Free TCRN Practice Test: 50 Questions With Answers

Topic: Glasgow Coma Scale

Correct answer: B. Eyes open to sound (E3). Speech is coherent but not oriented, which scores as confused (V4). Following a two-part command is obeying commands (M6). 3 + 4 + 6 = 13.

Why not the others:

• A. E2 means eyes open only to pressure. This patient opened their eyes to a spoken cue.
• C. V5 requires correct orientation. Getting the month and place wrong makes the verbal response confused, not oriented.
• D. E4 is spontaneous eye opening before any stimulus, and V5 needs orientation. Neither is described.

Takeaway: Score each component from what you actually observed, then add. Record the components (E3 V4 M6), not just the total, so the next nurse can see what changed.

Source: Glasgow Coma Scale Assessment Aid, p. 1, eye/verbal/motor response table.

Topic: TBI blood pressure targets

Correct answer: C. BTF's suggested SBP thresholds for severe traumatic brain injury (TBI) depend on age: at or above 100 mm Hg for ages 50 to 69, and at or above 110 mm Hg for ages 15 to 49 or over 70. This is a Level III recommendation. At 74, the suggested threshold is 110 or higher, so 104 is below it.

Why not the others:

• A. 90 mm Hg is an older, general hypotension threshold, not BTF's current age-based target.
• B. 100 mm Hg applies to patients aged 50 to 69.
• D. 130 mm Hg is not a BTF target.

Takeaway: Older adults with severe TBI get the higher target. Age matters here in a way many people don't expect.

Source: Brain Trauma Foundation: Severe TBI, 4th edition, Blood Pressure Thresholds, Level III.

Topic: Cerebral perfusion pressure

Correct answer: D. CPP = MAP − ICP, so 82 − 26 = 56 mm Hg. BTF's recommended CPP target is 60 to 70 mm Hg, so 56 is low. The ICP of 26 is also above BTF's treatment threshold of 22 mm Hg.

Why not the others:

• A. 108 comes from adding ICP to MAP instead of subtracting it.
• B. The arithmetic is right, but 56 is below the 60 to 70 mm Hg range, not inside it.
• C. 70 mm Hg isn't the result of this calculation.

Takeaway: Two numbers matter at once here: a low CPP and an ICP above 22. Both are reasons to alert the team.

Source: Brain Trauma Foundation: Severe TBI, 4th edition, Intracranial Pressure Thresholds and Cerebral Perfusion Pressure Thresholds; ACS Best Practices Guidelines: Traumatic Brain Injury, Intracranial Pressure Monitoring, printed p. 22: CPP = MAP − ICP.

Topic: Hyperventilation in severe TBI

Correct answer: C. BTF does not recommend prolonged prophylactic hyperventilation to a PaCO2 of 25 mm Hg or less. The guideline treats hyperventilation as a short-term measure for raised ICP, not a routine setting.

Why not the others:

• A. Good oxygen saturation doesn't make prophylactic hypocapnia safe.
• B. It's the reverse. BTF's earlier recommendation, restated in the 4th edition, says to avoid hyperventilation in the first 24 hours, when cerebral blood flow is often critically low.
• D. No such requirement exists.

Takeaway: "Temporizing" is the key word: short-term use for rising ICP is different from a standing order.

Source: Brain Trauma Foundation: Severe TBI, 4th edition, Ventilation Therapies, Level IIB and restated prior recommendations.

Topic: Steroids in severe TBI

Correct answer: C. BTF gives a Level I recommendation against steroids for improving outcome or lowering ICP in severe TBI. High-dose methylprednisolone was linked to higher mortality and is contraindicated.

Why not the others:

• A. No time window makes steroids recommended in severe TBI.
• B. An ICP threshold doesn't change the recommendation.
• D. The recommendation isn't about which steroid. None are recommended for this purpose.

Takeaway: Steroids for swelling from other causes are not a reason to use high-dose steroids for severe TBI.

Source: Brain Trauma Foundation: Severe TBI, 4th edition, Steroids, Level I.

Topic: Autonomic dysreflexia

Correct answer: D. This is autonomic dysreflexia. The first steps are to sit the patient up and loosen anything tight, then check BP and heart rate every 1 to 2 minutes while looking for the trigger, starting with the bladder. If SBP is at or above 150 mm Hg before catheterization, consider an ordered rapid-onset, short-duration antihypertensive before the procedure; do not wait for all triggers to be removed.

Why not the others:

• A. Sit the patient up immediately. Medication can be needed promptly for this marked hypertension, but giving it does not replace positioning or the search for a trigger.
• B. Lying flat with legs raised pushes the blood pressure higher.
• C. The bladder is checked first. Bowel is looked at later if symptoms continue.

Takeaway: Sit up, loosen, find the trigger. Bladder first: a full bladder or kinked catheter is the usual cause.

Source: PVA: Evaluation and Management of Autonomic Dysreflexia, Recommendations 2.6–2.13: positioning, monitoring, urinary triggers and SBP ≥150 mm Hg before catheterization.

Topic: Neurogenic shock

Correct answer: A. Low blood pressure with a slow heart rate and warm skin after a cord injury above T6 is the typical picture of neurogenic shock, a type of distributive shock. The injury can interrupt sympathetic control of vascular tone and heart rate. However, the findings listed here do not rule out internal bleeding, and hemorrhagic and neurogenic shock can coexist.

Why not the others:

• B. Nothing in the stem suggests a cardiac injury or pump failure.
• C. There's no infection source or time course for sepsis.
• D. Hemorrhage usually causes a fast heart rate and cool, pale skin, rather than the pattern described. It remains a possible coexisting cause: negative FAST and a stable pelvic examination do not exclude bleeding.

Takeaway: Recognize the neurogenic pattern without closing the search for bleeding.

Source: PVA: Early Acute Management in Adults with Spinal Cord Injury, Recommendations 18–19, printed p. 20; ACS TQIP Best Practices Guidelines in Imaging, Head imaging and neurologic deterioration; chest/abdominal trauma and pediatric considerations, printed pp. 15–18 and 39–43.

Topic: Incomplete cord syndromes

Correct answer: C. Central cord syndrome usually follows a low-energy hyperextension injury in an older adult with a narrowed cervical canal. Weakness is worse in the arms than the legs, and sacral sensation is often spared.

Why not the others:

• A. Brown-Séquard splits deficits by side of the body, not arms versus legs.
• B. Anterior cord syndrome causes motor loss plus loss of pain and temperature sensation, and it doesn't selectively spare the legs.
• D. Cauda equina involves the lumbosacral nerve roots, not a cervical cord injury.

Takeaway: Picture it: older adult, forward fall, chin strike, "weak arms, better legs."

Source: AANS: Central Cord Syndrome, Overview, Causes and Symptoms.

Topic: Basilar skull fracture

Correct answer: B. Bruising around both eyes (raccoon eyes) and clear nasal drainage suggest a basilar skull fracture. With suspected anterior skull-base injury, a blindly passed nasal tube can enter the cranial vault. Use the oral route for gastric decompression while the injury is evaluated.

Why not the others:

• A. A smaller tube is still passed through the nose and carries the same risk.
• C. Completing a CT is not the same as excluding an anterior skull-base fracture. The findings and imaging result must be assessed before nasal placement is considered.
• D. Nasal CPAP does not decompress the stomach or provide a protected airway; it is not an alternative to the ordered gastric tube.

Takeaway: Suspect an anterior skull-base fracture? Avoid blind nasal tube placement; use the oral route for gastric decompression.

Source: Orlando Regional Medical Center: NGT Placement in Craniofacial Fractures, pp. 1–2, recommendations and clinical discussion.

Topic: Open globe injury

Correct answer: C. A teardrop pupil with a protruding object suggests an open globe injury. The priorities are to protect the eye without pressing on it (building the shield around the object), prevent vomiting and straining that raise eye pressure, and leave the object in place for the ophthalmologist.

Why not the others:

• A. Pressure on an open globe can push eye contents out.
• B. Protruding objects are removed in the operating room, not at the bedside.
• D. Eye pressure measurement is delayed until an open globe has been ruled out, because the test itself presses on the eye.

Takeaway: Shield without pressure, stop the vomiting, leave the object alone.

Source: University of Iowa EyeRounds: Assessment and Management of Ocular Trauma, Open Globe Injury.

Topic: Tension pneumothorax

Correct answer: C. Tension pneumothorax is diagnosed at the bedside. When the patient is unstable, the team decompresses right away and establishes definitive chest drainage. The technique depends on available trained personnel and equipment; needle decompression is one emergency option when a chest tube is not immediately available.

Why not the others:

• A. Waiting for an x-ray delays a lifesaving procedure.
• B. More positive pressure can make a tension pneumothorax worse.
• D. Fluid doesn't relieve the pressure that is blocking blood from returning to the heart.

Takeaway: Unstable plus one-sided absent breath sounds plus hyperresonance means you treat, then image.

Source: WSES-AAST: Thoracic Trauma Guidelines, Pleural injuries: unstable tension pneumothorax and emergency decompression.

Topic: Cardiac tamponade

Correct answer: B. Low blood pressure, distended neck veins, and muffled heart tones make up Beck's triad, the classic picture of tamponade. A wound over the heart makes it more likely.

Why not the others:

• A. One-sided absent breath sounds and hyperresonance would favor tension pneumothorax. Equal breath sounds and the other findings make tamponade the better answer here.
• C. A large hemothorax causes decreased breath sounds and dullness on the affected side, and heavy blood loss usually flattens the neck veins.
• D. Chest-wall bleeding explains neither the distended neck veins nor the muffled heart sounds.

Takeaway: A wound over the heart plus hypotension, distended neck veins, and muffled heart sounds raises concern for tamponade.

Source: ESC: Cardiac Tamponade—A Clinical Challenge, Clinical presentation: paragraph beginning “Several signs may be present”; WSES-AAST: Thoracic Trauma Guidelines, Pleural injuries: pneumothorax and hemothorax recommendations.

Topic: Massive hemothorax

Correct answer: C. An immediate return of about 1,500 mL or more is a traditional trigger for urgent surgical evaluation. The 2025 WSES-AAST guideline also identifies output above 200 mL/hour for 3 consecutive hours as a reason for operative management. Here, 1,600 mL immediately warrants urgent preparation for exploration; the team also considers hemodynamics and ongoing transfusion needs, not output alone.

Why not the others:

• A. The bleeding source is inside the chest. Clamping the tube doesn't stop it and hides how much is being lost.
• B. Stripping the tube doesn't address the source.
• D. Checking every 4 hours would miss bleeding at a surgical rate.

Takeaway: Know both triggers: a large initial return, and steady ongoing output. Do not wait for a volume threshold when the patient is unstable from thoracic bleeding.

Source: WSES-AAST: Thoracic Trauma Guidelines, Hemothorax: immediate and ongoing drainage, hemodynamic instability and operative management.

Topic: Rib fractures in older adults

Correct answer: C. Uncontrolled rib pain leads to shallow breathing, poor coughing, and lung complications. Effective multimodal analgesia is central to care; regional techniques can be selected for the patient when appropriate. EAST's 2022 older-adult guideline found insufficient evidence to recommend for or against epidural analgesia over nonregional treatment. It does not make age over 65 plus four fractures an automatic epidural indication.

Why not the others:

• A. Untreated pain is what drives the breathing problem.
• B. Bed rest does nothing for the pain and doesn't help her breathe deeply or cough.
• D. She already has known fractures and severe pain. Delaying analgesia doesn't help.

Takeaway: For rib fractures, pain control is the breathing treatment.

Source: EAST/CWIS: Nonsurgical Management and Analgesia for Older Adults with Multiple Rib Fractures, Epidural Analgesia and Using These Guidelines in Clinical Practice.

Topic: Interpreting a negative FAST

Correct answer: D. The ACS imaging guideline states plainly that a negative FAST does not rule out intra-abdominal injury. FAST can miss injury without detectable free fluid. Its 2018 adult-trauma discussion reports about 63% sensitivity for solid organ injury; that is not a rule-out guarantee for an individual patient.

Why not the others:

• A. This is the exact misreading the guideline warns against.
• B. A solid organ injury can be present without free fluid detected by FAST.
• C. In a stable patient with a concerning exam, contrast CT is the definitive study.

Takeaway: A positive FAST changes decisions in unstable patients. A negative FAST doesn't close the case.

Source: ACS TQIP Best Practices Guidelines in Imaging, Adult abdominal trauma: FAST limitations and reported solid-organ sensitivity.

Topic: Imaging the stable abdomen

Correct answer: D. For stable blunt trauma patients, the ACS imaging guideline calls contrast-enhanced CT the best practice for screening the abdomen. IV contrast is needed to show organ injury and active bleeding.

Why not the others:

• A. A plain radiograph can't characterize solid organ or vascular injury.
• B. The guideline says oral contrast is not indicated in blunt trauma, and IV contrast is the part that matters.
• C. Serial FAST improves sensitivity but still isn't definitive in a stable patient.

Takeaway: Stable patient with suspected blunt abdominal injury: CT with IV contrast. Routine oral contrast is not needed.

Source: ACS TQIP Best Practices Guidelines in Imaging, Adult blunt abdominal trauma: CT with IV contrast in the stable patient.

Topic: Unstable patient with positive FAST

Correct answer: A. This patient has persistent shock and a positive abdominal FAST, supporting the planned emergency laparotomy. The ACS imaging guideline warns against using CT to pin down a source that earlier imaging has already confirmed when that would delay operative bleeding control.

Why not the others:

• B. A CT trip delays hemorrhage control in an unstable patient.
• C. Waiting adds nothing when the operation is already indicated.
• D. Another diagnostic test doesn't change the plan and costs time.

Takeaway: Unstable plus positive FAST: operating room, not CT.

Source: ACS TQIP Best Practices Guidelines in Imaging, Adult abdominal trauma: unstable patient, positive FAST and operative hemorrhage control.

Topic: Delayed signs of pancreatic injury

Correct answer: B. The ACS imaging guideline notes that pancreatic injury may not be visible on CT in the first 12 to 24 hours after injury, and suggests considering a repeat CT at 6 to 24 hours when concern persists in adults. New or worsening pain is a reason to reassess.

Why not the others:

• A. Assuming it's a bruise can miss a real injury.
• C. An early normal CT doesn't exclude pancreatic injury.
• D. Treating the pain without telling the team delays reassessment.

Takeaway: A normal early CT and a worsening abdomen should make you speak up. Repeat imaging is driven by persistent suspicion or deterioration, not a routine schedule for every patient.

Source: ACS TQIP Best Practices Guidelines in Imaging, Pancreatic Injury, printed p. 42: early CT limitations and repeat imaging; WSES-AAST: Duodeno-pancreatic and Extrahepatic Biliary Tree Trauma, Diagnosis: repeat CT within 12–24 hours for stable patients with persistent high suspicion or pain.

Topic: Pelvic binder placement

Correct answer: D. The greater trochanters are the recommended landmark. The binder works by compressing the pelvic ring, and that is where it does so effectively.

Why not the others:

• A. The iliac crests are above the recommended greater-trochanter level. A binder should not be centered at the waist.
• B. The abdomen is the wrong level entirely.
• C. Mid-thigh doesn't compress the pelvic ring.

Takeaway: Feel for the trochanters, not the hip bones you'd put your hands on.

Source: Pelvic Binder Attachment-Level Cadaveric Study, Discussion: Application Above and Below the Greater Trochanter.

Topic: Suspected urethral injury

Correct answer: C. Blood at the meatus with a pelvic fracture raises strong suspicion of urethral injury. When a RUG is readily available, it is done before a catheter goes in, because blind passage can create a false passage or turn a partial tear into a complete one.

Why not the others:

• A. The 2025 ACS genitourinary guideline says the rectal exam for a high-riding prostate is no longer recommended for ruling out urethral injury.
• B. Catheter size doesn't remove the risk.
• D. Lubricant doesn't make blind passage safe.

Takeaway: If imaging isn't available and drainage is urgent, the ACS guideline allows one attempt by an experienced team member. That exception doesn't apply here, because a RUG is on hand.

Source: ACS Best Practices Guidelines: Management of Genitourinary Injuries, pp. 8–9: suspected urethral injury, RUG and catheterization exception.

Topic: Evaluating bladder injury

Correct answer: B. The 2025 ACS genitourinary guideline recommends CT or conventional cystography for suspected bladder injury. The bladder is actively filled through the catheter (at least 300 mL, until the patient can't tolerate more, or until contrast stops flowing). Clamping the catheter and waiting for contrast to drain down from the kidneys doesn't stretch the bladder enough to show an injury.

Why not the others:

• A. The guideline specifically calls this passive-filling approach inadequate.
• C. Ultrasound doesn't evaluate for bladder rupture.
• D. The urethra has already been evaluated. A urethrogram doesn't assess the bladder.

Takeaway: Bladder injury: fill the bladder through the catheter, then image. Don't just clamp and wait.

Source: ACS Best Practices Guidelines: Management of Genitourinary Injuries, p. 18: retrograde cystography and bladder distension.

Topic: Blunt cardiac injury

Correct answer: D. The ACS imaging guideline notes that chest CT has low sensitivity for blunt cardiac injury. It recommends formal echocardiography when serious blunt cardiac injury is suspected based on unexplained hypotension or arrhythmias.

Why not the others:

• A. A normal chest CT doesn't rule out blunt cardiac injury.
• B. New arrhythmia plus unexplained hypotension after chest impact needs evaluation, not reassurance.
• C. A chest radiograph can't assess heart function.

Takeaway: Persistent dysrhythmia or unexplained hypotension after chest impact needs monitored evaluation and echocardiography, even when the CT looks fine.

Source: ACS TQIP Best Practices Guidelines in Imaging, Blunt Cardiac Injury: CT limitations and formal echocardiography.

Topic: Nonoperative management of renal injury

Correct answer: B. The ACS genitourinary guideline calls nonoperative management the standard of care for hemodynamically stable patients with grade I to III renal injuries. That means close monitoring for signs of bleeding in a setting where specialists can step in if needed.

Why not the others:

• A. Removing the kidney isn't indicated in a stable patient with this grade of injury.
• C. Unnecessary exploration raises the chance of losing the kidney.
• D. Nonoperative doesn't mean unmonitored. The patient needs observation.

Takeaway: "Nonoperative" means watched closely by people who can intervene, not "nothing needed."

Source: ACS Best Practices Guidelines: Management of Genitourinary Injuries, pp. 25–26: nonoperative management of stable grade I–III renal injury.

Topic: Recognizing compartment syndrome

Correct answer: A. Pain out of proportion to the injury and pain with passive stretch are early findings. Loss of pulse, pallor, and paralysis are late findings.

Why not the others:

• B. Rising pain despite opioids plus pain on passive stretch is not the normal course of a fracture.
• C. Passive-stretch pain inside a tight compartment points to compartment syndrome.
• D. Rising pressure in the limb points the other way: a cast that may be too tight.

Takeaway: Don't wait for the pulse to disappear. By then the damage may be done.

Source: ACS TQIP Best Practices in Orthopaedic Trauma Management, Acute Compartment Syndrome, printed pp. 14–17; Open Fractures, p. 28; British Orthopaedic Association: Diagnosis and Management of Compartment Syndrome of the Extremities, Standards 7–9.

Topic: Initial compartment syndrome care

Correct answer: C. Removing anything constricting lowers external pressure on the limb. Keeping the limb at heart level, rather than raised well above it, and avoiding hypotension help maintain tissue perfusion while urgent surgical assessment proceeds. Confirmed compartment syndrome requires immediate surgical decompression.

Why not the others:

• A. Raising the limb high lowers arterial inflow to tissue that's already at risk.
• B. Compression adds pressure.
• D. Traction isn't a treatment for compartment syndrome.

Takeaway: Relieve, level, perfuse, and get the surgeon.

Source: Donaldson et al.: The Pathophysiology, Diagnosis and Current Management of Acute Compartment Syndrome, Abstract and Treatment; British Orthopaedic Association: Diagnosis and Management of Compartment Syndrome of the Extremities, Standards 7–9.

Topic: Open fracture antibiotics

Correct answer: A. The ACS orthopaedic trauma guideline recommends IV antibiotics within 60 minutes of presentation for open fractures. Delay is linked to higher infection rates, and waiting for the operating room is not appropriate.

Why not the others:

• B. Early antibiotics don't wait for culture results.
• C. Waiting three hours misses the target.
• D. This is prophylaxis. Waiting for fever defeats the purpose.

Takeaway: Open fracture: antibiotics do not wait for the operating room. Prompt antibiotics and urgent surgical wound care are both needed.

Source: ACS TQIP Best Practices in Orthopaedic Trauma Management, Open Fractures, p. 28: antibiotics within 60 minutes of presentation.

Topic: Tetanus prophylaxis

Correct answer: C. For a wound that isn't clean and minor, such as a soil-contaminated puncture, CDC advises both tetanus toxoid vaccine and TIG when the person has had fewer than 3 doses or an unknown history. TIG gives immediate antibodies, and the vaccine starts building the person's own immunity.

Why not the others:

• A. The vaccine alone doesn't give immediate protection to someone who may never have been immunized.
• B. TIG alone offers only temporary protection and doesn't build immunity.
• D. Antibiotics are not used to prevent tetanus. They don't replace vaccine or TIG.

Takeaway: Dirty wound plus unknown or incomplete history means vaccine and TIG, along with good wound care.

Source: CDC: Clinical Guidance for Wound Management to Prevent Tetanus, Vaccination Recommended and TIG Prophylaxis Indications.

Topic: Bruising in young children (TEN-4-FACESp)

Correct answer: D. TEN-4-FACESp is a screening rule for children under 4. It flags bruising on the torso, ears, or neck (TEN); bruising in the FACES areas (frenulum, angle of the jaw, fleshy cheeks, eyelids, subconjunctivae); any bruise at all in an infant 4 months and younger; and patterned bruising. This infant meets two criteria: an ear bruise, and a bruise at 3 months old.

Why not the others:

• A. The rule is for children younger than 4 years.
• B. Ear bruising is one of the regions the rule flags.
• C. Patterned bruising is one criterion, not a requirement.

Takeaway: The rule screens for who needs further evaluation. It doesn't diagnose abuse.

Source: Lurie Children's: TEN-4-FACESp Bruising Clinical Decision Rule, Single-page decision-rule poster.

Topic: Trauma in pregnancy

Correct answer: A. EAST's 2025 guideline conditionally recommends observing trauma patients with viable pregnancies for at least 4 to 6 hours. It advises Kleihauer-Betke testing in Rh-negative patients to set the Rh(D) immune globulin dose.

Why not the others:

• B. Feeling well doesn't replace the observation period.
• C. For Rh-negative patients, testing isn't limited to those with bleeding.
• D. The guideline says radiation concerns shouldn't block imaging that is medically indicated.

Takeaway: Resuscitating the mother is the best treatment for the fetus.

Source: EAST: Trauma in Pregnancy Practice Management Guideline, Conclusions: viable-pregnancy monitoring and Rh-negative testing.

Topic: Burn resuscitation

Correct answer: D. The target is 0.5 mL/kg/hour, so 0.5 × 80 = 40 mL/hour. The ABA burn-shock guideline recommends starting adult resuscitation at 2 mL/kg/%TBSA for burns of at least 20% TBSA: 2 × 80 × 40 = 6,400 mL over the first 24 hours from injury. That is an initial estimate to be adjusted to the response, not a fixed volume that every patient must receive. Urine output is one monitoring measure, not proof by itself that perfusion is adequate.

Why not the others:

• A. 20 mL/hour is only 0.25 mL/kg/hour for this patient, below the stated target; assess the cause rather than automatically giving more fluid.
• B. 200 mL/hour is 2.5 mL/kg/hour, above the stated target. A high output alone does not establish fluid overload.
• C. 120 mL/hour is also well above target.

Takeaway: Calculate the target with body weight. Use urine output with the rest of the clinical assessment to guide resuscitation.

Source: American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation, Initial fluid-volume recommendation; Table 1 study urine-output targets.

Topic: Chemical eye injury

Correct answer: A. Early, extensive irrigation limits chemical damage. Do not delay irrigation for the full eye examination, pH testing, or referral listed here.

Why not the others:

• B. A patch leaves the chemical in contact with the eye.
• C. Testing pH shouldn't delay the start of irrigation.
• D. Irrigation isn't delayed for a full exam.

Takeaway: Chemical in the eye: start irrigating right away.

Source: University of Iowa EyeRounds: Assessment and Management of Ocular Trauma, Chemical Injuries: immediate copious irrigation.

Topic: Warfarin reversal in older adults

Correct answer: A. For major traumatic bleeding in a patient taking warfarin, the European trauma-bleeding guideline recommends prompt prothrombin complex concentrate (PCC) together with IV vitamin K. Four-factor PCC rapidly replaces the depleted clotting factors; vitamin K supports continued factor production after the PCC effect wears off.

Why not the others:

• B. The cited guidance prefers PCC over plasma for this situation.
• C. Protamine reverses heparin, not warfarin.
• D. Platelets don't correct warfarin's effect on clotting factors.

Takeaway: Warfarin with major bleeding: expect rapid factor replacement plus IV vitamin K, not PCC alone.

Source: European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma, Sixth Edition, Recommendation 33: PCC plus IV vitamin K for vitamin K antagonist reversal.

Topic: Anticoagulated older adult after a fall

Correct answer: A. ACEP recommends against routine repeat CT or routine admission/observation solely for anticoagulant use when the initial CT shows no hemorrhage, the neurologic examination is at baseline, and there are no other monitoring criteria. Discharge can be appropriate after clinical assessment, with clear instructions about symptoms of rare delayed bleeding and when to return immediately.

Why not the others:

• B. A negative initial CT does not eliminate the possibility of delayed bleeding. Return instructions remain necessary.
• C. ACEP does not recommend routine admission or repeat imaging for every anticoagulated patient who meets the conditions in the stem.
• D. MRI is not a routine substitute for a repeat CT that is not indicated in this scenario.

Takeaway: Anticoagulant use alone does not require routine repeat CT or admission after a negative scan and baseline examination. Safe discharge still needs assessment, support, and clear return instructions.

Source: ACEP Clinical Policy on Mild Traumatic Brain Injury, Critical Question 2, Level B and Level C recommendations.

Topic: FAST in children

Correct answer: D. The guideline says FAST is less sensitive and specific in children than in adults. It recommends FAST in children only when the child is in shock or CT isn't available or feasible, and it points to validated rules such as PECARN to identify children at very low risk.

Why not the others:

• A. FAST is less reliable in children, not more.
• B. The guideline doesn't make a positive FAST alone a surgical trigger in a stable child.
• C. Oral contrast isn't indicated in pediatric blunt trauma.

Takeaway: Children aren't small adults: in a stable child, a FAST result doesn't decide whether to get a CT.

Source: ACS TQIP Best Practices Guidelines in Imaging, Head imaging and neurologic deterioration; chest/abdominal trauma and pediatric considerations, printed pp. 15–18 and 39–43.

Topic: Alcohol withdrawal

Correct answer: A. ASAM names benzodiazepines as first-line treatment because they reduce withdrawal seizures and delirium.

Why not the others:

• B. Alcohol should not be used to prevent or treat withdrawal.
• C. ASAM found insufficient evidence to support baclofen for withdrawal.
• D. Beta-blockers can be added for persistent high blood pressure or heart rate but don't prevent withdrawal seizures.

Takeaway: CIWA-Ar tracks how severe withdrawal is. It was built for monitoring, not for diagnosis.

Source: ASAM Clinical Practice Guideline on Alcohol Withdrawal Management, Recommendations V.13, V.16 and V.37–V.39; severity-scale cautions.

Topic: Massive transfusion activation (ABC score)

Correct answer: B. The ABC score gives one point each for penetrating torso injury, heart rate over 120, SBP under 90, and a positive FAST. This patient has all four. ACS TQIP lists a score of 2 or more as a trigger for massive transfusion protocol activation.

Why not the others:

• A. All four criteria are present, not two.
• C. The score is 4, and activation doesn't wait for labs.
• D. The count is wrong.

Takeaway: An ABC score of 2 or more is one activation trigger. Do not wait for a score or laboratory results when major ongoing hemorrhage already requires the protocol.

Source: ACS TQIP: Massive Transfusion in Trauma Guidelines, p. 4: ABC score/activation; laboratory monitoring during MTP.

Topic: Preventing hypothermia during transfusion

Correct answer: B. The European trauma-bleeding guideline recommends early measures to reduce heat loss and warm a hypothermic patient to maintain normothermia. Hypothermia impairs coagulation. Warming is part of resuscitation, alongside hemorrhage control, not a task to postpone until afterward.

Why not the others:

• A. Hypothermia worsens coagulation rather than protecting it.
• C. Delaying warming allows temperature-related coagulopathy to continue.
• D. A temperature of 34.6°C already requires attention; 32°C is not a threshold to wait for.

Takeaway: Control bleeding and prevent heat loss at the same time. Follow the approved warmer and blood-component instructions rather than assuming every device accepts every component.

Source: European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma, Sixth Edition, Recommendation 18: early prevention of heat loss and warming to maintain normothermia.

Topic: Tranexamic acid timing

Correct answer: C. The guideline recommends TXA as soon as possible for trauma patients who are bleeding or at risk of significant bleeding, within 3 hours of injury: 1 g IV over 10 minutes, then 1 g over 8 hours. Do not delay administration while waiting for viscoelastic results.

Why not the others:

• A. The recommendation doesn't depend on test results.
• B. 12 hours is outside the stated window.
• D. The setting doesn't matter. The time since injury does.

Takeaway: For TXA, the clock starts at the time of injury, not at arrival.

Source: European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma, Sixth Edition, Recommendation 23: TXA timing and adult regimen.

Topic: Hypocalcemia and the lethal diamond

Correct answer: D. Hypocalcemia is the fourth element. It is made worse by the citrate in stored blood products. TQIP lists ionized calcium among the values to monitor during massive transfusion.

Why not the others:

• A. Amylase has nothing to do with this concept.
• B. Magnesium isn't part of the lethal diamond.
• C. Sodium isn't part of the lethal diamond.

Takeaway: Giving a lot of blood? Check ionized calcium.

Source: Ditzel et al.: A Review of Transfusion- and Trauma-Induced Hypocalcemia, pp. 435–438, transfusion-related hypocalcemia and The Lethal Diamond; Figure 2; European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma, Sixth Edition, Recommendation 31: ionized calcium monitoring and correction; ACS TQIP: Massive Transfusion in Trauma Guidelines, p. 4: ABC score/activation; laboratory monitoring during MTP.

Topic: Transfusion reaction: TACO vs TRALI

Correct answer: B. CDC's NHSN surveillance definition for TACO combines respiratory distress or pulmonary edema with additional findings such as elevated BNP, hypertension, neck vein distension, or fluid overload, beginning within 12 hours of transfusion. This patient's findings favor TACO. Those surveillance criteria support recognition; they do not replace immediate clinical assessment of a suspected transfusion reaction.

Why not the others:

• A. The hypertension, distended neck veins, and elevated BNP favor hydrostatic circulatory overload rather than TRALI. New respiratory distress after transfusion still requires prompt evaluation.
• C. There are no hives, itching, or swelling.
• D. There's no fever or chills.

Takeaway: High blood pressure and signs of fluid overload after transfusion favor TACO. Bilateral infiltrates alone do not establish TRALI.

Source: CDC NHSN Hemovigilance Module Surveillance Protocol, Table 5 (TACO), p. 14; Table 6 (TRALI), p. 15.

Topic: Permissive hypotension with TBI

Correct answer: B. Permissive hypotension for uncontrolled bleeding is not the strategy recommended when severe TBI is present. For a 30-year-old with severe TBI, BTF suggests maintaining SBP at or above 110 mm Hg (Level III). The team supports cerebral perfusion while pursuing rapid hemorrhage control.

Why not the others:

• A. This is permissive hypotension, which puts the injured brain at risk.
• C. This patient has a specific, evidence-based target.
• D. A MAP of 50 is far too low for an injured brain.

Takeaway: With severe TBI and hemorrhage together, support cerebral perfusion while controlling the bleeding; do not deliberately use permissive hypotension.

Source: Brain Trauma Foundation: Severe TBI, 4th edition, Blood Pressure Thresholds, Level III; European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma, Sixth Edition, Recommendation 13: severe-TBI exception to restricted-volume hypotensive resuscitation.

Topic: Neurologic decline after admission

Correct answer: A. The ACS imaging guideline says any worsening of a patient's neurologic exam is an indication for an urgent head CT, as soon as possible.

Why not the others:

• B. A scheduled scan doesn't cover an acute change.
• C. Treating headache alone does not address a new decline in consciousness or replace urgent reassessment and imaging.
• D. Continuing routine checks without reporting a two-point drop delays action.

Takeaway: A decline in the neuro exam isn't something to hand off at shift change. Report it now.

Source: ACS TQIP Best Practices Guidelines in Imaging, Head imaging: urgent CT for worsening neurologic examination.

Topic: Organ donation requirements

Correct answer: B. Under the Medicare Condition of Participation, hospitals must notify the OPO in a timely way about patients whose death is imminent or who have died. The request to the family must come from an OPO representative or a designated requestor who has completed OPO-approved training.

Why not the others:

• A. The requester must be an OPO representative or a designated requestor with the required training. A nurse with that training can serve in the role; an untrained nurse does not qualify merely by being at the bedside.
• C. Notification is required when death is imminent, not only after it is declared.
• D. Notification doesn't depend on the family raising the subject.

Takeaway: Notify early. Let the trained person ask.

Source: 42 CFR 482.45: Organ, Tissue and Eye Procurement, Paragraphs (a)(1) and (a)(3).

Topic: Catheter-associated UTI prevention

Correct answer: B. CDC's guideline says to insert catheters only for appropriate indications and leave them in only as long as needed. For surgical patients, catheters should come out as soon as possible after the operation, preferably within 24 hours, unless there's a continuing indication.

Why not the others:

• A. Convenience isn't an indication.
• C. Changing the catheter doesn't address the unnecessary days it stays in.
• D. Routine irrigation isn't a CAUTI prevention measure.

Takeaway: Avoid unnecessary catheter-days. Recheck the indication and remove the catheter when it is no longer needed.

Source: CDC: CAUTI Guideline—Summary of Recommendations, I.A, I.A.4, III.E and III.H.

Topic: Trauma-informed care

Correct answer: C. The ACS mental health guideline describes trauma-informed care as including safety, transparency and trust-building, shared decision-making, and personalized care. Explaining, asking permission, and offering choices puts those into practice.

Why not the others:

• A. Silence and speed take away the patient's sense of control.
• B. Restraint risks re-traumatizing the patient.
• D. Care still needs to happen. Trauma-informed care changes how it's done, not whether it's done.

Takeaway: Tell, ask, offer a choice.

Source: ACS: Screening and Intervention for Mental Health Disorders and Substance Use and Misuse in the Acute Trauma Patient, p. 6: trauma-informed care principles.

Topic: Alcohol screening and brief intervention

Correct answer: A. In the SBIRT model (Screening, Brief Intervention, and Referral to Treatment), a brief intervention follows a positive screen. The ACS guideline advises giving it as early as possible while the patient is alert, before discharge. It notes that a screen is not a diagnosis.

Why not the others:

• B. A screening result isn't a diagnosis.
• C. A handout alone isn't a brief intervention.
• D. Documenting a positive screen without acting on it misses the opportunity for intervention.

Takeaway: Screen, intervene, refer. The hospital stay is a "teachable moment."

Source: ACS: Screening and Intervention for Mental Health Disorders and Substance Use and Misuse in the Acute Trauma Patient, pp. 9–13: screening, brief intervention and referral.

Topic: Post-injury mental health referral

Correct answer: D. The ACS guideline describes mental health screening as triage for risk, not a way to diagnose. Referral options should already be in place, and it encourages connecting patients to services, with a warm handoff when possible.

Why not the others:

• A. Waiting withholds help the guideline recommends offering now.
• B. A screen can't diagnose PTSD.
• C. Many people are resilient, but a positive screen is exactly the signal for referral.

Takeaway: A positive screen means refer. It does not mean a diagnosis.

Source: ACS: Screening and Intervention for Mental Health Disorders and Substance Use and Misuse in the Acute Trauma Patient, pp. 28–29 and 33: screening for risk and referral with a warm handoff.

Topic: START mass-casualty triage

Correct answer: A. In START, a victim who is breathing, has a respiratory rate of 30 or less, and has no radial pulse (or capillary refill over 2 seconds) is triaged as immediate.

Why not the others:

• B. Delayed requires adequate perfusion and the ability to follow simple commands.
• C. Minor is for the walking wounded.
• D. Expectant is for victims who don't breathe even after the airway is positioned.

Takeaway: For a breathing START patient, absent radial pulse indicates immediate priority even when the respiratory rate is below 30. Persistent apnea after airway positioning follows a different branch.

Source: HHS CHEMM: START Adult Triage Algorithm, Algorithm Description: triage categories and five clinical parameters; Los Angeles Fire Department: Simple Triage and Rapid Treatment, pp. 4–5: breathing, absent radial pulse and mental-status branches; page images checked.

Topic: EMTALA transfers

Correct answer: B. The EMTALA regulation requires treatment within the sending hospital's capacity to minimize risk, acceptance by a receiving facility with available space and qualified personnel, transfer of related medical records available at that time, and qualified transport personnel and equipment. Records not yet available must follow as soon as practicable. An unstabilized transfer also needs the applicable informed written request or medical benefits-versus-risks certification.

Why not the others:

• A. Payment status can't delay screening or stabilizing care.
• C. A family signature is not a substitute for the medical benefits-versus-risks certification. A patient or legally responsible person can instead make an informed written transfer request under the regulation; that is a distinct route, not a family member acting as the certifying physician.
• D. Transport must use qualified personnel and equipment.

Takeaway: Accepted, available records sent, pending records forwarded, and the right transport—with the required transfer authorization.

Source: 42 CFR 489.24: Emergency-Care and Transfer Responsibilities, Paragraph (e)(1)–(2), especially (e)(2)(iii).

Topic: Quality improvement: CAUTI rate

Correct answer: D. CDC's measure divides the number of CAUTIs by the total catheter-days, then multiplies by 1,000. (3 ÷ 1,500) × 1,000 = 2.0 infections per 1,000 catheter-days.

Why not the others:

• A. This expresses the numerical ratio as a percentage instead of the requested infections per 1,000 catheter-days; it is not the requested rate unit.
• B. The denominator is catheter-days, not patients.
• C. This is off by a factor of 10.

Takeaway: Use catheter-days, not patients, as the denominator. Rates per 1,000 device-days standardize exposure but do not by themselves adjust for differences in patient risk. (This unit is fictional.)

Source: CDC: CAUTI Guideline—Implementation and Audit, Outcome Measures: rates of CAUTI.