PCCN Exam 2024 Questions with Correct Answers
A cardiac patient with with DNR status is being managed medically. The nurse notes a
new cough, thick
... [Show More] yellow sputum and a temperature of 101.4 (38.4) Coarse crackles are
present in the right upper field. The nurse should most immediately anticipate
A. blood and sputum cultures followed by a broad spectrum abx
B. mucolytics and judicious IV fluid administration
C. an antyipyretic and conservative management
D. NPO status and encouragement of frequent activity ----------CORRECT ANSWER: A.
This patient symptoms are consistent with pneumonia. Management should include abx
therapy, oxygen therapy for hypoxemia, mechanical ventilation if acute respiratory
failure develops, fluid management for hydration, nutritional support, and treatment of
associated medical problems and complications.
Which of the following findings is most indicative of a ruptured aortic aneurysm
A. Back pain
B. bounding peripheral pulses
C. intermittent claudication
D. warm, flushed skin ----------CORRECT ANSWER: A. An aneurysm is the localized
dilation of an artery. Should an aneurysm rupture, blood will build up under pressure in
the tissues surrounding the aorta, which can result in acute pain and tenderness in these
areas. This is particularly the case if the aneurysm leaks from the back of the aorta.
Ruptured AAA presents with a classic triad of pain in the flank or back, hypotension and
a pulsatile abdominal mass; however, only about half of the full triad. The patient will
complain of the pain and may feel cold, sweaty and faint on standing. The patient may
also report abdominal pain. A small percentage may have vomiting
According to recommendations based on research findings, pain assessment should
occur
A. based on changes in vital signs
B. only when the patient movements indicate the patient is seeking attention
C. routinely, regardless of physical findings
D. only when the presence of pain can be validated ----------CORRECT ANSWER: C.
Pain is considered the fifth vital sign and must be assessed regularly. Presence of
physical findings may be part of the comprehensive assessment of pain. However,
physical findings may not be present in all patients with pain [Show Less]