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CCRN Questions with Correctly Solved Complete
Solutions
1.A patient has had a large anterior myocardial infarction last month and developed a ventricular aneurysm. He now has episodes of ventricular tachy- cardia that are not prevented or converted with antidysrhythmic agents. An im- plantable cardioverter-defibrillator (ICD) is implanted. Four days after surgery he develops ventricular tachycardia. The ICD has delivered three shocks but has not converted the rhythm. He is pulseless and apneic. Cardiopulmonary resuscitation is in progress. What is the priority action now? A. Administer epinephrine IV. B. Administer amiodarone. C. Defibrillate. D. Reset the ICD.: Defibrillate 2.A 28-year-old woman is admitted to the critical care unit from the emergency department with a diagnosis of asthma. Her initial arterial blood gases on a 28% Venturi mask are as follows: pH 7. PaCO2 30 mm Hg HCO3 24 mEq/L PaO2 64 mm Hg Which of the following repeat arterial blood gases on 40% oxygen indicate that the patient's condition is worsening? A. pH 7.48, PaCO2 30 mm Hg, PaO2 68 mm Hg B. pH 7.46, PaCO2 32 mm Hg, PaO2 61 mm Hg
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C.
pH 7.40, PaCO2 40 mm Hg, PaO2 62 mm Hg D. pH 7.39, PaCO2 30 mm Hg, PaO2 60 mm Hg: C. pH 7.40, PaCO2 40 mm Hg, PaO2 62 mm Hg The case study shows stage II asthma. Option c shows stage III asthma. The patient is still breathing at a fast rate, but carbon dioxide is starting to be retained as evidenced by the increase of the PaCO2 into normal range. Options a and b are still stage II. Option d shows a respiratory alkalosis with a metabolic acidosis because you would have expected the pH to be in an alkalotic range with the PaCO2 of 30. 3.A patient experiencing alcohol withdrawal syndrome describes the swirls in the wallpaper as being worms. This is an example of which of the following? A. Delusion B. Hallucination C. Illusion D. Visual impairment: C. Illusion An illusion is a misperception or misinterpretation of an actual external stimulus. Illusions and hallucinations (a perception that has no actual external stimulus) are common during alcohol withdrawal syndrome. 4.A patient arrives in the emergency department with multiple gunshot wounds. He requires massive transfusion for blood loss from chest and abdominal wounds. The electrocardiogram should be observed closely for changes indicative of which of the following? A. Atrioventricular block
4 / 55 Carbon dioxide is 20 times more diffusible than oxygen. In conditions that affect diffusion but do not affect ventilation, expect the PaO2 to be decreased and the PaCO2 to be normal (or decreased in hyperventilation, as in this patient). If venti- lation were affected, such as if this patient were fatiguing, the PaCO then would increase. Driving pressure is the fraction of the gas in inspired air multiplied by the barometric pressure. Because carbon dioxide is ~0.5% of inspired air, the driving pressure would be very low. The kidney eliminates bicarbonate and hydrogen ions, but the lungs eliminate carbon dioxide. 6.A 55-year-old patient has headache, nuchal rigidity, photophobia, and pos- itive Kernig's and Brudzinski's signs. These are consistent with which of the following? A. Intracranial hemorrhage B. Subarachnoid hemorrhage C. Epidural hemorrhage D. Subdural hemorrhage: Subarachnoid hemorrhage When there is bleeding from an aneurysm, that blood irritates the meninges. The clinical presentation is very similar to meningitis. This clinical presentation is not consistent with intracranial, epidural, or subdural bleeding because the blood is not in contact with the meninges in those situations. 7.An extra heart sound preceding S1 is most likely an S4 if the stethoscope's: A. diaphragm is over the apex. B. bell is over the aortic area.
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C.
diaphragm is over the aortic area. D. bell is over the apex.: bell is over the apex.
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D.
8 / 55 D waves: A waves, or plateau waves, are spontaneous, rapid increases in pressure between 50 and 200 mm Hg that last 5 minutes or more. A waves cause cerebral ischemia and are the most clinically significant ICP waveforms. Immediate interven- tion is necessary to prevent further brain injury and herniation. A waves are Awful 10.Which of the following diagnostic tests would provide definitive evidence of a pneumothorax? A. Arterial blood gases B. Chest x-ray film C. Pulmonary function studies D. Spiral computed tomography: Chest x-ray film (Which is not really true.. but the test says so.. 11.Which of the following does not shift the oxyhemoglobin dissociation curve to the left or the right? A. Blood pH B. 2,3-diphosphoglycerate (2,3-DPG) levels C. Body temperature D. Cardiac output: Cardiac output Body temperature, body pH, PaCO2 levels, and 2,3-DPG levels affect the
10 / 55 12.Which of the following is the primary difference between a tracheostomy tube and a laryngectomy tube? A. The laryngectomy tube is longer. B. The laryngectomy tube does not have a cuff. C. Only the tracheostomy tube has an inner cannula. D. The tracheostomy tube has a larger lumen.: The laryngectomy tube does not have a cuff. A cuff is not necessary because food and fluid from the mouth can go only to the esophagus and the stomach, and air going into the laryngectomy tube can go only into the lungs. The only way this patient can aspirate is if a fistula develops because the anatomy has been surgically altered by removal of the larynx. 13.The mean QRS axis of ventricular tachycardia is most likely to be: A. normal or left axis deviation. B. right axis deviation or indeterminate axis. C. right axis deviation or left axis deviation. D. left axis deviation or indeterminate axis.: left axis deviation or indeterminate axis. Ventricular tachycardia is most likely to be left axis deviation of 30 or greater or indeterminate axis, whereas aberrancy is more likely to be normal axis or right axis deviation.
11 / 55 14.A 58-year-old man is admitted to the critical care unit with upper gas- trointestinal bleeding. He has a history of chronic renal failure. When one is
13 / 55 Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis: Metabolic acidosis The stomach is acidic, but the gastrointestinal tract below the stomach is alkaline. Pancreatic secretions are rich in bicarbonate, and these losses would cause meta- bolic acidosis. 18.A 65-year-old man was admitted 2 hours ago after coronary artery bypass grafting. He has had the following vital sign changes: Admission 2 Hours Later Blood pressure (mm Hg) 110/80 96/ Heart rate (per minute) 85 100 Right atrial pressure (RAP; mm Hg) 6 2 Pulmonary artery pressure (PAP; mm Hg) 24/12 18/ Pulmonary artery occlusive pressure (PAOP; mm Hg) 10 5 Cardiac output (L/min) 6 4 Cardiac index (L/min/m2) 3.5 2. Systemic vascular resistance index (SVRI; dynes/sec/cm5) 1920 2590 What is the most likely cause of these changes? A. Stunned myocardium B. Blood loss C. Cardiac tamponade D.
14 / 55 Intraoperative myocardial infarction: Blood loss Note that all of the volume indicators (RAP, PAP, PAOP) have decreased. The increase in SVRI is compensatory and is caused by sympathetic nervous system stimulation. Stunned myocardium and intraoperative myocardial infarction more likely would cause an increase in PAOP because of heart failure. Cardiac tamponade would cause an increase in RAP, PAP, and PAOP. 19.Provision of adequate nutrition in a malnourished patient may cause se- vere deficiency of which of the following electrolytes? A. Potassium B. Magnesium C. Calcium D. Phosphate: Phosphate This often is called refeeding syndrome. Nutritional support allows the cells to begin making more adenosine triphosphate (ATP), and phosphate supplies are depleted. The same thing happens in diabetic ketoacidosis with treatment when insulin allows glucose to move into the cell increasing production of ATP and depletion of phos- phate. 20.Which of the following would be a contraindication to the use of fibrinolytic drugs, such as recombinant tissue plasminogen activator? A. Hypotension B. Heart block C. Uncontrolled hypertension
16 / 55 mo- torcycle collision. His Glasgow Coma Scale score was 12 in the emergency department, and it is still 12 upon his admission to the neurologic intensive care unit. Both eyes are ecchymotic and swollen shut, and he has multiple abrasions on his face. Which of the following is the most likely diagnosis?
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A.
Linear skull fracture B. Basal skull fracture C. Orbital fracture D. Mandibular fracture: Basal skull fracture 23.Which leads are most helpful in differentiating ventricular tachycardia from a supraventricular tachycardia with aberrancy? A. Leads II and III B. Leads V1 and V C. Leads I and aVL D. Leads V3 and V4: Leads V1 and V Looking at the heart from either side helps to identify whether the impulse originated in one ventricle or the other. Inferior, lateral, and anterior leads have a predominantly positive QRS complex because the wave of depolarization through the heart is downward and to the left. Lead V1 is the single most helpful lead to differentiate ventricular ectopy from aberrancy. Leads V1 and V6 together are the two most helpful leads. 24.Which of the following describes the primary role of a case manager? A. Educator
19 / 55 Evaluator C. Facilitator D. Advocate: Advocate 25.A patient develops carpopedal spasm and neuromuscular irritability man- ifested by Chvostek's and Trousseau's signs. Which electrolyte imbalance should you suspect? A. Hyperkalemia B. Hypercalcemia C. Hypermagnesemia D. Hyperphosphatemia: Hyperphosphatemia The patient's signs/symptoms are associated with hypocalcemia and its reciprocal condition, hyperphosphatemia. The same signs/symptoms also are seen in hypo- magnesemia. 26.A patient with which of these conditions would have a normal serum lactate? A. Ventricular fibrillation B. Cardiogenic shock C. Severe anemia D.
20 / 55 Renal failure: Renal failure All of these will cause metabolic acidosis, but in renal failure the acidosis is related to accumulation of nonvolatile acids (e.g., urea and uric acid). Ventricular fibrillation, cardiogenic shock, and severe anemia would decrease tissue oxygen delivery, resulting in the conversion of metabolism from aerobic to anaerobic and the buildup of lactic acid. Lactic acidosis is reflected as an increase in serum lactate level. 27.A patient has a diagnosis of pulmonary embolism made by pulmonary arteriography. He now is receiving 100% oxygen via a non-rebreathing mask for 24 hours. The nurse is concerned about the possibility of oxygen toxicity. What is a common, early sign of oxygen toxicity? A. Cyanosis B. Hypercapnia C. Substernal chest pain D. Moist, productive cough: Substernal chest pain Early indications of oxygen toxicity are substernal distress, paresthesias in ex- tremities, and gastrointestinal symptoms (e.g., anorexia, nausea, vomiting, fatigue, malaise, dyspnea, and restlessness). Late indications are hypercapnia, cyanosis, decreasing compliance, increasing A:a gradient, and pulmonary edema. 28.While hyperventilation therapy was used routinely in the past for patients with neurological injury, it is now reserved for indications of acute herniation. What is the physiologic rationale for this restriction? A. The resultant vasodilation increases cerebral blood flow but increases in- tracranial volume and pressure. B.
