TNCC Nursing Skills — Questions and Answers
Question 1: A trauma patient requires rapid fluid resuscitation through a large-bore IV catheter. Which gauge is most appropriate for this situation?
- 22-gauge
- 20-gauge
- 14-gauge or 16-gauge (Correct answer)
- 24-gauge
Correct answer: 14-gauge or 16-gauge
Large-bore IV catheters (14- or 16-gauge) are recommended for rapid fluid resuscitation in trauma patients because they allow the highest flow rates.
In trauma resuscitation, the rate of fluid delivery is critical. IV flow rate is determined by catheter diameter (gauge) and length per Poiseuille's law. A 14-gauge or 16-gauge short peripheral catheter provides the fastest flow rates, often exceeding 300 mL/min under pressure. Smaller gauges like 20 or 22 significantly limit flow and are inadequate for aggressive resuscitation. The TNCC emphasizes establishing two large-bore IVs as a priority in the primary survey.
Question 2: During a trauma assessment, the nurse notes paradoxical chest wall movement. This finding is most consistent with which injury?
- Simple pneumothorax
- Flail chest (Correct answer)
- Cardiac tamponade
- Hemothorax
Correct answer: Flail chest
Paradoxical chest wall movement, where a segment moves inward on inspiration and outward on expiration, is the hallmark sign of flail chest.
Flail chest occurs when three or more adjacent ribs are fractured in two or more places, creating a free-floating segment. This segment moves paradoxically — inward during inspiration and outward during expiration — because it is no longer connected to the intact chest wall. The underlying pulmonary contusion, rather than the mechanical flail itself, is the primary cause of respiratory compromise. Treatment focuses on pain management, positive pressure ventilation if needed, and monitoring for deterioration.
Question 3: Which nursing intervention is the priority when caring for a patient with a suspected cervical spine injury?
- Administering pain medication
- Maintaining manual in-line stabilization (Correct answer)
- Obtaining a CT scan immediately
- Inserting a nasogastric tube
Correct answer: Maintaining manual in-line stabilization
Manual in-line stabilization of the cervical spine is the priority to prevent secondary spinal cord injury during assessment and interventions.
In trauma patients with suspected cervical spine injury, maintaining manual in-line stabilization (MILS) is the top priority nursing intervention. MILS keeps the head and neck in a neutral position without applying traction, preventing further displacement of potentially unstable vertebrae. This must be maintained during airway management, logrolling, and any patient movement. Per TNCC guidelines, cervical spine precautions should remain in place until clinical or radiographic clearance is obtained. A rigid cervical collar supplements but does not replace MILS during procedures.
Question 4: A trauma nurse is preparing to assist with a chest tube insertion for a hemothorax. The correct anatomical landmark for insertion is:
- Second intercostal space, midclavicular line
- Fifth intercostal space, anterior axillary line (Correct answer)
- Fourth intercostal space, midaxillary line
- Seventh intercostal space, posterior axillary line
Correct answer: Fifth intercostal space, anterior axillary line
The fifth intercostal space at the anterior axillary line (or midaxillary line) is the standard insertion site for a chest tube to drain a hemothorax.
Chest tubes for hemothorax or hemopneumothorax are inserted in the 'triangle of safety' — bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major, and a line superior to the horizontal level of the nipple (approximately the fifth intercostal space). The anterior axillary line at the fifth intercostal space is the preferred site. The second intercostal space midclavicular line is reserved for needle decompression of tension pneumothorax. Proper placement ensures effective drainage while avoiding injury to the diaphragm, liver, or spleen.
Question 5: Which assessment finding in a trauma patient indicates the need for immediate surgical intervention?
- Heart rate of 110 bpm
- Initial chest tube output of 1,500 mL of blood (Correct answer)
- Blood pressure of 100/70 mmHg
- Respiratory rate of 24 breaths per minute
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.
According to TNCC and ATLS guidelines, a massive hemothorax is defined as an initial chest tube output of 1,500 mL or more, or ongoing output exceeding 200 mL/hour for 2-4 hours. An initial output of 1,500 mL indicates significant intrathoracic hemorrhage, likely from an intercostal artery, internal mammary artery, or great vessel injury, requiring emergent surgical exploration (thoracotomy). The other findings — tachycardia, mildly decreased blood pressure, and tachypnea — are concerning but do not independently mandate immediate surgery.
Question 6: When performing a focused assessment with sonography for trauma (FAST), which area is NOT routinely examined?
- Right upper quadrant (Morrison's pouch)
- Left upper quadrant (splenorenal recess)
- Suprapubic region
- Bilateral lung apices (Correct answer)
Correct answer: Bilateral lung apices
The standard FAST exam evaluates four areas: right upper quadrant, left upper quadrant, suprapubic region, and subxiphoid (pericardial) view. Bilateral lung apices are not part of the standard FAST.
The FAST exam is a bedside ultrasound used to rapidly detect free fluid in trauma patients. The four standard views are: (1) right upper quadrant/Morrison's pouch (hepatorenal space), (2) left upper quadrant/splenorenal recess, (3) suprapubic/pelvis (pouch of Douglas or rectovesical space), and (4) subxiphoid/pericardial view. The extended FAST (eFAST) adds bilateral anterior chest views to detect pneumothorax, but bilateral lung apices are not a standard component of either FAST or eFAST protocols.
Question 7: A trauma patient presents with Beck's triad. Which combination of signs does this include?
- Hypertension, bradycardia, irregular respirations
- Hypotension, distended neck veins, muffled heart sounds (Correct answer)
- Tachycardia, hypotension, flat neck veins
- Dyspnea, tracheal deviation, absent breath sounds
Correct answer: Hypotension, distended neck veins, muffled heart sounds
Beck's triad — hypotension, distended neck veins, and muffled heart sounds — is the classic presentation of cardiac tamponade.
Beck's triad describes the three classic signs of cardiac tamponade: (1) hypotension from decreased cardiac output due to impaired ventricular filling, (2) jugular venous distension from increased venous pressure as blood cannot enter the compressed heart, and (3) muffled heart sounds as pericardial fluid dampens acoustic transmission. In trauma, penetrating injuries to the cardiac box are the most common cause. However, all three signs are present in only 10-40% of tamponade cases. Treatment is emergent pericardiocentesis or thoracotomy.
Question 8: During trauma resuscitation, which blood product should be administered first in a massive transfusion protocol?
- Fresh frozen plasma
- Platelets
- Packed red blood cells (PRBCs) (Correct answer)
- Cryoprecipitate
Correct answer: Packed red blood cells (PRBCs)
Packed red blood cells are administered first to restore oxygen-carrying capacity. Current protocols emphasize a balanced ratio of PRBCs, plasma, and platelets.
In a massive transfusion protocol (MTP) for hemorrhagic shock, packed red blood cells (PRBCs) are the first priority to restore oxygen-carrying capacity and intravascular volume. Current evidence-based protocols (including PROPPR trial findings) recommend a balanced 1:1:1 ratio of PRBCs to plasma to platelets. Type O-negative (or O-positive for males) uncrossmatched blood should be available within minutes. While plasma and platelets are essential for coagulopathy prevention, the immediate life threat is inadequate oxygen delivery from blood loss, making PRBCs the first-line product.
Question 9: A trauma nurse is assessing a patient using the Glasgow Coma Scale. The patient opens eyes to pain, makes incomprehensible sounds, and exhibits abnormal flexion. What is the GCS score?
- 6
- 7 (Correct answer)
- 8
- 9
Correct answer: 7
Eye opening to pain = 2, incomprehensible sounds = 2, abnormal flexion = 3, totaling a GCS of 7.
The Glasgow Coma Scale has three components: Eye (E), Verbal (V), and Motor (M). Eye opening to pain scores E2 (spontaneous=4, to voice=3, to pain=2, none=1). Incomprehensible sounds scores V2 (oriented=5, confused=4, inappropriate words=3, incomprehensible=2, none=1). Abnormal flexion (decorticate posturing) scores M3 (obeys commands=6, localizes pain=5, withdrawal=4, abnormal flexion=3, extension=2, none=1). Total: 2+2+3=7. A GCS of 8 or less generally indicates the need for definitive airway management per TNCC guidelines.
Question 10: Which intervention is contraindicated in a patient with a suspected basilar skull fracture?
- Oral airway insertion
- Nasogastric tube insertion (Correct answer)
- Cervical collar application
- Intravenous fluid administration
Correct answer: Nasogastric tube insertion
Nasogastric tube insertion is contraindicated in suspected basilar skull fracture due to the risk of intracranial penetration through the cribriform plate.
Basilar skull fractures can involve the cribriform plate of the ethmoid bone, which forms the roof of the nasal cavity. Inserting a nasogastric tube through the nose in this scenario risks the tube passing through the fracture into the brain, causing potentially fatal intracranial injury. Signs of basilar skull fracture include Battle's sign (mastoid ecchymosis), raccoon eyes (periorbital ecchymosis), CSF rhinorrhea or otorrhea, and hemotympanum. An orogastric tube should be used instead when gastric decompression is needed.
Question 11: A trauma patient's arterial blood gas shows pH 7.28, PaCO2 28 mmHg, HCO3 14 mEq/L, and lactate 6.2 mmol/L. This pattern is most consistent with:
- Respiratory acidosis
- Metabolic alkalosis
- Metabolic acidosis with respiratory compensation (Correct answer)
- Mixed respiratory and metabolic alkalosis
Correct answer: Metabolic acidosis with respiratory compensation
The low pH, low bicarbonate, and elevated lactate indicate metabolic acidosis. The low PaCO2 reflects respiratory compensation (hyperventilation).
This ABG demonstrates metabolic acidosis with appropriate respiratory compensation. The primary disorder is metabolic acidosis (pH <7.35, HCO3 14 mEq/L, well below normal 22-26). The elevated lactate (6.2 mmol/L, normal <2.0) confirms lactic acidosis from tissue hypoperfusion — a hallmark of hemorrhagic shock. The PaCO2 of 28 mmHg is below normal (35-45), indicating the patient is hyperventilating to compensate (blowing off CO2 to raise pH). In trauma, persistent lactic acidosis despite resuscitation indicates ongoing hemorrhage or inadequate perfusion and is a key indicator for escalating intervention.
Question 12: When applying the TNCC primary survey framework, which component is assessed during 'B' (Breathing)?
- Bilateral pupil reactivity
- Breath sounds and chest wall integrity (Correct answer)
- Blood glucose level
- Bleeding from external wounds
Correct answer: Breath sounds and chest wall integrity
The 'B' in the primary survey stands for Breathing and Ventilation, which includes assessment of breath sounds, chest wall movement, respiratory rate, and chest integrity.
In the TNCC primary survey (ABCDE approach), 'B' stands for Breathing and Ventilation. This assessment includes: respiratory rate, depth, and pattern; chest wall symmetry and integrity (looking for flail segments, open wounds); auscultation of bilateral breath sounds; oxygen saturation monitoring; and identification of life-threatening conditions like tension pneumothorax, open pneumothorax, or massive hemothorax. Interventions during B may include needle decompression, chest seal application, or assisted ventilation. This follows 'A' (Airway with cervical spine protection) and precedes 'C' (Circulation).
TNCC Nursing Skills
A trauma patient requires rapid fluid resuscitation through a large-bore IV catheter.
Which gauge is most appropriate for this situation?
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Sources & references
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- ena.org — Score validity, eligibility, retake policy · verified Oct 2026
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