TNCC - Trauma Nurse Core Curriculum Initial Assessment and Triage Questions and Answers 1

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?

Accepted Answer

Airway and alertness with cervical spine stabilization

Answer

The TNCC systematic approach to the primary survey follows the ABCDE mnemonic. If the 'across-the-room' observation reveals no catastrophic external hemorrhage (), 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?

Accepted Answer

A weak, thready radial pulse at a rate of 110 beats/min

Answer

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?

Accepted Answer

Assign them to the 'minor' (green) category and have them await further instruction.

Answer

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?

Accepted Answer

Placement of a nasogastric tube

Answer

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?

Accepted Answer

Preparing for a definitive airway.

Answer

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]

TNCC - Trauma Nurse Core Curriculum Practice Test

TNCC - Trauma Nurse Core Curriculum Practice Test

TNCC - Trauma Nurse Core Curriculum Initial Assessment and Triage Questions and Answers 1