CCRN EXAM QUESTIONS AND ANSWERS, Exams of Nursing

Download CCRN EXAM QUESTIONS AND ANSWERS and more Exams Nursing in PDF only on Docsity! CCRN EXAM QUESTIONS AND ANSWERS The nurse is caring for a patient with acute inferior wall MI, post-coronary artery stent deployment, For optimal care of the patient, the nurse should: - Answers -Continuously monitor the patient in lead II It is best practice to monitor the patient status post PCI with stent, in the lead that was most abnormal during the acute occlusion. The ECG demonstrates ST elevation in leads II, III and aVF. The nurse needs to monitor the patient closely for which of the following? - Answers -Complication likely to occur after an acute inferior wall MI include bradycardia secondary to ischemia to the SA and/or AV node, and papillary muscle rupture or dysfunction due to the anatomical distance between the RCA and the papillary muscle. Which of the following hemodynamic profiles would benefit from the aggressive fluid administration, pressers and antibiotics therapy? a. RAP: 1mm Hg; PAOP: 4 mmHg; SVR: 1800 dynes/sec; CO: 2L/min b. RAP: 5; PAOP: 7; SVR: 400; CO; 8L - Answers -B. the hemodynamic profile of RAP 5, PAOP 7, SVR 400 is typical of septic shock, and choice B would be the best approach. Which of the following is indicative of a mixed acid-base disorder? A. pH 7.18; PaCO2 25; PaO2 64; HCO3 11 B. pH 7.33; PaCO2 29; PaO2 72; HCO3 15 - Answers -The decrease in PaCO2 is evidence of respiratory alkalosis and the decreased HCO3 is evidenced of a metabolic acidosis. The pt with severe sepsis or septic shock may present with this mixed acid- base disorder. The patient with a temporary pacemaker develops pacemaker malfunction. The oriented is instructed to reposition the patient to try and correct the problem. The cardiac monitor most likely demonstrates? - Answers -Failure to capture (pacemaker without a QRS) may be corrected by repositioning the patient to the side. The patient with diastolic heart develops SVT, heart rate 220/min. The most dangerous hemodynamic effect is a decrease in: - Answers -coronary artery perfusion. Diastolic heart failure results in a problem with left ventricular FILLING secondary to ventricular thickening, and contractility and ejection are maintained in diastolic failure. The rapid heart rate will decrease filling time, worsen left ventricular filling and because coronary artery perfusion occurs during diastole, this arrhythmia may be life-threatening. The patient is receiving heparin infusion for the treatment of pulmonary embolism. There has been a 60% decrease in the platelet count and no clinical change. Which of the following is indicated? - Answers -Discontinue heparin and being argatroban. The patient most likely has HIT. Exposure to heparin needs to discontinued and a direct thrombin inhibitor started for continued anticoagulation. Which of the following is a systemic effect of the therapeutic hypothermia during the cooling phase? - Answers -Hyperglycemia secondary to insulin resistance. During the cooling phase of clinical hypothermia there is typically insulin resistance. Additionally, during the phase there is vasoconstriction, decreased neutrophil production and during rewarming, rebound hyperkalemia may occur (not during the cooling phase). The patient presented to the ED with a history of palpitations and dyspnea, persisting on and off for one week. The heart monitor shows trail fibrillation with rapid ventricular response, blood pressure 112/70. Treatment will most likely include: - Answers -CCB and anticoagulation The patient history seems to be one of intermittent atrail fibrillation over the past week. Controlling rate and addressing potential left atrial clot formation are priority treatments. Which of the following clinical findings would you expect to find in the patient with septic shock? - Answers -Lactate 8, SvO2 85 Elevated lactate is evidence of anaerobic metabolism and elevated Sv02 is evidence of decreased oxygen utilization at the cellular level - both definitive for septic shock. The patient has a massive pulmonary embolism. Which of the following would be expected? - Answers -Hypotension, increased alveolar dead space. Massive pulmonary embolism results in sudden extremely elevated pulmonary pressures with resultant right ventricular failure and decreased left ventricular pressure. The drop in CO results in hypotension. The clot obstructs pulmonary perfusion which results in increase headspace ventilation. The patient presents with left leg pain; ankle-brachial index (ABI) is 0.7. The patient would benefit from which of the following interventions? - Answers -dependent position of legs The clinical signs are indicative of peripheral arterial occlusive disease. Dependent leg position will aid perfusion. Which of the following are clinical signs of variant (Prinzmetal's) angina? - Answers -ST- elevation, resolves with nitrate therapy. Do NOT elevate the affected extremity - will decrease perfusion Meds: Thromolytics, Anticoagulants, ASA, Vasodilators Drugs that cause Prolongation of the QT interval ? - Answers -Procainamide, haloperidol, quinidine, amiodarone Electrolyte problems: hypokalemia, hypocalcemia, hypomagnesemia Pacemaker code: - Answers -First initial: Paced 2nd initial: Sensed 3rd: inhibited What is contraindicated with Diastolic heart failure? - Answers -Positive inotropes Dehydration further worsens filling Tachyarrhythmias decrease filling time and worsen symptoms Chest x-ray finding in systolic heart fx? - Answers -may be evidenced by large, dilated heart or by normal heart size on chest film. Causes of Right side heart failure? - Answers -Acute RV infarct Pulmonary Embolism Septal defects Pulmonary stenosis/regurgitation COPD Pulmonary htn Left Ventricular fx Cause of Left sided heart failure? - Answers -CAD, ischemia Myocardial infarction Cardiomyopathy Fluid overload Chronic, uncontrolled htn Aortic stenosis/insufficiency Mitral stenosis/insufficiency Cardiac tamponade IABP: Inflates and deflates when? - Answers -Inflates at the dicrotic notch of the arterial waveform, beginning of diastole Defeats right before systole begins - determined by set trigger for deflation, R wave of ECG or upstroke of the arterial pressure wave Post-Op CABG Assessment for complications of CABG: - Answers -Tamponade Pericarditis Mediastinal tubes remove what? - Answers -serosanguinous fluid from the operative site; whereas pleural chest tubes remove air, blood, or serious fluid from the pleural space. Treatment of Aneurysms: - Answers -Aneurysms less than 5cm in diameter and no symptoms: Monitor regulary - ultrasound or CT scan, treat htn: drug choice is beta blockers, which may slow growth. Thoracic aneurysms causing symptoms or greater than 6cm: Surgical repair Disection: Surgery Aggressive treatment of htn and heart rate control - labetalol drip Neuro Assessment: First sign of a neuro problem? - Answers -LOC - except for an epidural hematoma that may cause pupil changes before an LOC change. GSC Score: - Answers -15 (best) 3 (worst) If the score is 8 or less, outcome is poor Which is worse, obtunded or stuporous? - Answers -Stuporous - pt cannot speak, moan, grimace. Obtunded - can speak, mumble words. Uncle Herniation: - Answers -Lateral shift, NO initial change in LOC Most often caused by epidural hematoma that occurs in temporal area, some strokes Central Herniation: - Answers -Swelling on both sides, downward displacement of hemispheres Slight change in LOC and then coma First both pupils are small (1-3mm) then parasympathetic innervation on both sides is suppressed and both pupils dilate Treatment of Vasospasm? - Answers -Prevent vasospasm by providing CCB - nimodipine (Nimotop) 60mg q 4hrs, for aneurysmal SAH The first sign of an increase in ICP? - Answers -LOC since the "higher" centers of the brain show symptoms first and then progress down toward the brain stem. Hypotension in the presence of Elevated ICP? - Answers -Can be devastating!!! Higher MAP is better than low MAP Brain death is less 30mmHg s&s of increased ICP? - Answers -Altered LOC Restlessness/agitation Headache Pupillary changes When using the fluid-filled system, the level of the transducer should be at the? - Answers -External auditory meatus, which is at the level of the foramen of Monro Neuro Waves? - Answers -"A" are awful "B" are bad "C" are common In the presence of Elevated ICP: AVOID? - Answers -Acidosis - causes vasodilation which increases ICP Alkalosis - causes vasoconstriction which decreases flow to head. PEEP - increases thoracic pressure, prevents optimal jugular venous outflow Strategies to Lower ICP? - Answers -Decrease volume: mannitol/furosemide/3% saline, patient position (upright to facilitate venous drainage from the brain) Propofol has been demonstrated to reduce ICP by as much as 15mmHg Difference between Bacterial and Viral meningitis? - Answers -Bacterial has lower glucose Apnea test: Positive or Negative to support brain death? - Answers -Positive supports brain death. When administering sodium pentobarbital (Nembutal) to a patient with a closed-head injury, the goal is ? - Answers -Reduce cerebral metabolism This med will decrease seizure activity which are important to stop in this kind of injury. A patient with longstanding COPD is currently intubated and mechanically ventilated, has a cardiac monitor, and has an arterial line in his left radial artery. A nurse should be concerned with monitoring the ? - Answers -Telemetry for arrhythmias BUN in liver dz? - Answers -breakdown of BUN releases ammonia - so make sure patient is not dehydrated because this will lead to high levels of BUN Do you want people with liver dz to have high levels of protein? Why not? Do you want people with liver dz to have an increase in acid? - Answers -No - it leads to ammonia which will lead to hepatic encephalopathy No! Metabolic acidosis due to low BP Do you give Ringers Lactate to someone with Liver dz? - Answers -No! It cannot convert to bicarb because of the liver dz - it will convert to lactic acid Which medication do you give to someone with liver dz? - Answers -Neomycin - because it does not release ammonia, BUT it leads to Vitamin deficiency How to tell if you have hepatic failure or billiary tract dz? - Answers -Bilirubin and albumin are unconjucated until they go to the liver, where they get conjucated and go to the gallbladder. If someone has indirect or unconjucated bilirubin is it hepatic failure or billiary tract dz? - Answers -Hepatic failure Opposite would be gallbladder problem Ruptured spleen has what signs? - Answers -Kehrs sign - left shoulder pain What does diuretics do to someone with liver dz? - Answers -Lowers their potassium Pre renal failure: - Answers -kidneys are healthy, but blood is not getting down to the kidneys, so no urinary output. TX: FLUIDS or INOTROPIC DRUGS Renal stage of acute renal failure: - Answers -Kidney damage - most common cause is acute tubular necrosis Nephrotoxicity is caused by: - Answers -eating heavy metals/Meds/street drugs/ rhabdomyolysis How to tell Pre renal vs Renal? - Answers -Pre renal - needs fluids and inotropic drugs - check urinary sodium level: 20 or less is pre renal. Check BUN/Creatinine levels: BUN 20:1 or Bun of 60 and creatinine of 3 is pre renal Renal - urinary sodium level: 40 or more is renal stage. BUN/Creatinine levels: BUN 10:1 Bun of 60 and Creatine 6 is Renal Treatment for hyperkalemia ? - Answers -Calcium chloride and insulin and glucose and sodium bicarbonate The patient with oat cell carcinoma has the following clinical findings: low urine output, low serum osmolality, hyponatremia, and elevated urine sodium. The nurse anticipates which of the following as part of the treatment plan? - Answers -Phenytoin (Dilantin), 3% saline. The patient has signs of SIADH which results in production of excessive ADH. Dilantin will inhibit ADH secretion and 3% saline will increase serum sodium. Peep therapy and mechanical ventilation are ordered for the patient with acute respiratory failure. Which of the following is a possible complication? - Answers - Barotrauma The addition of positive end-expiratory pressure will increase alveolar recruitment, prevent atelectasis and improve oxygenation. However, the increase in intrathoracic pressure may lead to pneumothorax or subcutaneous emphysema. The postoperative thoracic surgery patient has bubbling in the water seal drainage chamber of the chest tube. Which of the following interventions is indicated? - Answers - avoid high airway pressures Bubbling in the water seal chamber is due to a pleural air leak, and high airway pressure will either prevent resolution of the current air leak or make it worse. Which clinical sign might patients with both systolic and diastolic heart failure have in common? - Answers -Lung crackles Both a problem with systolic (ejection problem) and diastolic (filling problem) will increase left heart pressure and cause cardiogenic pulmonary edema (lung crackles). Which of the following is most likely to result in a low Sv02? A. Hypotermia B. Fever C. Severe sepsis - Answers -Fever Fever increases metabolic rate and consumption, which may lead to a drop in mixed venous oxygen saturation. The nurse needs to assess adequacy of the tubing/catheter system for the arterial line. Which of the following interventions will best assess this? - Answers -Perform a square wave test The patient requires fluid resuscitation and 8 units of PRBC's status post traumatic injury. Which of the following interventions is most appropriate? - Answers -Warm blood products and crystalloids Warming fluids and blood needed for traumatic injury will prevent hypothermia and its related adverse effects. Which of the following therapies should be avoided for the patient with cardiogenic shock? - Answers -high dose vasopressors Vasopressors increase left ventricular after load, which would increase myocardial work of a failing heart. The patient is status post repair of an aneurysm for subarachnoid hemorrhage. Which of the following interventions is indicated to prevent vasospasm? - Answers -Nimodipine (Nimotop) is a calcium channel blocker that is started immediately post-op to prevent arterial spasm of the brain. The patient presents with a rigid abdomen, rebound tenderness, and a free air in the peritoneum seen on KUB x-ray. Which of the following should the nurse anticipate? - Answers -Powell perforation; provide fluids, prepare for surgery. The clinical signs are those of bowel perforation. Which is the priority treatment for the pt with DKA who presents with hyperglycemia, ketosis, and normal serum potassium? - Answers -replace potassium The patient with DKA will have a low pH and metabolic acidosis. In a state of metabolic acidosis, hydrogen ions move into the intracellular space. In exchange, potassium leaves the intracellular space. The movement of K into the extracellular space results in hyperkalemia. People with kidney dz always have a low what? - Answers -Calcium or high phosphate levels. This will lead to C&T signs. Low potassium levels S&S? - Answers -U wave and ST depressions Sympathetic Nervous System increases what? - Answers -Heart rate and contractility which maintains B/P Compensatory Phase of Shock: - Answers -B/P maintained Tachycardia How do you treat people with DIC? - Answers -HEPARIN, then fresh frozen plasma, then cryoprecipitate (8,13, fibrinogen) Get rid of the triggering event/cause Heparin: - Answers -Heparin inhibits the conversion of prothrombin into thrombin Heparin inactivates circulating thrombin Heparin inhibits the conversion of fibrinogen into fibrin Heparin Induced Thrombocytopenia: - Answers -In patients who do not have anti- thrombin III. Heparin may have the opposite effect, thus causing blood to clot. Idiopathic (immune) Thrombocytopenic Purpura: - Answers -In ITP antibodies form and destroy the body's platelets resulting in thrombocytopenia Etiologies: Bone Marrow does not produce enough platelets Platelets become entrapped in enlarged spleen Use or destruction of platelets increases ITP s&s - Answers -Platelets are less than 50,000 Both Hb and HCT are decreased Pallor, petchiae, purpura, ecchymoses, and oozing of blood from venipuncture sites Difference between DIC and ITP: - Answers -DIC has increased fibrin splits products whereas ITP does not Multisystem Trauma: Know what? - Answers -AMPLE a- allergies m- meds p- past illnesses l - last meal e- event preceding injury Release of what substance into the circulation secondary to retained dead fetus, abruptio placenta, and stress may cause disseminated intravascular coagulation? - Answers -Tissue thromboplastin The beneficial effects of heparin in DIC are thought to be due to its: - Answers - Neutralizing of free-circulating thrombin Complications of PEEP? - Answers -Barotrauma (rupture of lung tissue) Renal transplant acute rejection occurs within? - Answers -1-2 weeks A-sline, dicrotic notch is the closure of ? - Answers -aortic valve. ARDS...Keep patient what? Acidosis causes what? - Answers -keep patient dry (decrease fluids) Increased potassium levels A 55-year-old man has had an anterior myocardial infarction. He developed a third- degree AV heart block and required insertion of a temporary transvenous pacemaker. The pacemaker is functioning in VVI mode. The rhythm strip shows pacing spikes landing indiscriminately in relation to the patient's inherent rhythm. Which of the following would be the best action to correct the situation? - Answers -Increase the sensitivity If a nurse were to leave her unit and the hospital after deciding that staffing was inadequate, which ethical principle would be violated? - Answers -Fidelity - refers to an individual's faithfulness or loyalty to agreements and responsibilities that the individual has accepted. If you have agreed to work a shift and you do not arrive to work or you leave work before the end of your shift, you have violated the ethical principle of fidelity. Diuretics can cause both hypokalemia and metabolic alkalosis T/F? - Answers -True How would carbon dioxide levels change with an increase in minute ventilation? - Answers -PaCO2 levels would go down, and end-tidal carbon dioxide would go down. An increase in minute ventilation would increase ventilation, so the PaCO2 and the end- tidal carbon dioxide would go down. Remember that the PetCO2 is usually 1 to 5 mm Hg below the PaCO2. Acute pancreatitis causes elevations in serum amylase, serum lipase, and possibly bilirubin, whereas calcium and albumin are decreased T/F? - Answers -True The primary result of carbon monoxide poisoning is: - Answers -Hypoxia Which of the following sign or symptom is most specific to a small-bowel obstruction? - Answers -Vomiting of fecal matter Remember that time is muscle, so reperfusion is the priority. Also remember an actual problem (decreased contractility) takes priority over a potential problem (dysrhythmias) T/F? - Answers -True patient returns to the critical care unit after insertion of a transvenous pacemaker. There are pacing spikes not followed by a QRS. Which of the following is a method to facilitate capture during pacing? - Answers -Increase milliamperage Consider that failure to capture occurs when the electricity from the pacemaker does not cause depolarization of the ventricle (or atria if an atrial pacemaker). It would be logical to consider using more electricity (i.e., milliamperage). Which of the following statements about colloids is correct? - Answers -They increase intravascular colloidal oncotic pressure. She has had a craniotomy to evacuate the clot, and an intraventricular catheter was placed during surgery. While the nurse is monitoring the patient's intracranial pressure (ICP), the pressure climbs to 40 mm Hg but returns to 15 mm Hg almost immediately. This describes which of the following? - Answers -B wave Normal ICP has a pressure of 5 to 15 mm Hg. An elevation of ICP to 20 to 50 mm Hg occurring every 30 seconds to 2 minutes is a B wave. An elevation of ICP to 50 to 100 mm Hg lasting longer than 2 minutes is an A wave. An elevation of ICP to 20 to 25 mm Hg every 4 to 8 minutes is a C wave. What three things tell you heart catheter has flipped back into right ventricle? - Answers -Three things tell you that the catheter has flipped back into the right ventricle: drop in diastolic pressure, loss of dicrotic notch, and initiation of ventricular ectopy. Which of the following is the preferred lead for ST segment monitoring for a patient with a suspected left anterior descending (LAD) artery occlusion? - Answers -V3 Normal osmolality of body fluids? - Answers -275-295 Normal urine osmolality? - Answers -1.010 - 1.020 What is the biggest danger to hyponatremia? - Answers -Seizure What is the dilute urine range of DI? - Answers -1.001 - 1.005 Treatment of DI? - Answers -Give ADH (Pitressin, DDAVP) Characteristics of DKA? - Answers -Blood sugar: >250 Elevated potassium in the presence of acidosis, although total body potassium is low, it decreases as acidosis is corrected Younger/Type 1 diabetes Insulin production: No Dilators: nitrates/nitroprusside/nesiritide Morphine After load therapies: Increases? - Answers -Levo Neo High-dose dopamine Epi drip After load therapies: Decreases? - Answers -Nitroprusside ACE Hydralazine CCB IABP Nitro (high doses) Contractility therapies: Increases? - Answers -Positive Inotropes: Dobutamine Dopamine 5-10mcg/kg/min Primacor Epi drip Contractility therapies: Decreases? - Answers -Negative inotropes: Beta blockers/CCB Metabolic problems: Metabolic acidosis/endotoxins of sepsis SvO2 Increases/decreases? - Answers -Septic shock Hypothermia Paralysis Decreases: Low C/O Decreased PaO2 >02 demand (fever, shivering, seizures, increased WOB) Giant V waves is most likely caused by? - Answers -Mitral Valve Insufficiency TIA RIND Cerebral Infarct - Answers -Transient Ischemic Attack - some one has a stroke, 24hrs later they're better. Reversible Ischemic Neuro deficit - same as TIA, except it takes three about 3 months to get better. Stroke - problem is caused by basal vestibular artery. Lacking blood to brain stem. When you have a stroke - what is the goal? - Answers -Reduce cerebral edema. Give d5w Problem with the cortex? - Answers -Decorticate Brainstem problem? - Answers -Decerebrate Positive babinski in both feet - problem with what? - Answers -Problems on both sides of your head. parasympathetic innervation makes pupil what? Sympathetic innervation makes pupil what? - Answers -Pinpoint Dilates Lateral shift in the brain is called what? - Answers -uncal herniation - first change is pupil dilation on affected side. Uncal herniation - don't give this? - Answers -Mannitol - Supertorial herniation? - Answers -Whole brain is coming down - change in LOC, then dilated pupils on both sides, then hyperventilation (to decrease ICP), last thing you get is Cushings dz. Cushing Dz? Tx? - Answers -Brain is coming down through foramen magnum Widening pulse pressure (120/70, 200/70) <RESP and HR Tx: Mannitol Does acidosis increases ICP? - Answers -Yes - keep them alkalotic Do you give Dextrose or D5W to someone with ICP? - Answers -NO! Decrease protein intake Wrist restraints > ICP ICP - MAP = - Answers -CPP - normal is 70-95 Basal skull fx: - Answers -Raccoon eyes Battle signs Mastoid bone (black and blue) Leak CSF (check for glucose to confirm) Lose cranial nerve # 1 (can't smell) Bacterial vs Viral meningitis ? - Answers -Bacterial is caused by staph problem usually. Has lower glucose CSP is purulent Leukocytes present Viral is caused by entero virus or herpes virus Glucose level is normal Kernig's sign? - Answers -extend leg out and get pain in the neck. When you have a stroke - what is the goal? - Answers -