TCRN IV ANSWERS & RATIONALES (2025)

Continuum of Care for Trauma

Question One: The correct answer is A: “Legs”

Rationale: In side impact or angular collisions involving a motorbike, the rider’s legs are caught between the second object involved and the motorbike leading to lower leg injuries including open fractures of the femur, tibia/fibula and malleolus.  Although injuries to the head, chest and cervical spine may occur, these occur with less frequency than lower leg injuries.

Question Two: The correct answer is C: “Apply a tourniquet to the bleeding extremity”

Rationale: This patient appears to have alterations in the airway, breathing, circulation and neurological status (disability).  The standard of care is to intervene for circulation first when uncontrolled bleeding is noted.  That would include application of a tourniquet to a mangled extremity with uncontrolled external bleeding.  Once that is done, then attention can be turned to the airway (jaw-thrust maneuver) and breathing (either supplemental oxygen or assisting respirations with a bag-mask device.)

Question Three: The correct answer is A: “Obstructive”

Rationale: A cardiac tamponade is one cause of obstructive shock.  A cardiac tamponade compresses the ventricles preventing them from filling with blood.  This is a mechanical obstruction that fits the definition of obstructive shock.  Cardiogenic shock is defined as a reduction in cardiac contractility due to cardiac dysfunction. In a pericardial tamponade, the effectiveness of the heart itself to pump blood is not affected, therefore it is not obstructive shock.  Distributive shock is defined as a vasodilatory shock.  A pericardial tamponade does not cause vasodilation.  Hypovolemic shock is defined as a lack of volume.  Volume is not impacted by a pericardial tamponade. 

Question Four: The correct answer is A: “D-Dimer”

Rationale: Trauma induced coagulopathies (TIC) results in abnormal increase in clotting. Fibrin degradation products are released from the breakdown of formed clots therefore increasing the D-dimer. The bleeding associated with TIC would cause the hematocrit to decrease rather than elevate.  Consumption of clotting factors caused by abnormal clotting would cause the platelet count and fibrinogen level to drop rather than elevate.

 Question Five: The correct answer is A: “Loss of pedal pulses”

Rationale: REBOA occludes blood flow to the lower body and should cause distal pulses to disappear.  Reappearance of those pulses may actually indicate displacement of the REBOA balloon and is not desirable.  A sudden decline in urinary output may also be associated with displacement of the REBOA balloon and reflects organ ischemia, which is non a desirable outcome.  A reduction of pain is not associated with REBOA treatment.  A return of color to the lower extremities suggests ongoing perfusion to the distal extremities and would imply a failure of the aortic occlusion which is desired with REBOA.

Question Six: The correct answer is C: “Hypocalcemia”

Rationale: Massive transfusion protocols involve the administration of large volumes of blood products.  Citrate is added to packed red blood cells to prevent clotting of stored blood.  Citrate is known to deplete calcium (this is done therapeutically in banked blood to prevent clotting during manipulation of the blood product).  But if large volumes of blood are given to a patient, the citrate in the blood products may result in systemic hypocalcemia the binding of citrate to calcium.  Banked blood is high in potassium, therefore hyperkalemia rather than hypokalemia is associated with the transfusion of large volumes of blood products.  Hypercarbia is not associated with mass transfusion.  Banked blood has a low pH and tends to cause acidosis rather than alkalosis.

Question seven:  The correct answer is B: ‘ventilator assisted pneumonia.”

Rationale: Endotracheal tubes (ETTs) equipped with subglottic (not supraglottic) secretion drainage allow for the continuous or intermittent removal of secretions that pool above the cuff of the ETT. These secretions are a major source of microaspiration, which is a key risk factor for ventilator-associated pneumonia (VAP).  Ensuring the cuff of the endotracheal tube is fully inflated and using post-pyloric feedings are more effective than utilizing an endotracheal tube with supraglottic secretion drainage to prevent aspiration.  Acute respiratory distress syndrome is an inflammatory condition and is not affected by utilizing endotracheal tubs with supraglottic secretion drainage.  Transfusion related acute lung injury is an inflammatory condition related to the administration of blood products and is not impacted by utilizing an endotracheal tube with supraglottic secretion drainage.

Question eight: The correct answer is A: “reduce the symptoms of delirium.”

Rationale: Sensory deficits may contribute to delirium in the hospitalized patient.  Correction of sensory deficits (e.g., improving vision through use of glasses or improving hearing through the use of hearing aids) may help reduce the symptoms of delirium.  Correction of vision is unlikely to decrease the analgesia needs of a patient.  Bringing glasses to the hospital will not reduce survival guilt in family members.  There is no correlation between the family bringing a patient glasses and enhancement of the relationship between the patient and the family.

Question nine: The correct answer is A.  “Discharge”

Rationale: A patient’s personality—such as being cooperative, motivated, resilient, or conversely, being resistant or anxious—can significantly affect discharge planning. Patients with optimistic, proactive personalities may adhere better to rehabilitation plans and be discharged sooner or with fewer barriers. Personality traits may also influence willingness to accept care, participate in therapy, or manage home care instructions.  Personality has no impact on severity of injury, length of stay and development of complications. 

Question ten: The correct answer is C: “Creates an additional emotional burden for the staff in the room.”

Rationale: One of the most consistently reported challenges in studies and surveys is the increased emotional pressure healthcare professionals may feel when family members are present during high-stakes interventions like resuscitation. Staff may feel self-conscious, fear judgment, or experience additional stress about performance, communication, or outcomes in front of observers.  Allowing the family to be present may actually facilitate the grieving process.  There is no reason for resuscitation efforts to be prolonged in a family presence program.  The same policies surrounding resuscitation remain in place.  There is some evidence that some families may request cessation of efforts when present which may actually decrease the length of resuscitation.  When family members are present, they can also be consulted in real time about care decision which may decrease the time a resuscitation is carried out.  Evidence shows that legal liability may be decreased in a family presence program because the family is able to visualize efforts which can reduce their desire to seek legal recourse.

Clinical Practice: Trunk and Pelvis

Question eleven: The correct answer is B: “Between the scapulae”

Rationale: Bruits associated with aortic injuries are often heard in the intrascapular region.  Injuries to the aorta will not cause bruits of the carotids.  The third intercostal space (midclavicular line) and fifth intercostal space (right of the sternum) are too far from the injury and bruits associated with aortic injuries are less likely to be heard here.

Question twelve.  The correct answer is A: “The site of the pleural disruption”

Rationale: An open pneumothorax is caused by a disruption from the external body into the pleural space.  A simple pneumothorax is a disruption from the lung into the pleural space.  Therefore, the differentiation between these two is the site of pleural disruption.  The size of an open pneumothorax and a simple pneumothorax can be large or small for either, therefore this is not used to differentiate the two.  The depth of the pleural disruption and the number of alveoli involved does not differentiate these two types of pneumothoraxes.  

Question thirteen: The correct answer is D: “Improvement in arterial oxygenation”

Rationale: Inhaled nitric oxide selectively vasodilates pulmonary vessels in ventilated lung regions improving V/Q matching and increasing PaO2.  Nitric oxide has no analgesic effects and does not cause bronchodilation (which would decrease auscultated wheezes).  Inhaled nitric oxide works directly in lung vasculature and does not influence the vasculature of the systemic circulation, therefore it would have no effect on mean arterial pressure.

Question fourteen: The correct answer is C: “Amylase”

Rationale: Amylase levels may rise in cases of intra-abdominal injury, especially with bowel perforation, due to absorption of enzymes and inflammatory response. While not specific to the small bowel, elevated amylase has been observed in some patients with gastrointestinal trauma. Troponin reflects cardiac injury, creatinine is a renal function marker, and D-dimer reflects clot breakdown, more useful in evaluating thromboembolic events than GI trauma.

Question fifteen: The correct answer is D: “Elevation of the patient’s aspartate transaminase (AST) 24 hours after admission to the critical care unit.”

Rationale:  Liver trauma typically results in hepatocellular injury, which causes elevations in liver transaminases, especially AST and ALT, usually within hours of injury, peaking in the first 24–48 hours. AST tends to rise quickly in response to acute cellular damage. ALT also rises, but AST may rise more rapidly and prominently in early injury, especially from blunt trauma.  Liver enzymes tend to elevate, not decrease after liver trauma.

Question sixteen: The correct answer is C: “underwent damage control surgery”

Rationale:  Damage control surgery is an abbreviated surgical procedure in which the abdomen is opened, rapid repair of defects such as packing of bleeding areas is performed and the patient is then transferred to the critical care unit with the abdomen opened awaiting further definitive surgical care once the risks of trauma diamond of death are reduced.  There is no reason to leave the abdomen open for patients who undergo a splenorrhaphy, who are greater than 55 years of age or who have acute respiratory distress syndrome.

Question seventeen: The correct answer is A: “Control blood loss”

Rationale: Although a properly applied pelvic binder may accomplish numerous goals including reducing patient discomfort and reducing the movement of bony fragments, the main purpose of the pelvic binder is apply direct pressure to the pelvis with the goal of reducing blood loss.  The goal of a pelvic binder is not to realign bony fragments.  Damage to the lower genitourinary tract occurs at the time of trauma and the incidence of genitourinary trauma is not reduced by the application of a pelvic binder.

Question eighteen: The correct answer is D: “over the 11th and 12th ribs where they meet the spinal column.”

Rationale: Costovertebral angle tenderness may be present in the patient with renal trauma.  It is best measured at the angle formed by the 12th rib and the vertebral column as the kidney lies directly below this.  Assessing below the scapula is too high and too central.  Assessing below the ribcage is lower than the location of the kidneys (found under the 11th and 12th ribs).  Assessing above the iliac crests is too low and may not adequately assess for the presence of pain associated with renal injury.

Question nineteen: The correct answer is D: “Continuous renal replacement therapy”

Rationale: Continuous renal replacement therapy (CRRT) provides slow continuous fluid and solute removal minimizing the risk of increasing cerebral edema in the patient with elevated intracranial pressure.  Peritoneal dialysis elevates intra-abdominal pressure impairing cerebral venous return which may worsen intracranial pressure.  Intermittent hemodialysis causes rapid and significant shifts in fluid which can worsen cerebral edema.  Although sustained low efficiency hemodialysis is gentler than intermittent hemodialysis, it will cause greater shifts in fluid then CRRT and would have less effects on intracranial pressure. 

Clinical Practice: Head and Neck

Question twenty: The correct answer is B: “Shallow and deep respirations with an unpredictable pattern”

Rationale: Ataxic respirations are completely irregular with no discernible pattern and often include sudden periods of apnea. This pattern reflects medullary damage and is usually a preterminal sign in patients with severe brain injury.  Deep, rapid respirations with a regular pattern describes central neurogenic hyperventilation, not ataxic breathing. It’s often seen with midbrain or upper pons injury, and is regular, not erratic.  Prolonged inspiration followed by a 2 to 3 second pause before exhalation describes apneustic breathing, which is typically caused by a lesion in the pons. It is characterized by prolonged inspiratory effort and an inefficient expiration, not the erratic nature of ataxic breathing.  Cyclic respirations that gradually increase in depth to hyperpnea then decrease to apnea describes Cheyne-Stokes respirations, often seen in bilateral cerebral hemisphere dysfunction or congestive heart failure. The predictable crescendo-decrescendo pattern is distinctly different from ataxic breathing’s irregularity.

Question twenty-one: The correct answer is B: “22 mm Hg”

Rationale: Cerebral perfusion pressure is calculated by subtracting the intracranial pressure from the mean arterial pressure.  The first step in calculating CPP would be to calculate the mean arterial pressure.  This is done by multiplying the diastolic pressure times two (60 times 2 equals 120) and adding it to the systolic pressure (120 plus 168 is 288) then dividing that number by three (288 divided by 3 is 96).  Therefore the mean arterial pressure is 96 mm Hg.  The intracranial pressure is subtracted from the mean arterial pressure (96 minus 74 equals 22).  Therefore, the intracranial pressure is 22 mm Hg. 

Question twenty-two: The correct answer is B: “An epidural hematoma”

Rationale: The middle meningeal artery is located on the inner surface of the temporal bone and fractures of this bone may disrupt this artery leading to an epidural hematoma.   Although patients with fractures of the temporal bone may have diffuse axonal injuries and unstable cervical vertebral fractures, these are not directly related to a fracture of the temporal bone, they are simply concomitant injuries.  Damage to cranial nerves II and III are not related to fractures of the temporal bone.

Question twenty-three: The correct answer is A: “Profuse diaphoresis isolated to the face and neck.”

Rationale: Sweating in the face (and sometimes the chest) may occur with severe diffuse axonal injuries and are sometimes referred to as “neurosweats”.  The sweating is associated with autonomic dysfunction with the thalamus and hypothalamus.    Electrical shock sensations to the face are associated with neuropathic pain and may be seen in conditions such as trigeminal neuralgia.  A patient with a diffuse axonal injury would have a Glasgow coma score of 3 and would not be able to complain of pain sensations.  Flushing to one side of the face with paleness to the other side of the face is not associated with a diffuse axonal injury.  A diffuse axonal injury is a diffuse brain injury and is unlikely to cause unilateral changes such as unilateral pupillary dilation and lack of accommodation to light.

Question twenty-four: The correct answer is B: “Cervical”

Rationale: Hanging weight traction refers to a method of applying continuous, longitudinal force using weights and pulleys to align and stabilize the spine.  This is typically done using skeletal traction systems like Gardner-Wells tongs or halo traction.  It is generally reserved for fractures involving cervical vertebrae and is generally not utilized for fractures of the thoracic or lumbar vertebrae.   Braces are more likely to be used for fractures in this area of the vertebral column.

Question twenty-five: The correct answer is B: “Subluxation of the vertebrae at the time of injury”

Rationale: A spinal cord injury without radiological abnormality (SCIWORA), as the name implies, is an injury to the spinal cord with a cause that is not evident on standard chest x-rays or even computerized tomography of the spine.  A frequent mechanism of injury is subluxation of the vertebrae at the time of the injury, but the vertebrae return to their original position after the trauma so the abnormality cannot be seen on radiological exams.  But the subluxation can cause spinal cord injury with motor and sensory deficits.  Although a patient with SCIWORA may have acute anxiety, this is not the cause of motor and sensory deficits.  Compression fractures and hematomas would show up on radiological exams so these would not be associated with SCIWORA.

Question twenty-six: The correct answer is C: “Cerebrospinal fluid in the nose”

Rationale: LeFort fractures are fractures of the maxillary bone.  LeFort II and LeFort III fractures involve the bridge of the nose and frequently involve fractures of the cribriform plate allowing leakage of cerebrospinal fluid from the nose.  Ocular entrapment is associated with orbital blowout fractures and zygomatic fractures.  Tear-drop shaped pupils are associated with ruptures of the globe.  Numbness to the chin and lower lip are associated with mandibular fractures

Question twenty-seven: The correct answer is B: “Immediately move the patient to a sink and begin flushing the eye until a Morgan lens is available to continue flushing.”

Rationale: If a chemical ocular exposure presents to triage, flushing of the eye should commence immediately and should not be delayed for activities such as measuring visual acuity, measuring vital signs or performing a thorough visual acuity.  Flushing should start under running water or an eye wash station if available and the patient can be moved to a Morgan lens once that is available.  But flushing should not be delayed waiting for the Morgan lens to be set up.  There is no need to delay flushing to contact poison control.  Flushing should commence immediately on arrival.

Clinical Practice: Musculoskeletal and Wound

Question twenty-eight: The correct answer is C: “Flush the wound with 500 mL of tap water irrigated continuously into the wound from intravenous tubing.”

Rationale: Wound cleansing should be done using normal saline or tap water.  Antiseptics such as chlorhexidine and hydrogen peroxide can be cytotoxic and are not recommended for routine wound cleansing.  Low pressure irrigation (<7 pounds per square inch) is preferred for clean wounds as it distorts wounds edges less.  This can be accomplished by pouring solution into the wound or running solution into the wound with intravenous tubing.  Using a syringe applies high pressure which is not desirable unless the wound is grossly contaminated.  High pressure can distort wound edges and affect wound healing.  Soaking a wound is not recommended prior to wound closure as it softens the skin and may decrease the effectiveness of wound closure.  The recommended amount of cleansing solution for a wound is 50 to 100 mL per centimeter of wound length (which would be 250 to 500 mL of solution for a 5 centimeter laceration).

Question twenty-nine:   The correct answer is D: “Radial pulse distal to the injury”

Rationale:  A Smith’s fracture is a distal radius fracture with volar (anterior/palmar) displacement of the distal fragment.  This injury involves the wrist and forearm, so neurovascular assessment must focus on the upper extremity, particularly the distal arm.  Assessing the radial pulse would be appropriate.  Numbness in the axilla is above the injury and would not give useful information about neurovascular status in the lower arm.  Assessing the great toe for paresthesia or the ability of the patient’s to dorsiflex the foot assess neurovascular function in the lower extremity which is not helpful to assess for neurovascular compromise related to a Smith’s fracture.

Question thirty:  The correct answer is C: “elevated above the level of the heart.”

Rationale: Generally, injured extremities, especially with edema, should be elevated to reduce the edema.  If the patient were to have compartment syndrome, then the extremity should be kept at the level of the heart.  However, a compartment pressure of 10 mm Hg is not consistent with compartment syndrome. Generally, compartment syndrome is any intercompartmental pressure above 20 mm Hg.  It is not appropriate to position an injured extremity below the level of the heart, with or without compartment syndrome as this can reduce venous return to the heart and exacerbate edema (or compartment syndrome should it be present).  There is no therapeutic value in repositioning the limb every 30 minutes as this may exacerbate the injury.

Professional Practice

Question thirty-one: The correct answer is D: “identified by co-workers before the individual experiencing them.”

Rationale: One of the symptoms of compassion fatigue is denial, therefore individuals experiencing this are unlikely to recognize the symptoms within themselves.  The symptoms also tend to have a slow onset so the individual may not notice the changes.  Although compassion fatigue may occur after a single incident, it is more likely to be a cumulative disorder that occurs over time and repeated exposure.  Compassion fatigue is not transient and does not fluctuate throughout the day.  A delay in symptoms of three months or more is more descriptive of post-traumatic stress disorder.  Compassion fatigue tends to be cumulative disorder that increases over time.

Question thirty-two: The correct answer is A: “reduce variations in care.”

Rationale: A clinical practice guideline is designed to standardize care based on the best available evidence.  The promote consistent clinical decision making and reduce unwarranted practice variation among providers.  Clinical practice guidelines focus on quality care, not on patient satisfaction.  Although improved care may improve patient satisfaction, these two are loosely related and many practice guidelines may not impact patient satisfaction.  Clinical practice guidelines may not address blood product administration but rather address other issues, A clinical practice guideline does not impact the need for concurrent reviews.  In fact, a concurrent review may be used to ensure that clinical practice guidelines are being utilized appropriately.

Question thirty-three: The correct answer is C:” He was hypotensive on arrival but stabilized after fluid resuscitation and has remained hemodynamically stable.”

Rationale:  The “A” portion of “SBAR” represents “Assessment” and includes information that describe what is assessed relative to the situation.  The fact that the patient was hypotensive on arrival, that the patient responded to fluids and remained stable all represent an assessment of the patient’s condition.  The description of the patient’s medical background and smoking history better represent the “B” or background section of “SBAR”.  The description of the patient’s mechanism of injury and resulting injuries best represents the situation which is the “S” in “SBAR”.  The “R” in “SBAR” represents recommendations.  This is best embodied in the nurse’s recommendation to monitor the patient’s peak pressures on the ventilator.

Special Populations

Question thirty-four: The correct answer is C: “may be applied across the lower hips and symphysis pubis below the level of the uterus.”

Rationale: Treatment for pelvic fractures in pregnant patients is not different than if the patient were not pregnant.  The patient should receive fluid resuscitation based on hemodynamic parameters and a pelvic binder should be applied across the lower hips and symphysis pubis below the level of the uterus.  Although the pelvic binder should be applied BELOW the level of the uterus to reduce injury to the fetus, if applied properly, it is not contraindicated and will not harm the fetus.  The pelvic binder should be applied firmly to reduce blood loss.

Question thirty-five: The correct answer is A: “Fetal heart rate”

Rationale: Reduced uteroplacental perfusion directly impact the fetus.  Fetal tachycardia is first to appear and without intervention, fetal bradycardia may appear.  The maternal pulse rate and blood pressure (including pulse pressure) may not change immediately because the pregnant patient has a higher blood volume and normal compensatory changes to maternal vital signs are often delayed.  Fetal movement is subjective and does not necessarily change, especially initially, with maternal hypovolemia.  Therefore, changes to fetal heart rate are the most likely to be seen initially in the face of maternal shock.

Question thirty-six: The correct answer is B: “Visualization of the fontanelles”

Rationale: The fontanelles, especially the anterior fontanelles, may provide clues associated with over hydration (bulging fontanelles) or dehydration/hypovolemia (sunken fontanelles).  It is not appropriate nor useful to percuss the skull.  Auscultation of the carotids is more appropriate for a cardiovascular assessment and would be difficult if not impossible in the 2-month-old infant with a short, fat neck.  Palpation of the lower extremities is unlikely to contribute any useful information in the fluid status of a two-year-old.

Question thirty-seven: The correct answer is C: “The tongue and roof of the mouth are burnt and bruising is noted on the lips.”

Rationale: Burns to the lips, mouth and tongue, especially when accompanied by bruising to the area are strongly indicative of forcing a child to drink hot liquids.  Children with abusive injuries tend to cry less than those with unintentional injuries.  Crying disproportionately is not necessarily a sign of abuse.  Intentional burns are more likely to be symmetrical as opposed to asymmetrical.  When the stories of the child and the caregiver do not match or the story does not match the injury, the index of suspicion for intentional injuries increases.  Although matching stories does not rule out abuse, it does indicate that there is a lower risk that the injury was caused by abuse.

Question thirty-eight: The correct answer is C: “Widespread ST elevation”

Rationale: Electrical burns can cause direct myocardial injury as the electrical current passes through the heart and also from thermal damage to cardiac tissue.  This manifests as ST elevation in multiple leads.  A biphasic RS complex is more common with bundle branch blocks but is not associated with electrical burns.  Prolonged PR interval (first degree heart block) is not as common after an electrical burn as widespread ST segment elevation.  The appearance of J waves is associated with hypothermia, not electrical burns.

Question thirty-nine: The correct answer is D: “Directly and compassionately assess the patient’s suicidal thoughts, including intent and current risk”

Rationale: Assessing suicide risk is essential to allow the trauma team to plan safety interventions and to begin interventions for the patient’s underly9ing psychiatric condition.  The trauma nurse should begin nonjudgmental, direct but compassionate inquiry about intent.  Although psychiatric consultation is appropriate, it does not replace the role of the trauma nurse in initial psychosocial evaluation.  Delaying psychiatric intervention until critical care discharge delays implementing essential psychiatric care for the patient and may minimize the safety interventions that the staff should consider during the patient’s care.  Avoiding implication of self-harm when it is already known or suspected is not clinically helpful.

Question forty: The correct answer is D: “The trauma nurse who collects the evidence will ideally give that evidence to a law enforcement officer.”

Rationale:  The “chain of evidence” is the process that evidence goes through between the time it is collected and the time that it is turned over to law enforcement.  Ideally, only on individual will handle the evidence between these two steps.  The strongest “chain of evidence” is one in which the trauma nurse who collects the evidence maintains that evidence from the time of collection until the time it is handed over to law enforcement.  Although preservation of evidence in paper rather than plastic bags is always preferred, this does not contribute to maintenance of the “chain of evidence”.  In a resuscitation, clothing may be cut off and placed on a clean sheet placed on the floor of the resuscitation room before being placed in a paper bag. Provided that the evidence is carefully observed for unintentional tampering, this does not weaken the “chain of custody”.  In the resuscitation of a critically injured patient that may have evidence on the clothing, cutting the clothing off may be necessary as opposed to removing it manually.  The “chain of custody” may be maintained in this situation.

Question forty-one: The correct answer is D: “An elderly patient who lives with her adult children is transported to the trauma unit with infections to buns sustained several days ago after tipping hot tea in her lap.”

Rationale: Although each situation requires further investigation to ensure the story is appropriate and there are not additional factors, the patient who sustained burns several days ago and has developed infections despite living with her adult children is highly suspicious for neglect/abandonment (medical neglect).  A patient who lives alone and falls, remaining unfound for a period of time is not consistent with abuse and is therefore not subject to mandatory reporting.  Elderly patients are more likely to attempt suicide.  A suicide attempt does not imply abuse as long as the patient was found in a timely manner and appropriate care was administered prior to transport.  A patient who falls in the shower sustaining pelvic fractures is not suspicious for abuse.  This mechanism of injury is common in the elderly.  The fact that the caregiver identified the situation, facilitated immediate treatment and accompanied the patient to the ED is not consistent with abuse.