TCRN practice questions, all six domains

Bursitis is an overuse condition with point tenderness, not a large fluctuant collection after acute trauma with numb, loose skin.

A soft, fluctuant collection over the greater trochanter with loose, numb skin is a Morel-Lavallée lesion: shear separates skin and fat from the fascia and the space fills with blood and lymph. It can become infected or necrotic and needs surgical evaluation.

A posterior dislocation shortens and internally rotates the leg with severe pain and blocked motion; it does not create a fluctuant, numb skin pocket.

Pelvic fracture bleeding spreads into the retroperitoneum and flank; a superficial pocket with hypermobile skin is a separate soft-tissue injury that should not be dismissed.

Older adults bleed from pelvic arteries more often than younger patients, even with lateral compression patterns, because their vessels are stiffer and many take antithrombotics. A falling hemoglobin with a contrast blush makes angioembolization likely.

The reverse is true: arterial bleeding becomes more frequent with age, and assuming venous oozing delays angiography.

Limited reserve and beta-blockers make older adults tolerate hemorrhage worse and hide the early tachycardia that warns of shock.

Lateral compression, the usual pattern after falls in older adults, can still cause major arterial bleeding; the fracture pattern does not rule it out.

Heat dilates vessels and can enlarge an expanding hematoma; early care uses cold, and an expanding lesion needs surgical control.

A large, expanding vulvar hematoma that blocks voiding needs a catheter to drain the bladder and surgical evaluation for evacuation and control of the bleeding vessel. Small, stable hematomas can be managed with cold and analgesia.

Aspiration does not stop ongoing bleeding, often fails because the blood has clotted, and can introduce infection.

Ice and analgesics suit a small, stable hematoma; this one is expanding and causing urinary retention, so discharge is unsafe.

Most pediatric duodenal hematomas resolve with nonoperative care: bowel rest, nasogastric decompression, and parenteral nutrition, often over 1–3 weeks. Surgery is kept for perforation or failure to resolve.

A single contrast study may assess the obstruction, but repeated oral feedings worsen vomiting while the duodenum is blocked.

Feeding into a duodenum blocked by hematoma brings more vomiting and aspiration risk; the bowel has to rest.

Operating on an uncomplicated hematoma adds risk without benefit; laparotomy is for perforation, other injuries, or prolonged obstruction.

Most grade III injuries in stable patients heal without surgery; planning a nephrectomy confuses injury grade with instability.

Adequate hydration keeps urine flowing and helps clear clots; restricting fluids does not protect the injured kidney.

NSAIDs impair platelet function and reduce renal blood flow, a poor match for an injured, bleeding kidney; pain plans use acetaminophen and opioids instead.

Nonoperative care of a renal laceration depends on catching ongoing or delayed bleeding: serial hemoglobin, vital signs, and urine color. A falling hemoglobin or returning gross hematuria prompts imaging and possible embolization.

Conservative care fits a contusion with an intact tunica; with rupture, delay leads to atrophy, infection, or orchiectomy.

Aspiration cannot close a ruptured capsule and adds infection risk; extruded tubules must be debrided and the tunica repaired.

Waiting a week loses the salvage window; the first scan already showed the finding that calls for surgery.

Disruption of the tunica albuginea on ultrasound means testicular rupture. Early exploration and repair, ideally within 72 hours, gives the best chance of saving the testis.

An ABI screens for hidden arterial injury when pulses are present; an absent pulse with an expanding hematoma has already answered the question.

An expanding hematoma and an absent pulse are hard signs of arterial injury, and hypotension shows ongoing hemorrhage. Hard signs with shock go straight to the operating room; imaging only delays control.

CTA helps with soft signs in a stable patient; in a hypotensive patient with hard signs it spends time outside the OR.

A binder closes an open pelvic ring; it does not control a penetrating iliofemoral vessel injury, and watching lets the patient bleed out.

A 90-minute delay in a patient who stays hypotensive despite blood raises mortality; time to hemorrhage control is what counts.

A negative FAST makes an intraperitoneal source unlikely, and opening the abdomen can release the tamponade of a pelvic hematoma without stopping pelvic bleeding.

When an unstable pelvic fracture does not respond to a binder and balanced transfusion and angiography is not quickly available, preperitoneal packing controls venous and small-artery bleeding within minutes. Angiography can follow if bleeding continues.

Taking the binder off releases the reduced pelvic volume and can restart bleeding; it stays on until definitive control.

Laparotomy is for peritonitis, instability, or evisceration; a stab that never crossed the fascia has no intra-abdominal injury to repair.

If local wound exploration shows the anterior fascia is intact, the peritoneum was not breached. A stable patient without peritonitis can have the wound closed or dressed and go home.

Laparoscopy is used when fascial penetration is uncertain or confirmed in a stable patient; an intact fascia already excludes penetration.

Triple-contrast CT evaluates flank and back stab wounds for retroperitoneal injury; for an anterior wound with intact fascia it adds radiation without changing care.

Pulling the tube without an order can let a pneumothorax recur, and plain gauze does not seal the site.

Advancing an external segment drags skin bacteria into the pleural space; repositioning is a sterile provider procedure.

A partly dislodged tube with an eyelet outside the skin is entraining air, which shows as new continuous bubbling. The nurse secures the tube as it lies, reinforces an occlusive dressing, and calls the provider to reposition or replace it.

Clamping a tube with an active leak risks tension pneumothorax, and suction far above the usual −20 cm H₂O injures lung tissue.

A lateral impact on the driver's door compresses the lower chest wall and shears the diaphragm; blunt ruptures are far more common on the left because the liver shields the right. Side impacts carry several times the risk of frontal crashes.

A single low-speed rollover distributes force over time and is a weaker predictor than a direct lateral hit to the left chest.

Low-speed frontal crashes with airbags rarely generate the abdominal pressure needed to tear the diaphragm.

Rear impacts cause hyperextension injuries to the neck, not the abdominal pressure spike that ruptures the diaphragm.

Surgery is for massive initial drainage, continued high output, or instability; this patient meets none of them.

Clamping does not stop bleeding; it hides it, lets blood collect in the chest, and can cause tension physiology.

A second tube is not the answer even for a retained clot, which is managed with early VATS; with falling output, nothing more is needed now.

Thoracotomy thresholds are about 1,500 mL on insertion or 200 mL per hour for several hours; 450 mL followed by falling hourly output in a stable patient is below both. The nurse keeps trending output, vital signs, and hemoglobin.

Volume loading tends to reduce reflex vasoconstriction, and higher afterload would worsen output from a compressed heart.

Fluid given IV does not leave the pericardial sac; only pericardiocentesis or surgery removes the blood.

In tamponade, the heart fills only when venous pressure exceeds pericardial pressure. A bolus raises that gradient briefly and buys time, but drainage is still the definitive treatment.

Crystalloid has no inotropic effect; the benefit is from improved filling, not a stronger contraction.

Repairing a contained aortic tear while the abdomen bleeds treats the less urgent lesion first; the sequence follows the active hemorrhage.

Impulse control with beta-blockade is for a stable patient with an aortic injury; in hemorrhagic shock it would remove the compensating tachycardia and worsen hypotension.

A hypotensive patient with a positive FAST should not go back to the scanner; the source is already known.

Free intra-abdominal fluid with shock is the bleeding that will kill first, while a contained aortic injury can be temporized. Abdominal hemorrhage is controlled first, and the aortic repair follows once the patient is stabilized.

Opioid toxicity slows breathing; a respiratory rate of 32 is the opposite pattern, and reversal would also remove the analgesia this patient needs.

Extra oxygen may help briefly, but waiting 30 minutes with hypotension risks arrest from an untreated tension pneumothorax.

New dyspnea, tachypnea, hypotension, and hypoxemia after rib fractures suggest a developing tension pneumothorax or hemothorax, not opioid excess. A rapid focused chest assessment comes first because it decides whether decompression is needed.

Calling it an expected drug effect overlooks a life-threatening chest complication that matches the findings.

Pulmonary contusion often looks normal on the first film and blossoms over 24–48 hours into a patchy infiltrate beneath the impact site, with crackles and hypoxemia. Care is oxygen, analgesia, and avoiding fluid overload.

Tension causes absent breath sounds, tracheal deviation, and shock; crackles with an infiltrate point to lung tissue injury.

ARDS is diffuse and bilateral; an infiltrate confined to the area under the impact is a local contusion.

A hemothorax shows as a dependent fluid layer with dullness, not a patchy parenchymal infiltrate at the impact site.

Changing a dose on a family report without prescriber confirmation is outside the nurse's scope and may be wrong.

Discharging on a dose the family says was reduced risks overanticoagulation and bleeding.

A discrepancy between the discharge list and a recent dose change is a medication reconciliation error waiting to happen, and warfarin dosing errors cause bleeding or clotting. The nurse resolves it with the prescriber before discharge, ideally with the cardiologist's record.

Dropping an anticoagulant from the list risks a gap in therapy and thrombosis; the INR does not resolve which dose is current.

A wheelchair user who needs help with dressing and bathing cannot safely live alone in a walk-up apartment. Discharge planning addresses housing, home modification, caregiver support, or inpatient rehabilitation before the patient goes home.

Controlled pain on oral drugs supports discharge rather than blocking it.

Incision care is routine and does not prevent discharge.

Many people with a T6 injury learn self-catheterization; it is a teaching need, not the main barrier.

An index under 1.0 does not exclude shock, especially when medications blunt tachycardia.

The shock index (HR divided by SBP) depends on a heart rate response; beta-blockers cap that response, so the index stays low even with significant blood loss. A pale, dizzy older patient on metoprolol is treated by findings, not by the number.

A small rise in blood pressure with persistent pallor and dizziness is not proof of adequate resuscitation.

Older adults often have blunted heart rate responses and higher baseline blood pressures, which make the index less reliable, not more.

An alert patient with one injury can report other pain, so the chance of a missed injury is low.

A patient with a normal GCS and a minor injury can describe symptoms, lowering the risk of missed injury.

An isolated penetrating extremity wound in an alert patient is easy to evaluate fully.

Missed injuries cluster in patients who cannot report pain and have many competing injuries: intubated, sedated, or head-injured multitrauma patients. They get the tertiary survey first and again when awake.

Induction drugs and positive pressure both drop venous return and sympathetic tone, so a hypotensive patient can arrest during intubation. Resuscitation with blood products starts before induction whenever time allows; resuscitate before you intubate.

Inducing a patient in shock invites peri-intubation arrest; the airway may be urgent, but correcting perfusion first is part of the airway plan.

Moving a hypoxic patient with blood in the airway to CT risks losing the airway outside the resuscitation room.

Radiographs do not change the need for an airway; spinal precautions are maintained with manual in-line stabilization.

An open abdomen is not a contraindication to enteral feeding once the patient is off vasopressors and the bowel is in continuity. Early feeding lowers infection, improves fascial closure rates, and reduces fistulas.

Parenteral feeding is for a nonfunctional or discontinuous gut; here the bowel is usable, and enteral feeding carries fewer infections.

Closure may take days to weeks; waiting starves a hypermetabolic trauma patient and lowers closure rates.

An open-abdomen patient is usually sedated and intubated, and clear liquids do not meet protein and calorie needs; tube feeding is the route.

A tourniquet is converted only when the patient is resuscitated, the wound can be watched, and bleeding can be controlled another way. Removing it during ongoing shock risks rebleeding that the patient cannot tolerate.

Having packing material ready is part of a safe conversion, not a reason to stop it.

Forty minutes is well within safe tourniquet time; conversion is considered before 2 hours, so this supports the plan rather than arguing against it.

A visible, packable wound is a condition for conversion; it makes a pressure dressing more likely to work.

Erythema at the insertion site points to the line; starting with a urine culture looks in the wrong place.

One line-drawn set cannot separate catheter colonization or contamination from bacteremia; paired line and peripheral sets are needed.

Suspected central line infection is evaluated with paired blood cultures, one drawn through the catheter and one from a peripheral vein, before antibiotics. Comparing time to positivity helps confirm that the line is the source.

Lock solutions are not a substitute for cultures and systemic therapy and would contaminate the cultures.

Incident reports are filed separately, not in the medical record, and documentation comes after the urgent notifications.

Discarding the unit destroys evidence the blood bank needs to investigate the reaction and the error.

After stopping an incompatible transfusion and keeping the IV open with saline, the nurse notifies the provider and blood bank and returns the bag and tubing with new blood and urine samples. Hemolysis can appear later, so close monitoring continues.

Absence of early symptoms does not make an ABO-incompatible unit safe; more volume means more hemolysis.

A structured handoff such as MIST (mechanism, injuries, signs, treatment) gives the team what it needs to act in under a minute while the patient is being moved. Details can follow once the primary survey is underway.

A chronological story buries the decision-critical facts and takes too long at the bedside.

A single set hides the trend and omits mechanism and treatment, which shape team decisions.

History matters but is rarely complete at handoff; leading with it delays the information that drives immediate care.

Rh status matters mainly for red cells; plasma ABO compatibility is the issue here.

Group B plasma contains anti-A antibodies and is not safe for A or AB recipients.

AB plasma lacks anti-A and anti-B antibodies, so it is safe for recipients of any ABO type and is issued before the patient's type is known. Some protocols use low-titer group A plasma when AB is scarce.

Group O is the universal donor for red cells, not plasma; O plasma contains anti-A and anti-B antibodies that can hemolyze A, B, or AB recipients.

New tachypnea, hypoxemia, crackles, and JVD in a patient with an ejection fraction of 25% signal fluid overload from the bolus. The nurse stops the infusion, sits the patient up, applies oxygen, and calls the provider.

Continuing fluid into a failing ventricle worsens pulmonary edema; waiting 30 minutes delays care.

Low-flow oxygen does not correct hypoxemia from edema, and continuing the bolus feeds the cause.

Imaging can confirm edema, but the bedside findings already justify stopping the fluid now.

Untreated pain causes suffering and tachycardia and is not required for diagnosis; withholding it is an outdated practice.

Oral opioids act slowly and may need to be held for surgery; this patient needs relief now.

IM absorption is unpredictable in trauma patients with variable perfusion, and it is painful; IV titration is safer and faster.

Severe pain in an alert trauma patient with acceptable blood pressure is treated during resuscitation with small IV doses, often fentanyl, titrated to effect with monitoring. Pain control does not mask findings and reduces stress responses.

Infiltration wastes products but does not explain persistent shock after an otherwise successful transfusion.

Persistent shock after transfusion with external bleeding controlled means hidden hemorrhage; the classic cavities are the chest, abdomen, retroperitoneum and pelvis, and long-bone fractures. Each is reassessed with exam, eFAST, chest radiograph, and pelvic imaging.

External bleeding is already controlled; rechecking dressings is reasonable but does not explain ongoing shock.

Intracranial bleeding cannot hold enough blood to cause hemorrhagic shock in an adult; hypotension points elsewhere.

Autonomic dysreflexia can occur with a T4 injury, but it presents as sudden hypertension, headache, and flushing above the level, not a warm, stiff thigh.

Heterotopic ossification, bone forming in soft tissue around large joints below the injury, typically appears 1–4 months after spinal cord injury with warmth, swelling, and loss of hip motion. With DVT excluded, it is confirmed by imaging, and range-of-motion therapy and medication limit its progress.

Lymphedema is soft and diffuse and does not cause warmth or a progressive loss of joint motion.

Cellulitis causes redness and tenderness spreading from a wound, but it does not restrict hip motion.

Pin adjustment is done by a trained provider; tightening a pin without assessment can drive it through the skull or misalign the frame.

Removing the vest removes spinal immobilization; the vest stays on, and the wrench is kept at the bedside only for emergency CPR access.

A loose pin and moving ring are never expected; this response misses a loss of stabilization.

A loose halo pin with ring movement means the fixation is failing and the neck is no longer immobilized. The nurse keeps the head still, avoids moving the patient, and calls the provider to replace or tighten the pin.

Central herniation pushes the diencephalon straight down, causing small pupils early and bilateral signs, not one blown pupil with one-sided weakness.

The medial temporal lobe slides over the tentorium and compresses the oculomotor nerve and cerebral peduncle, causing a dilated, nonreactive pupil on the same side and weakness on the opposite side. A falling GCS with these signs calls for emergency treatment.

Subfalcine herniation shifts the cingulate gyrus under the falx and may cause leg weakness, but it does not compress the third nerve.

Tonsillar herniation compresses the medulla, causing apnea and cardiovascular collapse rather than a unilateral blown pupil.

Ice risks cold injury to insensate skin and does not change the course of neurogenic priapism.

Priapism after an acute high spinal cord injury results from unopposed parasympathetic tone and usually resolves on its own within hours. Unlike ischemic priapism, it is not painful and does not need aspiration.

Surgery is not indicated; the finding is a sign of the cord injury that resolves without intervention.

Aspiration is for ischemic, low-flow priapism; neurogenic priapism after cord injury is not ischemic.

Earlier is better; TXA given after 3 hours showed no benefit in bleeding trials and may cause harm.

CRASH-3 used a 1 g bolus followed by 1 g over 8 hours; no 24-hour dose was studied.

Benefit was seen in mild to moderate injury, not in patients presenting with GCS 3 and fixed pupils.

CRASH-3 found that TXA within 3 hours reduced head-injury death in patients with mild to moderate TBI, but not in those with a GCS of 3 or bilateral unreactive pupils, whose injuries are usually unsurvivable.

A symphysis fracture causes chin pain and a step in the lower teeth, not a depression over the cheekbone.

A dislocated jaw is stuck open and cannot close, rather than being unable to open fully.

A depression just in front of the ear with limited mouth opening is classic for a zygomatic arch fracture, because the depressed arch blocks the coronoid process of the mandible. Surgical elevation often restores opening.

A Le Fort I fracture moves the upper dental arch and causes malocclusion, not a depression in front of the ear.

DAI follows severe acceleration injury and presents with immediate coma, not mild symptoms after a normal CT.

Epilepsy requires seizures; none are described.

Persistent headache, irritability, poor concentration, and sleep problems weeks after a mild TBI with a normal CT fit postconcussion symptoms. Care includes symptom management, graded return to activity, and referral if symptoms persist.

An epidural hematoma causes declining consciousness within hours to days, not stable symptoms over three weeks.

New bulging with decreased consciousness is a change in neurologic status, not routine swelling.

Without bone, pressure goes straight onto the brain and can cause injury; the defect is protected, never compressed.

A tense, bulging flap with new drowsiness after decompressive craniectomy suggests rising pressure from swelling or bleeding beneath the defect. It is reported immediately so imaging and treatment can follow.

Lying on the side of the defect compresses unprotected brain; the patient is positioned off it.

Polyuria and thirst suggest hyperglycemia or diabetes insipidus, not complications of collar treatment.

GI cramping and diarrhea are not a recognized complication of collar immobilization.

A collar does not cause hypertension; these signs suggest other problems such as pain or autonomic dysreflexia.

A rigid collar in an older adult pushes the jaw up and the head forward, impairing swallowing; combined with age-related swallowing changes, it raises aspiration risk. A swallow screen and aspiration precautions are needed.

Opening the eyes to voice is unchanged from the baseline E3, so it is not new deterioration.

Going from localizing (M5) to withdrawal (M4) is a drop in the motor score, the most sensitive GCS component for deterioration. It is reported promptly and usually prompts repeat CT.

A mild headache that responds to acetaminophen is expected after a head injury and is not a sign of worsening.

A single episode of vomiting without other changes is common and less specific than a fall in motor score.

Clear, watery drainage from one nostril that increases with leaning forward after a frontal sinus or anterior skull base fracture is typical of CSF rhinorrhea. The fluid can be tested for beta-2 transferrin, and the patient avoids nose blowing.

Sinus drainage is usually tinged and does not increase markedly with leaning forward; assuming it is benign misses a leak.

A septal hematoma is a bluish swelling of the septum that blocks the nose; it does not produce watery drainage.

A torn tear duct causes tearing from the eye, not watery nasal drainage that worsens with position.

A soft catheter clogs and cannot keep up with heavy bleeding and clots.

A nasal airway is avoided with midface fractures because it can pass through a cribriform plate fracture into the cranium.

Brisk oropharyngeal bleeding from midface fractures needs high-volume rigid suction (Yankauer or larger) to clear the airway and allow intubation.

Nasal tubes risk intracranial placement with these fractures; an orogastric tube is used if needed.

Loosening the straps lets the frame shift and the neck move; skin under the vest is cleaned with the vest secured.

Removing the vest removes immobilization of an unstable fracture; only trained staff adjust it.

A wet sheepskin liner causes skin breakdown and cannot dry inside the vest, so patients sponge bathe and keep the liner dry. The vest stays fastened to keep the neck immobilized.

Showering soaks the liner, leading to maceration and pressure injury under the vest.

Self-transfer twists and flexes the spine and is unsafe with an unstable fracture.

A sling lets the trunk sag, which flexes an unstable thoracolumbar fracture.

Lifting by the arms and knees flexes the trunk at the fracture site, risking cord injury.

A slide board with enough staff moving the patient as one unit, on the count of the person at the head, keeps the spine aligned. Lifting by limbs or self-transfer lets the spine bend or twist at the fracture.

A splint protects an associated tuft fracture, but it does not relieve the pressure that causes the pain.

A painful subungual hematoma with an intact nail and nail margins is drained by trephination: a small hole through the nail plate releases the blood and relieves the pressure at once. Removing an intact nail adds no benefit, even when the hematoma is large.

Cutting through the nail fold can damage the germinal matrix and leave a permanent nail deformity; drainage goes through the nail plate.

Cold and elevation help swelling, but blood trapped under the nail keeps up the pressure and throbbing pain until it is released.

Revascularizing muscle ischemic for 9 hours risks reperfusion injury and sepsis, and the transected nerve leaves a limb without function.

A patient in shock with obvious arterial and nerve injury does not need CT to decide; imaging delays control.

Ongoing shock, a transected tibial nerve, and 9 hours of warm ischemia predict a nonviable, nonfunctional limb; attempting salvage prolongs surgery and risks the patient's life. Primary amputation is the life-saving choice.

Hyperbaric oxygen is an adjunct for some crush injuries in stable patients, not a step before hemorrhage control in shock.

The command center needs resource status to match patients to capacity: beds, ventilators, staff, and supplies. Unit reports during an incident are short, numerical, and tied to what is available or running low.

Patient-level detail floods the command channel and exposes protected information; it does not answer the capacity question.

Canceling elective cases is a decision for incident command based on reports from all units, not a unit status report.

Staff fatigue matters, but naming individuals is not resource status; staffing numbers and needs are what command uses.

A massive transfusion protocol works only if products arrive fast, so time from activation to the first cooler at the bedside is a standard performance indicator, along with ratios delivered and appropriate activation. It measures exactly what the protocol is meant to speed up.

Shift distribution describes when activations happen, not how well the protocol performs.

Training counts describe preparation, not whether blood reaches the patient quickly.

Inventory size is a capacity figure; a large stock can still arrive slowly.

Filling in values to fit the outcome falsifies the record and biases risk-adjusted comparisons.

Benchmarking and peer review depend on accurate registry data; missing GCS components and transfer status distort risk adjustment. The registrar validates the record against the chart before it is submitted or reviewed.

Peer review may follow, but it needs an accurate record; reviewing first risks conclusions based on missing data.

Submitting known-incomplete data corrupts benchmarking reports and violates registry data-quality standards.

Bringing a contaminated patient inside can contaminate staff and close the department.

Contaminated clothing is bagged, labeled, and kept outside as hazardous waste or evidence, never sent to regular linen.

Identification can take hours; decontamination proceeds without knowing the agent.

An unknown liquid soaking the clothing must be removed before entry so staff, other patients, and the department are not contaminated. Removing clothing removes most of the contaminant, followed by water decontamination outside, with staff in PPE.

Dumping follows meals and does not explain persistent pain and vomiting after a crash; settling on it delays the diagnosis.

After Roux-en-Y bypass, an internal hernia or other bowel injury can follow abdominal trauma while early CT looks normal, and obesity with altered anatomy makes the exam less reliable. Persistent pain and vomiting call for serial exams and early surgical involvement, ideally by a surgeon familiar with bariatric anatomy.

A nondiagnostic CT does not clear a patient whose pain and vomiting persist; discharge risks a missed bowel injury or internal hernia.

A blind nasogastric tube can perforate the small gastric pouch or the anastomosis; any tube is placed only with surgical guidance.

A dry dressing lets the particles smolder and burn deeper; they must be removed under water.

White phosphorus is fat-soluble; oily ointments increase absorption and systemic toxicity.

Drying exposes the particles to air and lets them reignite.

White phosphorus ignites on contact with air, so the wound is kept wet with water or saline-soaked dressings while particles are removed. Removed particles go into water.

A dependent position increases swelling; elevation is used after rewarming.

Debriding hemorrhagic blisters exposes deeper damaged tissue to drying and infection.

Rewarming is done once in water at about 37–39 °C; hotter water burns numb tissue, and repeat thawing is not indicated.

Hemorrhagic blisters indicate deeper injury, and leaving them intact protects the underlying tissue; clear blisters may be debrided. The hand is elevated to reduce edema and protected with loose dressings.

Parallel U-shaped bruises match a looped cord or belt and are a classic sign of inflicted injury. The backs of the thighs are protected areas rarely bruised in play, so the nurse reports suspected abuse.

Birthmarks are stable, flat, and not loop-shaped; these are new bruises.

Sports injuries bruise the front of the shins and knees, not the backs of the thighs in a loop pattern.

Easy bruising does not create a patterned injury; the shape reflects the object used.

Forcing the leg flat and extended is uncomfortable and unnecessary; the leg is positioned for comfort.

Preoperative skin traction for hip fractures does not reduce pain or improve outcomes and can injure fragile skin, so current guidance advises against routine use. The leg is supported with pillows in a comfortable position.

Buck's traction was once routine, but evidence shows no benefit and a risk of skin injury in older adults.

A tight wrap can impair circulation and damage skin.

Ataxia and slurred speech after a head strike raise doubt about competence; letting the patient leave without assessment risks harm.

Sedation without capacity assessment or consent and without airway planning is unsafe and is a last resort under specific protocols.

A competent adult may refuse care, but intoxication and a possible head injury can impair capacity. The nurse first assesses whether the patient can understand, appreciate, reason, and choose, and involves the provider.

An AMA form is only valid if the patient has capacity; signing does not settle that question.

Normal vital signs do not exclude fractures or bleeding in older adults, who often lack the usual signs.

Calling it fatigue explains away a new functional loss that is often the only sign of fracture in older adults.

Discharging a patient who cannot stand risks another fall and leaves an injury undiagnosed.

A new inability to stand after a fall in an older adult with osteoporosis suggests an occult fracture, such as hip, pelvis, or spine, even with normal vital signs. The decline is reported and imaging follows.

Holding the patient for an open-ended family plan is not a care plan; the team should explore services and rehabilitation.

Needing help with balance and failing teach-back show the discharge plan is unsafe for someone living alone. The nurse involves therapy and case management to arrange services, equipment, or a rehabilitation stay.

A handout does not address the balance deficit or inability to learn the walker technique.

Agreement is not understanding; teach-back failure shows the patient cannot safely follow the plan.

Airway edema progresses after inhalation injury, and these patients need repeated bronchoscopy and suctioning of soot and casts, so a large tube of about 7.5–8.0 mm is chosen for an average adult.

A 6.5-mm tube limits suctioning and bronchoscopy and raises the work of breathing through it.

A 10.0-mm tube is larger than an average adult larynx accepts and risks laryngeal injury, especially in swollen tissue.

A 6.0-mm tube is too narrow for bronchoscopy and clogs easily with carbonaceous secretions.

Ancillary tests are used only when part of the exam or the apnea test cannot be completed or interpreted; they are not required after a complete examination.

Death by neurologic criteria is legal death even while the ventilator keeps the heart beating; waiting for asystole is not part of the determination.

Two separate examinations are the pediatric standard and appeared in older adult hospital policies; under the current guideline, an adult does not need a repeat exam after a complete one.

The 2023 AAN/AAP/CNS/SCCM consensus guideline accepts a single complete examination with an apnea test for adults once all prerequisites are met; two examinations are required only in children. The time of death is when the determination is completed, and family support continues.