TNCC Trauma Nurse Core Curriculum Exam — Questions and Answers

Question 1: Which clinical finding differentiates Brown-Sequard syndrome from other incomplete spinal cord injury patterns?

Loss of motor function in upper extremities only with preserved lower extremity function
Bilateral loss of pain and temperature with preserved motor function
Ipsilateral motor loss and proprioception loss with contralateral pain and temperature loss (Correct answer)
Loss of all motor and sensory function below the injury

Correct answer: Ipsilateral motor loss and proprioception loss with contralateral pain and temperature loss

Brown-Sequard syndrome results from hemisection of the spinal cord, producing ipsilateral motor paralysis and proprioception loss (posterior columns) with contralateral pain and temperature loss (spinothalamic tract) below the injury.

Question 2: A trauma patient has oxygen saturation of 85% despite bag-valve-mask ventilation with 100% oxygen. Breath sounds are absent on the left with tracheal deviation to the right. The immediate intervention is:

Increase the respiratory rate of bag-valve-mask ventilation
Needle decompression at the left 2nd intercostal space, midclavicular line (Correct answer)
Left chest tube insertion
Emergent intubation

Correct answer: Needle decompression at the left 2nd intercostal space, midclavicular line

Absent breath sounds, tracheal deviation away from the affected side, and hypoxemia indicate tension pneumothorax requiring immediate needle decompression.

Question 3: A TBI patient's ICP monitor shows sustained readings of 25 mmHg. The first-line medical intervention is:

Barbiturate coma induction
IV dexamethasone
Osmotic therapy with mannitol or hypertonic saline (Correct answer)
Emergent decompressive craniectomy

Correct answer: Osmotic therapy with mannitol or hypertonic saline

Osmotic therapy (mannitol 20% or hypertonic saline 3-23.4%) is the first-line medical treatment for sustained intracranial hypertension (ICP >20-22 mmHg).

Question 4: A 25-year-old male is brought in by police after being found wandering in the street, smelling strongly of alcohol. He has a GCS of 13 (E4, V4, M5) and a laceration on his forehead. He is uncooperative with the cervical collar. What is the most appropriate approach to assessing this patient's altered mental status?

Assume the altered mental status is solely due to alcohol intoxication.
Administer a reversal agent for alcohol to facilitate the exam.
Rule out a traumatic brain injury before attributing altered mental status to intoxication. (Correct answer)
Defer the neurological exam until the patient is clinically sober.

Correct answer: Rule out a traumatic brain injury before attributing altered mental status to intoxication.

In trauma care, any altered mental status must be presumed to be from a traumatic brain injury until proven otherwise. While alcohol intoxication can cause altered mental status, it can also mask the signs and symptoms of a serious head injury. A thorough neurological assessment, including imaging if indicated, is required.

Question 5: A patient with a closed femur fracture is at risk for significant hemorrhage. The estimated blood loss from a single femur fracture is approximately:

2,500-3,000 mL
200-500 mL
500-750 mL
1,000-1,500 mL (Correct answer)

Correct answer: 1,000-1,500 mL

A closed femur fracture can result in 1,000-1,500 mL of blood loss into the thigh compartment, representing a significant source of hemorrhagic shock.

Question 6: A patient arrives after a penetrating wound to the central chest. The nurse assesses hypotension, distended jugular veins, and muffled heart sounds. These findings, known as Beck's Triad, are the classic signs of which life-threatening condition?

Pulmonary contusion
Aortic dissection
Tension pneumothorax
Pericardial (cardiac) tamponade (Correct answer)

Correct answer: Pericardial (cardiac) tamponade

Beck's Triad consists of hypotension, jugular venous distention, and muffled heart sounds. This triad is the classic presentation for acute pericardial (cardiac) tamponade, where fluid accumulation in the pericardial sac compresses the heart, impairing its ability to pump blood effectively. [3, 6, 7, 9]

Question 7: Which of the following best sums up the fundamentals of ventilation connected to a bag-mask device?

apply direct pressure. Direct pressure is the first stage. Use a torniquet in the second step.
fundamental shortfall When combined with serum lactate, base deficits function as an endpoint test of the sufficiency of cellular perfusion and aid in the prediction of the resuscitation's outcome.
shifts in mental state Older, aware babies or toddlers may not obey orders and are typically wary of strangers.
Breathe out at a rate of 10 to 12 times each minute. Help ventilations at 10 to 12 breaths per minute or one every 5 to 6 seconds if ventilation is not working. (Correct answer)

Correct answer: Breathe out at a rate of 10 to 12 times each minute. Help ventilations at 10 to 12 breaths per minute or one every 5 to 6 seconds if ventilation is not working.

When providing ventilations with a bag-mask device for an adult, the recommended rate is 10 to 12 breaths per minute. This translates to one breath every 5 to 6 seconds, ensuring adequate oxygenation and ventilation without causing hyperventilation, which can lead to complications.

Question 8: A patient with Class III hemorrhagic shock (30-40% blood volume loss) would be expected to present with which combination of findings?

Tachycardia 120-140, hypotension, tachypnea 30-40, confused and anxious (Correct answer)
Obtunded, pulse barely palpable, agonal respirations
Tachycardia 100-120, normal blood pressure, slightly anxious
Normal vital signs and mild anxiety

Correct answer: Tachycardia 120-140, hypotension, tachypnea 30-40, confused and anxious

Class III hemorrhage (1,500-2,000 mL, 30-40% blood volume) presents with significant tachycardia, the first measurable drop in systolic blood pressure, marked tachypnea, and confusion.

Question 9: A patient arrives after a motor vehicle crash with significant maxillofacial trauma, making oral intubation difficult. The patient is apneic. If endotracheal intubation attempts are unsuccessful, what is the next appropriate step in securing an airway?

Insert a supraglottic airway device. (Correct answer)
Wait for the patient's breathing to resume spontaneously.
Perform a blind nasotracheal intubation.
Ventilate with a bag-valve-mask until an anesthesiologist arrives.

Correct answer: Insert a supraglottic airway device.

In a 'can't intubate, can't oxygenate' scenario, or when intubation is unsuccessful, placing a rescue airway such as a supraglottic airway (e.g., LMA, King LT) is a critical next step. These devices can often be placed quickly and provide effective ventilation until a definitive surgical airway can be established if needed. Blind nasotracheal intubation is contraindicated in patients with significant facial trauma.

Question 10: The base deficit on an arterial blood gas is a useful marker in trauma because it indicates:

The severity of tissue oxygen debt and anaerobic metabolism (Correct answer)
The amount of bicarbonate administered during resuscitation
Adequate fluid resuscitation has been achieved
The degree of respiratory failure

Correct answer: The severity of tissue oxygen debt and anaerobic metabolism

Base deficit reflects the degree of metabolic acidosis from tissue hypoperfusion and anaerobic metabolism, serving as a surrogate marker for the severity and duration of shock.

Question 11: An 82-year-old male on a beta-blocker for hypertension fell down a flight of stairs. His initial blood pressure is 110/70 mmHg, and his heart rate is 78 bpm. He has a fractured femur. Which of the following is the most accurate interpretation of this patient's vital signs?

The patient's blood pressure indicates he is hemodynamically stable.
The heart rate is low due to a potential cervical spine injury.
The patient is likely in compensated shock, and the beta-blocker is masking tachycardia. (Correct answer)
The vital signs are within normal limits and not concerning.

Correct answer: The patient is likely in compensated shock, and the beta-blocker is masking tachycardia.

Geriatric patients often have a blunted physiological response to trauma, and pre-existing conditions like hypertension mean a blood pressure of 110/70 mmHg may represent relative hypotension. Beta-blockers prevent the expected tachycardic response to hypovolemia. A 'normal' heart rate and blood pressure in this context can be misleading and may represent occult hypoperfusion or compensated shock.

Question 12: When assessing a geriatric trauma patient, which physiological change most increases vulnerability to thoracic injuries?

Chest wall stiffening from calcified costal cartilage and osteoporotic ribs (Correct answer)
Enhanced cough reflex and airway protection
Increased respiratory muscle strength
Increased lung compliance and elastic recoil

Correct answer: Chest wall stiffening from calcified costal cartilage and osteoporotic ribs

Age-related changes including calcified costal cartilage, osteoporotic ribs, and decreased chest wall compliance increase the risk of rib fractures and associated pulmonary injuries from relatively minor mechanisms.

Question 13: Tranexamic acid (TXA) administration in trauma hemorrhage is most effective when given within what time frame from injury?

24 hours
12 hours
6 hours
3 hours (Correct answer)

Correct answer: 3 hours

The CRASH-2 trial demonstrated that TXA reduces mortality from hemorrhage when administered within 3 hours of injury. Administration after 3 hours may increase mortality.

Question 14: In a patient rescued from a fire involving burning synthetic materials who remains hemodynamically unstable despite 100% oxygen therapy, the trauma nurse should suspect:

Concurrent cyanide poisoning in addition to carbon monoxide toxicity (Correct answer)
Cherry-red skin discoloration indicating CO poisoning only
Isolated thermal burns causing distributive shock
Nicotine toxicity from burning tobacco products

Correct answer: Concurrent cyanide poisoning in addition to carbon monoxide toxicity

Combustion of synthetic materials and plastics releases hydrogen cyanide; persistent instability unresponsive to oxygen therapy suggests combined CO and cyanide poisoning.

Question 15: In a patient with combined blast injury and thermal burns, what assessment takes priority after the airway is secured?

Applying topical antimicrobial agents to burn wounds
Assessing for blast lung injury (pulmonary barotrauma) as a life-threatening cause of hypoxia (Correct answer)
Calculating total TBSA burned using the Rule of Nines
Beginning Parkland formula fluid calculations

Correct answer: Assessing for blast lung injury (pulmonary barotrauma) as a life-threatening cause of hypoxia

Blast lung injury causes pulmonary barotrauma with pneumothorax or parenchymal hemorrhage and is immediately life-threatening, taking priority over burn surface area assessment.

Question 16: During rapid sequence intubation of a trauma patient, cricoid pressure (Sellick maneuver) is applied primarily to:

Prevent aspiration by occluding the esophagus (Correct answer)
Improve visualization of the vocal cords
Facilitate tube passage through the trachea
Reduce cervical spine movement

Correct answer: Prevent aspiration by occluding the esophagus

Cricoid pressure compresses the esophagus against the cervical vertebral body, reducing the risk of passive regurgitation and aspiration during intubation.

Question 17: When using the Rule of Nines to estimate total body surface area (TBSA) burned in an adult, what percentage is assigned to the entire head and neck?

9% (Correct answer)
1%
18%
4.5%

Correct answer: 9%

In adults, the Rule of Nines assigns 9% of total body surface area to the head and neck combined.

Question 18: Which vital sign change is the EARLIEST indicator of hypovolemic shock in an adult trauma patient?

Tachycardia (Correct answer)
Hypotension (systolic BP < 90 mmHg)
Widened pulse pressure
Decreased urine output

Correct answer: Tachycardia

Tachycardia is typically the earliest vital sign change in hypovolemic shock, as the heart rate increases to compensate for decreased stroke volume before blood pressure drops.

Question 19: A patient with a casted right tibial fracture develops severe, deep pain that is unrelieved by opioids. The toes are cool to the touch and swollen, and the patient reports numbness. Which of the following is the priority nursing action?

Administer the next scheduled dose of anxiolytic medication.
Immediately notify the provider and prepare for cast removal. (Correct answer)
Elevate the affected limb on two pillows to reduce swelling.
Apply a warm pack to the foot to improve circulation.

Correct answer: Immediately notify the provider and prepare for cast removal.

The patient is exhibiting classic signs of acute compartment syndrome, a limb-threatening emergency caused by increased pressure within a fascial compartment. [2, 9, 15] Pain out of proportion to the injury is the earliest and most sensitive sign. [2, 15, 22] The priority is to relieve the external pressure immediately by notifying the provider for cast removal or bivalving, and preparing for a potential fasciotomy. Elevating the limb can worsen ischemia by decreasing arterial inflow. [25]

Question 20: A trauma patient presents with absent breath sounds on the right, tracheal deviation to the left, severe respiratory distress, and hypotension. What is the immediate, life-saving intervention for this condition?

Administer a 1-liter bolus of crystalloid fluid.
Obtain a stat portable chest x-ray.
Perform an immediate needle decompression. (Correct answer)
Prepare for immediate chest tube insertion.

Correct answer: Perform an immediate needle decompression.

The patient's signs and symptoms are classic for a tension pneumothorax, a life-threatening emergency where air is trapped in the pleural space, causing mediastinal shift and cardiovascular collapse. The immediate intervention is to relieve the pressure by performing a needle decompression. This is a temporizing measure performed before the definitive treatment of a chest tube (tube thoracostomy). [13, 27, 29, 30]

Question 21: Which adjunct to the primary survey is performed to assess for free fluid in the abdomen?

Abdominal X-ray
Focused Assessment with Sonography for Trauma (FAST) (Correct answer)
Diagnostic peritoneal lavage (DPL)
Digital rectal examination

Correct answer: Focused Assessment with Sonography for Trauma (FAST)

The FAST exam is a bedside ultrasound adjunct to the primary survey used to rapidly detect free fluid (blood) in the peritoneal, pericardial, and pleural spaces.

Question 22: Which physiological change in pregnancy makes assessment of hemorrhagic shock more challenging?

Increased blood viscosity slowing hemorrhage
Decreased blood volume making hemorrhage more obvious
Decreased cardiac output reducing the significance of blood loss
Physiological hypervolemia of pregnancy masking significant blood loss (Correct answer)

Correct answer: Physiological hypervolemia of pregnancy masking significant blood loss

Pregnancy increases blood volume by 40-50% (1,500-2,000 mL), allowing the pregnant patient to lose significant blood before showing traditional signs of shock.

Question 23: During the resuscitation of a patient with hemorrhagic shock, a balanced approach using a 1:1:1 ratio of blood products is often initiated. This ratio refers to the administration of:

1 unit of packed red blood cells, 1 unit of albumin, and 1 unit of platelets.
1 unit of packed red blood cells, 1 unit of fresh frozen plasma, and 1 unit of cryoprecipitate.
1 unit of packed red blood cells, 1 unit of fresh frozen plasma, and 1 unit of platelets. (Correct answer)
1 unit of whole blood, 1 liter of crystalloid, and 1 unit of platelets.

Correct answer: 1 unit of packed red blood cells, 1 unit of fresh frozen plasma, and 1 unit of platelets.

Balanced resuscitation, often guided by a massive transfusion protocol (MTP), advocates for a 1:1:1 ratio of packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelets. This approach aims to mimic whole blood to more effectively treat the coagulopathy associated with massive hemorrhage by replacing not just oxygen-carrying capacity (RBCs) but also clotting factors (FFP) and platelets.

Question 24: SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) is most common in which population?

Elderly patients with osteoporosis
Middle-aged patients with degenerative disc disease
Young adult athletes
Pediatric patients under age 8 (Correct answer)

Correct answer: Pediatric patients under age 8

SCIWORA occurs predominantly in children under 8 due to the hypermobility of the pediatric spine — elastic ligaments and cartilaginous vertebrae allow the spine to stretch beyond the tolerance of the spinal cord without bony fracture.

Question 25: When managing elevated intracranial pressure, the nurse should position the trauma patient with the head of bed elevated to what degree?

45-60 degrees
90 degrees (sitting upright)
Flat (0 degrees)
15-30 degrees (Correct answer)

Correct answer: 15-30 degrees

Head of bed elevation to 30 degrees promotes venous drainage from the brain via gravity, helping to reduce intracranial pressure while maintaining adequate cerebral perfusion.

Question 26: A patient with a stab wound to the left chest at the 5th intercostal space, anterior axillary line presents with hypotension and muffled heart sounds. The most likely diagnosis is:

Cardiac tamponade (Correct answer)
Tension pneumothorax
Diaphragmatic rupture
Simple pneumothorax

Correct answer: Cardiac tamponade

A penetrating wound in the cardiac box with hypotension and muffled heart sounds strongly suggests cardiac tamponade from pericardial blood accumulation.

Question 27: During trauma triage, the nurse identifies a patient with a penetrating abdominal wound, blood pressure 88/50, and heart rate 128. The correct triage decision is:

Assign to a lower-acuity treatment area for monitoring
Send to radiology for CT scan
Obtain laboratory studies and reassess in 15 minutes
Activate the trauma team for immediate resuscitation (Correct answer)

Correct answer: Activate the trauma team for immediate resuscitation

This patient has penetrating trauma with hemodynamic instability (hypotension, tachycardia), meeting criteria for the highest triage acuity and immediate trauma team activation.

Question 28: When logrolling a patient with a suspected spinal injury, the minimum number of personnel required is:

Three — one at the head directing, plus two supporting the body
Two — one at the head and one at the torso
One experienced nurse can safely logroll a patient alone
Four — one at the head plus three supporting the body (Correct answer)

Correct answer: Four — one at the head plus three supporting the body

A minimum of four persons is recommended for logrolling: one maintains manual in-line stabilization of the head/neck and directs the maneuver, while three support the torso, pelvis, and legs to maintain spinal alignment.

Question 29: A patient with a tracheostomy from a previous surgery presents with trauma and respiratory distress. The first step in airway management is:

Remove the tracheostomy and intubate orally
Place an oropharyngeal airway alongside the tracheostomy
Perform a cricothyrotomy below the tracheostomy
Suction the tracheostomy tube and assess patency (Correct answer)

Correct answer: Suction the tracheostomy tube and assess patency

Suctioning and assessing patency of the existing tracheostomy tube is the first step, as obstruction by blood, secretions, or a mucus plug is the most common cause of respiratory distress in tracheostomy patients.

Question 30: Which of the following scenarios is a recognized exception to standard mass casualty triage principles, requiring the use of "reverse triage"?

A building collapse with crush injuries.
A multiple-victim lightning strike. (Correct answer)
A multi-vehicle highway collision with blunt and penetrating trauma.
An industrial explosion with numerous burn and blast injuries.

Correct answer: A multiple-victim lightning strike.

In a multiple-victim lightning strike, reverse triage is the standard of care. Victims who are in cardiopulmonary arrest should be treated first. Lightning acts like a massive defibrillation, causing temporary paralysis of the heart and respiratory centers. These victims have a good chance of resuscitation with immediate CPR, whereas those with vital signs are more likely to survive the initial event.

Question 31: The concept of 'permissive hypotension' is a strategy used in the initial management of certain trauma patients. In which of the following patient populations is this approach generally contraindicated?

Patients with suspected uncontrolled internal hemorrhage
Patients with penetrating torso trauma
Patients with extremity fractures and a palpable radial pulse
Patients with a severe traumatic brain injury (TBI) (Correct answer)

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

Permissive hypotension, or hypotensive resuscitation, aims to maintain a blood pressure just high enough for vital organ perfusion without dislodging newly formed clots at the site of injury. 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. A lower systemic blood pressure would compromise CPP.

Question 32: Central cord syndrome is most commonly seen in which patient population and mechanism?

Athletes after axial loading injuries
Children after diving accidents
Elderly patients with pre-existing cervical spondylosis after hyperextension injuries (Correct answer)
Young adults after high-speed MVCs with flexion injuries

Correct answer: Elderly patients with pre-existing cervical spondylosis after hyperextension injuries

Central cord syndrome most commonly occurs in elderly patients with pre-existing cervical spondylosis (narrow spinal canal) who sustain a hyperextension injury, often from a ground-level fall.

Question 33: A patient rescued from a house fire presents with headache, nausea, and confusion but has a pulse oximetry reading of 99%. Which explanation is most accurate?

The patient is hyperventilating and is not hypoxic
A normal SpO2 rules out significant carbon monoxide poisoning
Standard pulse oximetry cannot differentiate carboxyhemoglobin from oxyhemoglobin, yielding a falsely normal reading (Correct answer)
The confusion is caused by pain and not carbon monoxide

Correct answer: Standard pulse oximetry cannot differentiate carboxyhemoglobin from oxyhemoglobin, yielding a falsely normal reading

Pulse oximetry measures light absorption but cannot distinguish carboxyhemoglobin from oxyhemoglobin, so readings appear falsely normal despite significant CO poisoning.

Question 34: Which assessment finding in a trauma patient indicates the need for immediate surgical intervention?

Initial chest tube output of 1,500 mL of blood (Correct answer)
Respiratory rate of 24 breaths per minute
Blood pressure of 100/70 mmHg
Heart rate of 110 bpm

Correct answer: Initial chest tube output of 1,500 mL of blood

An initial chest tube output of 1,500 mL or more indicates a massive hemothorax requiring emergent thoracotomy.

Question 35: A 34-year-old male arrives after a motorcycle crash with a deformed left femur, a heart rate of 130 beats/min, blood pressure of 88/52 mmHg, and cool, clammy skin. After initiating two large-bore IVs, which fluid is most appropriate for initial resuscitation of this patient in suspected hemorrhagic shock?

Lactated Ringer's solution (Correct answer)
Hetastarch (6% Hydroxyethyl Starch)
5% Dextrose in water (D5W)
0.9% Sodium Chloride

Correct answer: Lactated Ringer's solution

Lactated Ringer's is an isotonic crystalloid solution that is the preferred initial fluid for resuscitation in hemorrhagic shock according to TNCC guidelines. It most closely resembles the body's plasma composition and helps to buffer the metabolic acidosis often seen in shock states. While 0.9% NaCl is also an isotonic crystalloid, large volumes can lead to hyperchloremic metabolic acidosis. D5W is hypotonic and not suitable for volume resuscitation. Colloids like Hetastarch are generally not recommended for initial resuscitation due to potential adverse effects on coagulation and renal function.

Question 36: A trauma patient with an unstable pelvic fracture is hemodynamically unstable. Which intervention most effectively controls pelvic hemorrhage in the emergency department?

Immediate surgical open reduction and internal fixation
Bilateral lower extremity traction
Bilateral MAST trousers inflation
Application of a pelvic binder or circumferential sheet (Correct answer)

Correct answer: Application of a pelvic binder or circumferential sheet

A pelvic binder or circumferential sheet reduces the pelvic volume, approximates fracture fragments, and provides tamponade of venous and cancellous bone bleeding in unstable pelvic fractures.

Question 37: A patient arrives following a high-speed motor vehicle collision. During the secondary survey, the nurse notes clear fluid draining from the patient's left ear and ecchymosis over the mastoid process. Which type of injury are these findings most indicative of?

Mandibular fracture
Cervical spine dislocation
Basilar skull fracture (Correct answer)
Nasal bone fracture

Correct answer: Basilar skull fracture

Clear fluid drainage from the ear (CSF otorrhea) and bruising behind the ear over the mastoid process (Battle's sign) are classic clinical signs of a basilar skull fracture. These signs indicate a fracture at the base of the skull, which can tear the underlying dura mater, allowing cerebrospinal fluid to leak.

Question 38: 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.
Collecting clothing as evidence for law enforcement.
Initiating warming measures to prevent hypothermia. (Correct answer)
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]

Question 39: A patient with blunt chest trauma develops progressive respiratory distress over 24-48 hours with bilateral diffuse infiltrates on chest X-ray. This presentation is most consistent with:

Aspiration pneumonia
Delayed hemothorax
Pulmonary contusion progressing to ARDS (Correct answer)
Bilateral simple pneumothorax

Correct answer: Pulmonary contusion progressing to ARDS

Pulmonary contusion is a common blunt thoracic injury that typically worsens over 24-48 hours and can progress to acute respiratory distress syndrome (ARDS) with bilateral infiltrates.

Question 40: Which of the following clinical findings in an alert, non-intoxicated adult patient with blunt trauma is a primary indication for maintaining spinal motion restriction?

Reported pain score of 8/10 from an extremity injury
A closed fracture of the clavicle
A large hematoma on the scalp
Midline cervical spine tenderness upon palpation (Correct answer)

Correct answer: Midline cervical spine tenderness upon palpation

According to established clinical decision rules like the NEXUS criteria, the presence of midline spinal tenderness is a key indicator of a potential vertebral column injury that necessitates spinal motion restriction until the spine can be radiologically cleared. [12, 14, 18] A distracting injury (severe pain elsewhere) is also an indication, but midline tenderness itself is a direct sign of potential spinal injury.

Question 41: A trauma patient requires a surgical airway. The anatomical landmark for cricothyrotomy is the membrane between the:

Thyroid cartilage and cricoid cartilage (Correct answer)
Hyoid bone and thyroid cartilage
Cricoid cartilage and first tracheal ring
First and second tracheal rings

Correct answer: Thyroid cartilage and cricoid cartilage

An emergency cricothyrotomy is performed through the cricothyroid membrane, located between the inferior border of the thyroid cartilage and the superior border of the cricoid cartilage.

Question 42: A trauma patient in hemorrhagic shock has received 4 units of PRBCs and remains hypotensive with a heart rate of 140. The next priority in the massive transfusion protocol is:

Continue balanced transfusion with plasma and platelets in a 1:1:1 ratio with PRBCs (Correct answer)
Stop all transfusion and obtain a CT scan
Switch to crystalloid-only resuscitation
Administer vasopressors as the primary intervention

Correct answer: Continue balanced transfusion with plasma and platelets in a 1:1:1 ratio with PRBCs

Current evidence supports a balanced 1:1:1 ratio of PRBCs to plasma to platelets during massive transfusion to address both oxygen-carrying capacity and coagulopathy simultaneously.

Question 43: Why is hypothermia a major risk in patients with major burn injuries?

Opioid analgesics suppress thermoregulatory centers in the brain
Burns dramatically increase the body's basal metabolic rate, causing hyperthermia
IV fluid administration produces vasodilation and heat dissipation
Loss of the skin barrier causes massive evaporative heat loss and eliminates thermoregulatory function (Correct answer)

Correct answer: Loss of the skin barrier causes massive evaporative heat loss and eliminates thermoregulatory function

Burned skin loses its thermoregulatory function, resulting in massive evaporative heat loss from the wound surface and an inability to maintain body temperature.

Question 44: Which of the following is considered a resuscitation adjunct, obtained after the primary survey (ABCDEs) is complete?

Placement of a nasogastric tube (Correct answer)
Application of a pelvic binder
Insertion of an oropharyngeal airway
Needle decompression of a tension pneumothorax

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 45: A trauma patient presents with a pale, cool, pulseless right lower leg after a knee dislocation. The nurse's priority is:

Document the findings and continue the secondary survey
Apply ice and elevate the extremity
Notify the physician immediately for emergent vascular assessment — limb-threatening vascular injury is likely (Correct answer)
Obtain bilateral ankle-brachial indices

Correct answer: Notify the physician immediately for emergent vascular assessment — limb-threatening vascular injury is likely

A pulseless extremity after knee dislocation suggests popliteal artery injury, which occurs in 20-40% of knee dislocations. This is a limb-threatening emergency requiring immediate intervention.

Question 46: Which clinical finding is most specific for esophageal perforation following penetrating neck or chest trauma?

Hemoptysis
Left-sided pleural effusion
Tachycardia
Mediastinal air on chest X-ray (pneumomediastinum) (Correct answer)

Correct answer: Mediastinal air on chest X-ray (pneumomediastinum)

Pneumomediastinum (air in the mediastinum) visible on chest X-ray is the most specific radiographic finding for esophageal perforation, as swallowed air and gas-producing bacteria escape into the mediastinal space.

Question 47: In pediatric trauma, which statement about anatomical differences is most clinically significant?

Children have a slower metabolic rate, reducing oxygen requirements
Children have a proportionally larger head and more pliable ribs, masking internal injuries (Correct answer)
Children have a proportionally smaller head, lowering cervical spine injury risk
Children's ribs are more calcified, leading to more rib fractures

Correct answer: Children have a proportionally larger head and more pliable ribs, masking internal injuries

Children have proportionally larger heads (increasing cervical spine vulnerability) and more pliable rib cages that can transmit force to underlying organs without fracturing, masking serious internal injuries.

Question 48: A trauma patient presents with subcutaneous emphysema of the neck and upper chest. This finding most likely indicates:

Superficial soft tissue infection
Pneumothorax, tracheal injury, or esophageal rupture (Correct answer)
Esophageal rupture only
Arterial air embolism

Correct answer: Pneumothorax, tracheal injury, or esophageal rupture

Subcutaneous emphysema in the neck and upper chest indicates air leaking into soft tissues, most commonly from pneumothorax, tracheobronchial injury, or less commonly esophageal perforation.

Question 49: When managing a patient with a flail chest segment, which ventilation strategy is most appropriate?

Mechanical stabilization by taping the flail segment externally
Immediate intubation regardless of respiratory status
Positive pressure ventilation if respiratory failure develops (Correct answer)
Encouraging deep breathing without analgesics to prevent sedation

Correct answer: Positive pressure ventilation if respiratory failure develops

Positive pressure ventilation provides internal pneumatic stabilization of the flail segment when respiratory failure develops. Adequate pain control is essential for non-intubated patients.

Question 50: The Parkland formula for fluid resuscitation in a burn patient calculates the first 24-hour crystalloid requirement as:

6 mL × kg body weight × %TBSA burned
4 mL × kg body weight × %TBSA burned (Correct answer)
10 mL × kg body weight × %TBSA burned
2 mL × kg body weight × %TBSA burned

Correct answer: 4 mL × kg body weight × %TBSA burned

The Parkland formula calculates 4 mL of lactated Ringer's solution × patient weight in kg × %TBSA burned, with half given in the first 8 hours and half over the next 16 hours.

Question 51: Which type of shock is characterized by decreased cardiac output due to impaired myocardial contractility following blunt chest trauma?

Hypovolemic shock
Obstructive shock
Distributive shock
Cardiogenic shock (Correct answer)

Correct answer: Cardiogenic shock

Cardiogenic shock from blunt cardiac injury (myocardial contusion) results in decreased contractility and reduced cardiac output despite adequate intravascular volume.

Question 52: When initiating mechanical ventilation for a trauma patient with suspected Acute Respiratory Distress Syndrome (ARDS), which strategy is most appropriate to prevent further lung injury?

High FiO2 and minimal PEEP.
Low tidal volumes and high PEEP. (Correct answer)
High tidal volumes and high respiratory rates.
Low respiratory rates and high tidal volumes.

Correct answer: Low tidal volumes and high PEEP.

For patients with or at risk for ARDS, a lung-protective ventilation strategy is recommended. This involves using low tidal volumes (e.g., 4-6 mL/kg of ideal body weight) to prevent volutrauma, and appropriate levels of Positive End-Expiratory Pressure (PEEP) to prevent atelectrauma by keeping alveoli open. The goal is to maintain adequate oxygenation while minimizing ventilator-induced lung injury.

TNCC Trauma Nurse Core Curriculum Exam

The TNCC written exam certifies trauma nursing knowledge, covering initial assessment, airway management, shock, and injury-specific care using the Trauma Nursing Process.

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