Session Number 409 CERTIFICATION REVIEW: Questions, Answers, Rationales, Strategy Content Description In response to frequent requests for more practice
... [Show More] with sample questions and answers, this session will be dedicated to fulfilling that request. We will present sample questions and include a discussion of rationale for correct and incorrect answers. Strategies for clues to correct answers will also be given. Sample questions will begin with subject-specific examples in the topics of cardiac, pulmonary, neuro, GI, renal, endocrine, hematologic, multisystem, synergy, and behavioral. The session will conclude with a “potpourri” of questions from all topics tested in the CCRN, PCCN, CCNS, CMC and CSC certification exams. The participant will leave with a plan for successful completion of the exam. Learning Objectives At the end of this session, the participant will be able to: 1. Analyze questions and identify clues to correct answer 2. Explore rationales for correct and incorrect answers 3. Develop a plan for successful certification References NOTE: Please refer to outline for references pertaining to this session. CCRN-PCCN Review: Questions, Answers, Rationale & Strategies Synergy 1. After cardiac surgery, a patient who is a Jehovah’s Witness had an HCT of 18% and accumulated chest-tube drainage of 1800cc in the first 3 hours. The most appropriate action would be to: A. Begin continuous-circuit autotransfusion B. Administer donated directed PRBCs C. Administer donated autologous whole blood D. Administer 500cc of albumin 2. An alert patient is emergently intubated during an episode of pulmonary edema. When family members come to visit the patient, they cry out, “Talk to me; talk to me!” The nurse should tell the family that: A. They must not excite the patient while visiting B. Communication is not a priority at this time C. The patient is too exhausted to converse with them D. The breathing tube temporarily prevents the patient from speaking Cardiac 3. The heart sound most often associated with heart failure is: A. An S3 B. A pericardial friction rub C. An S4 D. A systolic ejection murmur 4. A patient is admitted with acute decompensated heart failure. The physician orders that the patient receive nesiritide (Natrecor) for volume overload refractory to loop diuretics. The nurse would closely monitor the patient for which side effect of nesiritide? A. Hypokalemia B. Hypotension C. Ventricular dysrhythmia D. Nausea/vomiting 5. The nurse should be alert for complications associated with embolic phenomena in which group of patients regardless of their disease stage? A. Patients with dilated cardiomyopathy B. Patients with hypertrophic cardiomyopathy C. Patients with restrictive cardiomyopathy D. Patients with myocarditis 6. Which of the following physiologic changes occurs as direct result of cardiogenic shock? A. Increase in capacitance B. Increase in afterload C. Decrease in preload D. Decrease in SVR Pulmonary 7. A young patient is admitted to the ICU after a motorcycle accident involving the center median of the freeway in which she sustained blunt head and chest trauma. Within minutes of arrival on the unit, the patient complains of dysphasia and is coughing. She develops upper airway obstruction unrelieved by oxygen, becomes cyanotic, and has palpable subcutaneous emphysema near the sternal notch. For which of the following interventions should the nurse prepare? A. Intubation and mechanical ventilation B. Fiberoptic bronchoscopy C. Emergent tracheostomy D. Initiation of cardiac compressions for CPR 8. The nurse maintains an adequate water level in the water-seal chamber of a chest tube drainage system because the waterseal: A. Controls the suction level of the chest tube system B. Controls the rate of drainage from the pleural cavity C. Prevents air and pleural fluid from reentering the pleural cavity D. Determines the amount of drainage from the pleural cavity Neuro 9. Anna is an ICU patient with new-onset grand mal seizures. While at her bedside, you witness a seizure. What should your first action be? A. Hit the Code Blue Button B. Hold the patient down to prevent injury C. Insert an oral airway and call for help D. Roll Anna to her right side and protect the airway 10. Jason M., an 80 year old African American male, as had a left temporal cerebral vascular accident due to uncontrolled hypertension. As the critical care nurse you know Jason is likely to have which of the following deficits? A. Receptive Aphasia B. Motor Deficits C. Balance deficits D. Expressive Aphasia GI 11. Mr. Smith, is a 46 year old male who is frequently admitted to your ICU and step down for alcohol withdrawal syndrome. Most recently he spent the last week in the ICU for alcohol- induced coma and was transferred to Medical Step Down 2 days ago. Just prior to being transferred to GMF, Mr. Smith begins projectile vomiting bright red blood. As the critical care step down nurse you should: A. Position the patient flat to facilitate intubation, call RRT and get a set of vital signs B. Obtain and insert a Linton-NachlasTube for balloon tamponade and call RRT. C. Start dopamine at 5mcg/kg/min in anticipation of hypotension secondary to the bleeding and call RRT D. Protect Airway with Aspiration Precautions/HOB 30 degrees, verify IV access, get vital signs and call RRT. 12. Liam, a 45 year old alcoholic with chronic pancreatitis, develops respiratory distress with dyspnea and pulmonary edema. These symptoms are due to which of the following? A. Bronchospasm related to stress B. Aspiration C. Pulmonary capillary endothelial damage related to release of phospholipase A2, a digestive enzyme D. Atelectasis . Renal 13. You, the critical care RN, are preparing Laura for her first peritoneal dialysis session. It is important to tell her which of the following findings is normal?l A. During the instillation phase, the insertion site may leak B. During the dwell phase, you may feel abdominal fullness and shortness of breath C. During the dwell phase, subcutaneous fluid may be seen in the groin D. During the drain phase, you may feel dizzy and have palpitations 14. Eve is undergoing hemodialysis for renal failure as a result of uncontrolled Type I Juvenile Diabetes. Her mother asks you, the critical care RN, how do you know that the dialysis is effective. Adequacy of hemodialysis is measured by which of the following? A. Urine Creatinine clearance B. Sodium, Chloride and potassium levels C. Blood Pressure D. Urea Clearance Endocrine 15. Mr. Johnny Appleseed has been admitted to your critical care unit with DKA. His serum glucose was initially 675 and his K+ = 6.0. His insulin drip is currently at 5 units/hour and NSS is at 200 ml/hr. Mr. A’s most recent FSBG = 275 and his anion gap = 25. Which changes in his care you would anticipate? A. Change the IV fluids to D5NS, continue the insulin drip, and continue FSBG every one hour and recheck BMP every 4 hours B. Change the IV fluids to D5W, continue the insulin drip, continue FSBG every one hour and give Kayexylate to lower the K+ C. Discontinue the insulin drip and change FSBG to every 4 hours D. No changes in therapy; continue as is 16. The patient was admitted with a serum glucose level of 468 mg/dL. After 2 hours of therapy with 4 units/hr of regular Humulin in normal saline via the intravenous route, the patient’s serum glucose is 400 mg/dL. Which of the following is the most appropriate nursing intervention at this time? A. Document the laboratory results and continue to monitor B. Increase the hourly insulin infusion dose by 2 units/hr C. Begin administration of intravenous insulin at 8 units/hr and continue to monitor D. Change from a regular insulin infusion to subcutaneous insulin glargine Hematology 17. For a patient with disseminated intravascular coagulopathy (DIC), the primary goal of medical treatment is to: A. Accurately administer intravenous drip heparin to prevent “using up” clotting factors B. Administer subcutaneous fibrinolytics to dissolve clots formed in the microvasculature C. Identify and treat the underlying conditions that lead to the development of DIC D. Provide supportive care as needed until the DIC subsides. 18. You are caring for a Level I trauma patient, a 20 year old male who was shot multiple times in the abdomen and chest during a failed robbery attempt. He has received multiple blood transfusions that includes 20 units of PRBCs. This patient is susceptible to which increased serum levels? A. sodium and magnesium levels B. potassium levels C. BUN and creatinine levels D. bilirubin and amylase levels Multi-System 19. Your 80 kg patient exhibits the following signs and symptoms: T = 102.6, HR = 136 bpm, BP 90/50, UO for last hour = 40 ml/hr, WBC = 10, 000, lactate = 2mmol/L and pan cultures are negative to date. You suspect that the patient has which of the following? A. Systemic Inflammatory Response Syndrome (SIRS) B. Cardiogenic Shock C. Septic Shock D. Multiple Organ Dysfunction Syndrome (MODS) 20. Which of the following patient data supports the diagnosis of multiple organ dysfunction syndrome (MODS)? A.UO = 30ml/hr, BUN = 18mg/dL, WBC = 5,120. B. Upper GI bleeding, a GCS = 15, and Hct = 25% C. A total bilirubin of 15 mg/dL, a serum creatinine of 8 mg/dL, and a platelet count (plt) of 2,300 mm3 D. A respiratory rate of 45/min, a PaCO2 of 60 mmHg, and a CXR with diffuse bilateral infiltrates Let’s Mix ‘em Up! 21. A patient transferring out of the ICU says, “Why can’t I just stay a few days longer? I don’t feel strong enough.” Which of the following is the most appropriate response? A. “There’s a very sick patient who needs this bed” B. “You sound concerned about leaving the ICU” C. “Most people do just fine after transfer” D. “Your insurance limits the time you can stay in the ICU” 22. A patient with an acute GI hemorrhage is undergoing volume resuscitation with NSS at 150 cc/hr and 2 units PRBCs. Which of the following would best indicate continued hypovolemia? A. O2 saturation of 91% B. SVO2 of 50% C. PAWP of 9 mmHg D. CVP of 5 mmHg 23. During which phase of intra renal failure should fluid intake be most severely restricted? A. Onset B. Oliguric phase C. Nonoliguric phase D. Recovery 24. In caring for a patient in hypertensive crisis, the nurse should: A. Perform care activities in clusters B. Monitor neurological status frequently C. Administer phenylephrine (Neo-Synephrine) D. Initiate verapamil (Calan) 25. Before transferring a patient to a medical-surgical unit, the nurse conducts a pretransfer physical assessment. Suddenly, the patient develops tachycardia, tachypnea, dyspnea, and generalized chest discomfort. The most likely cause of these symptoms is: A. Myocardial infarction B. Tension pneumothorax C. Pulmonary embolism D. Acute anxiety response 26. A 70 kg patient with acute respiratory distress syndrome (ARDS) is intubated and mechanically ventilated. The patient is currently on a continuous vecuronium infusion titrated to maintain 2/4 twitch . Peak inspiratory pressure is 55 cm H2O. The patient currently has a PaO2 of 60 mmHg, and the physician orders the following ventilator settings: CMV; Vt 700 ml; rate 12/min; FiO2 100%; PEEP 15 cm H2O. The nurse knows that: A. CMV is an inappropriate ventilator mode for a patient receiving vecuronium B. A tidal volume of 700 ml is inappropriate for this patient C. The PEEP should be increased to 20 cm H2O to improve oxygenation D. The ordered ventilator settings are appropriate for this patient 27. A 70 kg patient with acute respiratory distress syndrome is mechanically ventilated on the following settings: FiO2 70%, tidal volume 450 ml, rate 10/min, PEEP 20 cm H2O. On these settings, the patient’s PaO2 is 76 mmHg. The patient currently has a core temperature of 370C, heart rate of 116/min, and blood pressure of 78/58 mmHg. Which of the following interventions should the nurse now anticipate? A. Decrease PEEP to decrease intrathoracic pressure B. Administer 500 ml fluid bolus of normal saline C. Initiate a norepinephrine infusion to maintain systolic BP at least 80 mmHg D. Increase tidal volume to 700 ml 28. Your patient’s lactate/lactic acid level has risen from 2 mmol/L to 6 mmol/L 8 hours after his MVC (motor vehicle crash). You, the critical care nurse, know that this likely indicates which of the following? A. Appropriate Fluid Resuscitation B. Inadequate Tissue Perfusion C. The need to start TPN immediately D. The need to transfuse 20 units of cryoprecipitate immediately. 29. A patient’s family expresses anxiety regarding the meaning of numbers on the patient’s monitor, and asks the nurse for clarification. The nurse’s most appropriate response would be: A. “The numbers indicate when the patient is having problems” B. “The numbers help us determine the best treatment” C. “Which numbers on the monitor concern you?” D. “What don’t you understand about the monitor?” 30. A patient admitted with the diagnosis of acute coronary syndrome is in the intensive care unit on oxygen 2L/min by nasal cannula and unfractionated heparin per protocol. The patient complains of upper abdominal pain, which is described as discomfort 1 out of 10. The most appropriate initial intervention for the critical care nurse to perform would be to: A. Obtain serum troponin B. Insert a nasogastric tube C. Administer 1/150 nitroglycerin sublingual D. Obtain a 12-lead ECG 31. Acetaminophen (Tylenol) Overdose may take up to 2 weeks to resolve. From 72-96 hours from ingestion, if not treated, symptoms of ingestion will include which of the following? A Increased renal function B. Pallor, lethargy, metabolic acidosis C. RUQ pain, increased serum liver enzymes D. Jaundice, confusion, coagulation disorders 32. Your patient was admitted for a low H&H, epistaxis, and bleeding into the diaphragm. This patient is bleeding from the gums, petechiae are noted on the chest and arms. Platelets are less than 100,000. The probable diagnosis is which of the following? A. ITP B. Hemolytic Anemia C. Aplastic Anemia D. Pernicious Anemia 33. The nurse manager feels that the number of blood culture samples that have been reported by the laboratory as being contaminated is excessive. The most appropriate action for the nurse manager would be to: A. Observe the staff as they obtain blood culture samples B. Track the number of blood cultures drawn and the number that are reported as contaminated C. Hold a staff meeting and discuss the problem D. Develop a poster demonstrating the correct procedure 34. Mrs A, a 42 year old with severe Crohn’s Disease and perforation, returns from surgery with an ileostomy. Mrs. A is at greatest risk for which of the following? A. Prolapsed stoma B. Dehydration C. Hypernatremia D. Hemorrhage 35. Which of the following measures is most effective in preventing aspiration of tube feeding in an unconscious, mechanically ventilated patient? A. Provide frequent and scrupulous mouth care B. Instill blue food coloring into the feeding solution C. Keep the patient turned on the left side D. Elevate the head of the bed at 30 to 45 degrees unless medically contraindicated 36. What is the clinical presentation of a patient with a NORMAL response to the “doll’s eye” maneuver? A. Conjugate gaze in the opposite direction as the head is turned B. Nystagmus with head turn C. Conjugate gaze in the same direction as the head is turned D. Disconjugate gaze with head turn 37. On postoperative day 3, a patient (status: post roux-en-y-gastric bypass) is admitted to the ICU with a diagnosis of sepsis secondary to gastric perforation On postoperative day 5, the patient’s weight increases by 10 kg, urine output is less than 325 ml/day for the last 3 days, and there are crackles bilaterally on lung auscultation. The patient’s BP is 94/40 mmHg, HR 140 bpm, RR 38/min, CVP 22 cm H2O, PAOP 25 mmHg. The patient’s current laboratory values are: Na+ 123 mEq/L, potassium 9.2 mEq/L, phosphorus 6.0 mg/dL, calcium 4.7 mg/dL, BUN 148 mg/dL, and creatinine 7.4 mg/dL. Based on these findings, nursing management of this patient will need to include: A. Continued administration of fluid boluses B. Hemodialysis C. Continuous renal replacement therapy D. Peritoneal dialysis 38. On confirmation of a RV MI, the nurse would anticipate the following treatment plan: A. Administer fluids to maintain a PAWP > 15 mmHg B. Infuse IV nitroglycerin to keep the patient pain-free C. Administer nitroprusside to reduce afterload D. Administer furosemide to prevent heart failure 39. The daughter of a mechanically ventilated patient is to be taught how to suction. When developing a teaching plan, the nurse must first: A. Obtain written information about the procedure B. Determine a schedule for demonstrating the technique C. Assess the knowledge and skills the daughter needs to learn D. Encourage the daughter to observe the procedure on other patients 40. Which of the following nursing diagnoses would be the most appropriate for a patient who presents to your critical care unit with Guillain-Barre syndrome? A. Impaired respiratory function, impaired nutrition, acute pain B. Impaired respiratory function, impaired motor weakness, acute pain C. Impaired motor weakness, impaired bowel function, acute pain D. Impaired respiratory function, impaired bowel function, chronic pain 41. A pregnant 26-year-old woman presents with a history of progressively increasing abdominal pain over her right upper abdomen and left lower abdomen for the past 5 days, and vomiting of a primarily bile-colored fluid. Her current temperature is 110.8oF, and her only prior hospitalization was for an appendectomy when she was an adolescent. Obstetrical examination reveals gestation of 26 weeks and no problems with the active, alive fetus. As soon as the nurse inserts a nasogastric tube and initiates IV fluids, the nurse will tailor interventions for a patient with suspected: A. Ectopic pregnancy B. Abruptio placenta C. Peptic ulcer disease D. Intestinal obstruction 42. The respiratory status of a patient with chronic obstructive pulmonary disease has improved, and she is using 2L/min of oxygen via cannula. She has ben receiving steroid therapy to decrease inflammation. This morning the patient’s previously normal laboratory results reveal a serum glucose of 280 mg/dL and the following arterial blood gas results: pH 7.22, PCO2 6 mmHg, PO2 92 mmHg, and HCO3- 21 mEq/L. Which of the following interventions is warranted to manage these findings? A. IV fluid and electrolyte replacement B. Administration of 6 units of regular insulin IV bolus C. Low-dose insulin in normal saline drip D. 50 mL bicarbonate solution bolus 43. The nurse is performing an admission assessment on a patient diagnosed with diabetes insipidus. Which of the following assessment findings would the nurse expect to see in a patient with that condition? A. Elevated systolic blood pressure, tachycardia, decreased urinary output B. Elevated serum potassium, bradycardia, numbness in hands C. Polyuria, extreme thirst, decreased urinary specific gravity D. Widened pulse pressures, dilated pupils, decerebrate posturing 44. Which of the following best indicates that fluid resuscitation for hypovolemic shock has been appropriate? A. SVO2 45%, CO 3.0 L/min, SVR 800 dynes/sec/cm-5 B. SVO2 45%, CO 5.0 L/min, SVR 1900 dynes/sec/cm-5 C. SVO2 68%, CO 5.0 L/min, SVR 2100 dynes/sec/cm-5 D. SVO2 68%, CO 4.4 L/min, SVR 1100 dynes/sec/cm-5 45. Shane was aggressively treated with 0.3% hypertonic saline for profound hyponatremia. Now he is experiencing tremors, LOC changes, and paresthesias. Shane is probably developing which of the following? A. ICU psychosis B. Hyponatremia veridans C. Osmotic demyelinization syndrome D. Red cell sequestration 46. A 65 YO female with a hx of COPD is placed on the following ventilator settings for weaning: FiO2 40% VT 600 ML IMV, 8 BPM PSV 10 CM H2O Twenty minutes after the ventilator changes have been made, the nurse assesses the patient and notices diaphorsis and labored respirations. VS: 160/90-160-44-99oF (37.2oC) Which of the following is the most likely cause of the patient’s clinical condition? A. Low FiO2 B. High tidal volume C. Low tidal volume D. IMV setting 47. The nurse discusses the patient’s condition with the physician and the respiratory therapist. A decision is made to: A. Increase peep to 10 cm h20 B. Increase VT to 700 ml C. Increase PSV to 14 cm D. Switch to pressure control 48. Your hospital receives word of a mass casualty incident. You are called on to report to the ED and assist with triage. The preliminary report is that your trauma center will be receiving 60 patients. The first patient you see is a 30 year old male with multiple lacerations. He is awake, alert, c/o of pain in right chest and right upper quadrant. There is no rebound tenderness. It is confirmed that ribs 7-9 are fractured. You would suspect which of the following underlying injuries? A. Liver laceration B. Splenic laceration C. Pneumothorax D. Mesenteric Infarction 49. The second patient you see during this mass casualty is a 18 year old female who was trapped in her car for 2 hours by the steering column. She c/o left shoulder pain, left upper quadrant pain with rebound tenderness. Fire rescue listed her as stable in the field because at the car accident scene she had no rebound tenderness or guarding. She now has a pulse and heart rate of 120 bpm and confirmed 9-10 rib fractures. You suspect which of the following? A. Ruptured Pancreas B. Splenic Injury C. Lacerated Liver D. Diaphragm rupture 50. An AMI patient is in critical condition in the CCU. His significant other has been at the bedside providing reassurance and support since his admission 12 hours ago. His estranged wife arrives and demands that the significant other not be allowed to visit or be given condition updates. The nurse should: A. Ask the physician to write an order to allow the significant other to have visitation privileges B. Request a multidisciplinary care conference to discuss visitation and communication of patient status C. Contact the hospitals’ medical-legal department and request that the hospital attorney speak to the wife D. Encourage the patient to express his desire to spend time with his significant other to his wife [Show Less]