TNCC - Trauma Nurse Core Curriculum Initial Assessment and Triage Questions and Answers 1 — Questions and Answers
Question 1: During the primary survey of a trauma patient, which assessment is completed first after an initial 'across-the-room' observation identifies no uncontrolled external hemorrhage?
- Circulation and control of bleeding
- Breathing and ventilation
- Disability and neurologic status
- Airway and alertness with cervical spine stabilization (Correct answer)
Correct answer: Airway and alertness with cervical spine stabilization
The TNCC systematic approach to the primary survey follows the <C>ABCDE mnemonic. If the 'across-the-room' observation reveals no catastrophic external hemorrhage (<C>), the next step is to assess Airway and Alertness while maintaining cervical spine stabilization. [3, 10, 14]
Question 2: A patient arrives with multiple injuries after a high-speed motor vehicle collision. During the 'C' component (Circulation) of the primary survey, which finding requires immediate intervention?
- Abrasions to the bilateral forearms
- Capillary refill of 4 seconds in the lower extremities
- A weak, thready radial pulse at a rate of 110 beats/min (Correct answer)
- A closed, deformed right femur
Correct answer: A weak, thready radial pulse at a rate of 110 beats/min
A weak, thready radial pulse indicates significant intravascular volume loss and is a key sign of shock. While other findings are important, the pulse quality and rate point to a life-threatening circulation problem that must be addressed immediately with interventions like fluid resuscitation and hemorrhage control. [1, 10]
Question 3: You are the triage nurse in the emergency department during a mass casualty incident (MCI). A victim is able to walk to the designated 'green' area. According to the Simple Triage and Rapid Treatment (START) method, what is the next immediate action for this patient?
- Perform a detailed head-to-toe assessment.
- Assign them to the 'delayed' (yellow) category for reassessment.
- Assign them to the 'minor' (green) category and have them await further instruction. (Correct answer)
- Immediately transport them to a non-trauma hospital.
Correct answer: Assign them to the 'minor' (green) category and have them await further instruction.
In the START triage system, any victim who is able to walk is categorized as 'minor' or 'green'. These individuals are considered the 'walking wounded' and are the lowest priority for immediate individual assessment, allowing responders to focus on more critically injured patients. [17, 18]
Question 4: Which of the following is considered a resuscitation adjunct, obtained after the primary survey (ABCDEs) is complete?
- Application of a pelvic binder
- Needle decompression of a tension pneumothorax
- Insertion of an oropharyngeal airway
- Placement of a nasogastric tube (Correct answer)
Correct answer: Placement of a nasogastric tube
Resuscitation adjuncts are additional assessments and interventions completed after the initial primary survey and initiation of life-saving measures. The mnemonic LMNOP (Labs, Monitor, Naso/orogastric tube, Oxygenation/ventilation analysis, Pain assessment) helps guide this. Insertion of an OPA, needle decompression, and pelvic binder application are life-saving interventions performed during the A, B, or C components of the primary survey. [14]
Question 5: A trauma patient has a Glasgow Coma Scale (GCS) score of 7. According to TNCC guidelines, what is the priority intervention related to this finding during the 'Disability' assessment?
- Obtaining a non-contrast head CT scan.
- Administering mannitol for increased intracranial pressure.
- Preparing for a definitive airway. (Correct answer)
- Checking for pupillary response.
Correct answer: Preparing for a definitive airway.
A GCS score of 8 or less indicates a severe head injury and the patient's inability to protect their own airway. Therefore, the priority intervention is to secure a definitive airway, such as through intubation. While a CT scan and pupillary assessment are crucial, protecting the airway is the most immediate life-saving priority. [2, 10]
Question 6: During the 'Exposure and Environmental Control' phase of the initial assessment, the trauma nurse removes all of the patient's clothing. What is the MOST critical nursing consideration immediately following this action?
- Documenting all visible injuries.
- Initiating warming measures to prevent hypothermia. (Correct answer)
- Collecting clothing as evidence for law enforcement.
- Performing a log roll to inspect the posterior surfaces.
Correct answer: Initiating warming measures to prevent hypothermia.
After exposing the patient by removing their clothing, it is critical to immediately initiate warming measures, such as using warm blankets or a forced-air warmer. Trauma patients are at high risk for hypothermia, which can lead to coagulopathy, acidosis, and increased mortality (the 'trauma triad of death'). [1]
TNCC - Trauma Nurse Core Curriculum Initial Assessment and Triage Questions and Answers 1
During the primary survey of a trauma patient, which assessment is completed first after an initial 'across-the-room' observation identifies no uncontrolled external hemorrhage?