TNCC Nursing Skills 2 — 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.
TNCC Nursing Skills 2
A trauma patient requires rapid fluid resuscitation through a large-bore IV catheter.
Which gauge is most appropriate for this situation?