamically unstable patient with a severe pelvic fracture and a positive FAST exam?

Immediate transfer for angiographic embolization.
Application of a pelvic binder and transfer to the operating room. (Correct answer)
CT scan to delineate the pelvic fracture pattern.
Insertion of a suprapubic catheter for bladder decompression.

Correct answer: Application of a pelvic binder and transfer to the operating room.

In a patient who is hemodynamically unstable with both a pelvic fracture and evidence of intra-abdominal hemorrhage (positive FAST), the priority is controlling both sources of bleeding. A pelvic binder should be applied immediately to address the pelvic bleeding. The patient should then be taken directly to the operating room for an exploratory laparotomy to control the intra-abdominal source of hemorrhage. Delaying for a CT scan or angioembolization is inappropriate in a patient with ongoing instability and a positive FAST.

Question 168: A well-known public figure is admitted to the trauma center, and a person claiming to be their sibling calls the unit asking for a detailed medical update. The patient is intubated and cannot give permission. To comply with HIPAA, what is the nurse's most appropriate action?

Use professional judgment to verify the caller's identity before providing limited, relevant information. (Correct answer)
Provide a detailed update to the caller to ensure the family is informed.
State that no information can be given over the phone due to HIPAA.
Refer the caller to the hospital's public relations department for an official statement.

Correct answer: Use professional judgment to verify the caller's identity before providing limited, relevant information.

The HIPAA Privacy Rule allows healthcare providers to share information with a patient's family or friends involved in their care if the provider determines, based on professional judgment, that it is in the patient's best interest, especially when the patient is incapacitated. However, the provider must take reasonable steps to verify the identity and authority of the person requesting the information before disclosing any Protected Health Information (PHI). A blanket refusal may be inappropriate, while giving a detailed update without verification is a clear violation.

Question 169: A trauma patient with known coagulopathy and hemorrhagic shock has a fibrinogen level of 80 mg/dL. Which product should be prioritized?

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

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 170: 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:

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

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 171: 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)
1.0 mL/kg/hr
1.5 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 172: 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)
Transfer the patient to a facility that accepts their insurance
Obtain insurance authorization before treatment
Contact the patient's primary care physician before evaluation

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 173: 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?

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

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 174: Autonomic dysreflexia in a patient with a spinal cord injury above T6 is most commonly triggered by which cause?

Pain from a minor abrasion
Hyponatremia
A distended bladder or bowel (Correct answer)
Hypoglycemia

Correct answer: A distended bladder or bowel

Bladder distension is the most common trigger of autonomic dysreflexia, causing massive sympathetic stimulation below the injury level.

Question 175: 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?

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

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 176: Which pelvic fracture pattern carries the highest risk of massive hemorrhage?

Anteroposterior compression type III (open-book) (Correct answer)
Acetabular fracture
Avulsion fracture of the anterior superior iliac spine
Lateral compression type I

Correct answer: Anteroposterior compression type III (open-book)

APC type III open-book pelvic fractures disrupt the pelvic ring anteriorly and posteriorly, tearing the venous plexus and internal iliac vessels causing massive hemorrhage.

Question 177: Which assessment finding is MOST specific for compartment syndrome in a closed tibial fracture?

Paresthesias distal to the fracture
Pain with passive stretch of compartment muscles (Correct answer)
Tense, firm compartment on palpation
Absent distal pulses

Correct answer: Pain with passive stretch of compartment muscles

Pain with passive stretch is the earliest and most specific finding for compartment syndrome, occurring before neurovascular deficits develop.

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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