Initial Assessment Flashcards
7 cards from real TNCC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Initial Assessment flashcards as text
During the reevaluation phase of the initial assessment, the trauma nurse notes a declining GCS from 13 to 9 over 20 minutes. The priority action is:
Answer: Repeat the primary survey and prepare for potential airway intervention
A declining GCS indicates neurological deterioration; the nurse must repeat the primary survey and anticipate definitive airway management.
Which finding during secondary survey of the head and neck suggests a basilar skull fracture?
Answer: Battle's sign (ecchymosis over mastoid) and raccoon eyes
Battle's sign and raccoon eyes are classic delayed signs of basilar skull fracture indicating bleeding into tissue planes.
A patient sustains a crush injury to the lower extremities. Which lab value change is the trauma nurse most concerned about in the initial assessment period?
Answer: Elevated serum potassium (hyperkalemia)
Crush injuries cause rhabdomyolysis, releasing intracellular potassium, which can cause life-threatening cardiac dysrhythmias.
The 'permissive hypotension' resuscitation strategy during initial assessment is contraindicated in which patient population?
Answer: Patients with traumatic brain injury (TBI)
TBI patients require adequate cerebral perfusion pressure; permissive hypotension can worsen secondary brain injury and is contraindicated.
During the primary survey, a patient has an open chest wound that produces a sucking sound with respirations. The immediate intervention is:
Answer: Apply a three-sided (flutter valve) occlusive dressing
A three-sided dressing allows air to escape but prevents air from entering, functioning as a flutter valve to prevent tension pneumothorax.
The Parkland formula for fluid resuscitation in burn trauma uses which fluid as the primary resuscitation solution?
Answer: Lactated Ringer's solution
The Parkland formula uses Lactated Ringer's (4 mL × kg × %TBSA burned) because its composition closely resembles plasma.
When performing a log-roll during the secondary survey, the trauma nurse's primary responsibility is to:
Answer: Maintain in-line cervical spine stabilization
The trauma nurse at the head maintains manual in-line stabilization throughout the log-roll to prevent cervical spine movement.