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CCRN Test with Accurate Solutions
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: - -Correct Answer- 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? - -Correct Answer-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 - -Correct Answer-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 - -Correct Answer-The decrease in PaCO 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? - -Correct Answer-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: - -Correct Answer-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? - -Correct Answer-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. 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? - -Correct Answer-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? - -Correct Answer- 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? - -Correct Answer-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? - -Correct Answer-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 - -Correct Answer-Fever
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: - -Correct Answer- 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? - -Correct Answer-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? - -Correct Answer-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? - -Correct Answer-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? - -Correct Answer-ST-elevation, resolves with nitrate therapy. This type of angina is thought to be due to arterial spasm at the point of coronary artery plaque, not due to plaque rupture. The ST elevation is transient because the spasm is relieved with nitrates; therefore infarction does not occur. The most specific clinical sign for the presence of brain death would include which of the following? - -Correct Answer-Absent oculocephalic reflex If eyes remain midline or turn to the side of head rotation, it is a sign of cranial nerve VIII damage and possible brain death. The apnea test is positive in the presence of brain
death; while coma is present during brain death, most patients with coma do not have brain death. The physician determines the patient has ARDS. The patient has developed refractory hypoxemia, bilateral infiltrates, and pulmonary edema on chest x-ray. What findings would be expected? a. increased lung compliance b. PAOP normal or low c. decreased cardiac output - -Correct Answer-b. The pulmonary edema of ARDS is due to lung capillary leak at normal or even low left heart pressure, unlike cariogenic pulmonary edema, which results in pulmonary edema at higher than normal left heart pressure. The patient presents one month status post gastric bypass bariatric surgery with vomiting, headache, diplopia, and memory loss. These are clinical signs of which of the following? - -Correct Answer-Malabsorption The signs and symptoms are those of malabsorption, which results in vitamin deficiency and may occur after bariatric surgery. The remaining choices are not manifested by the signs and symptoms described. Priority treatment for aortic dissection requires which of the following? - -Correct Answer-Aggressive management of hypertension and emergent surgery. Emergent surgery is essential for survival, and blood pressure control is essential preoperatively. Pain control and transfusion may be indicated, but the remaining therapies are not beneficial. Inferior MI is associated with? - -Correct Answer-RCA occlusion AV conduction disturbances: 2nd- degree Type 1, 3rd- degree heart block, Sick sinus syndrome, and sinus bradycardia Development of systolic murmur: mitral valve regurgitation secondary to papillary muscle rupture Also associated with RV infarct and posterior MI Right Ventricular Infarct S&S: What to avoid: - -Correct Answer-JVD at 45 degrees High CVP Hypotension Usually clear lungs
Pacemaker code: - -Correct Answer-First initial: Paced 2nd initial: Sensed 3rd: inhibited What is contraindicated with Diastolic heart failure? - -Correct Answer-Positive inotropes Dehydration further worsens filling Tachyarrhythmias decrease filling time and worsen symptoms Chest x-ray finding in systolic heart fx? - -Correct Answer-may be evidenced by large, dilated heart or by normal heart size on chest film. Causes of Right side heart failure? - -Correct Answer-Acute RV infarct Pulmonary Embolism Septal defects Pulmonary stenosis/regurgitation COPD Pulmonary htn Left Ventricular fx Cause of Left sided heart failure? - -Correct Answer-CAD, ischemia Myocardial infarction Cardiomyopathy Fluid overload Chronic, uncontrolled htn Aortic stenosis/insufficiency Mitral stenosis/insufficiency Cardiac tamponade IABP: Inflates and deflates when? - -Correct Answer-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: - -Correct Answer-Tamponade Pericarditis Mediastinal tubes remove what? - -Correct Answer-serosanguinous fluid from the operative site; whereas pleural chest tubes remove air, blood, or serious fluid from the pleural space.
Treatment of Aneurysms: - -Correct Answer-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? - -Correct Answer-LOC - except for an epidural hematoma that may cause pupil changes before an LOC change. GSC Score: - -Correct Answer-15 (best) 3 (worst) If the score is 8 or less, outcome is poor Which is worse, obtunded or stuporous? - -Correct Answer-Stuporous - pt cannot speak, moan, grimace. Obtunded - can speak, mumble words. Uncle Herniation: - -Correct Answer-Lateral shift, NO initial change in LOC Most often caused by epidural hematoma that occurs in temporal area, some strokes Central Herniation: - -Correct Answer-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? - -Correct Answer-Prevent vasospasm by providing CCB - nimodipine (Nimotop) 60mg q 4hrs, for aneurysmal SAH The first sign of an increase in ICP? - -Correct Answer-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? - -Correct Answer-Can be devastating!!! Higher MAP is better than low MAP Brain death is less 30mmHg s&s of increased ICP? - -Correct Answer-Altered LOC
Strategies to Lower ICP? - -Correct Answer-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? - -Correct Answer-Bacterial has lower glucose Apnea test: Positive or Negative to support brain death? - -Correct Answer-Positive supports brain death. When administering sodium pentobarbital (Nembutal) to a patient with a closed-head injury, the goal is? - -Correct Answer-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? - -Correct Answer-Telemetry for arrhythmias A patient with a history of HTN and renal failure reports a headache: BP: is 210/126 HR: 106 RR: 22 - Which drug is the preferred choice? - -Correct Answer-Labetalol (Trandate) is the drug of choice. giving Nitroprusside would be bad due to patient having renal failure. A patient with an inferior wall MI has sinus bradycardia with a BP 110/70 and HR 52. A nurse should plan to? - -Correct Answer-Continue to monitor vital signs A patient is at the highest risk of developing aspiration pneumonia? - -Correct Answer- Pt with endotracheal intubation with nasogastric tube Which of the following physiological changes should a nurse anticipate when caring for a postoperative pt with morbid obesity? - -Correct Answer-Decreased functional residual capacity Which fluid is the initial treatment for severe DKA? - -Correct Answer-IV fluids 0.9% Which of the following complicating factors is the most crucial in the care of a critically ill patient with CKD? - -Correct Answer-Volume status, electrolyte imbalance, and vascular access A pt with a diagnosis of small bowel obstruction has a Miller-Abbott tube in place. A nurse's first priority in the management of this tube is to? - -Correct Answer-Connect the tube to low intermittent suction
A pt who is suspected to have developing SIRS, a nurse should monitor for? - -Correct Answer-WBC of 14,000 and HR 123 Leukocytosis and tachycardia, along with hyper/hypothermia and tachypnea, are the defining criteria for SIRS ABG of early STATUS ASTHMATICUS? - -Correct Answer-Respiratory Alkalosis Lab values of increased INR, PTT, and FSP. Hgb, platelets, and fibrinogen are decreased. These values indicate what? - -Correct Answer-DIC The goal of permissive hypothermia is to do what? - -Correct Answer-decrease the ICP 15 or less. Higher readings exert pressure on the structures of the brain and impede adequate blood flow to the brain. During resuscitation phase of caring for a patient with a liver injury from acute abdominal blunt force trauma, the focus should be to? - -Correct Answer-stabilize hemodynamics What lab value is consistent with Rhabdomyolysis? - -Correct Answer-hyperkalemia and hypocalcemia Is pulmonary fibrosis related to Status Asthmaticus? - -Correct Answer-PF is generally idiopathic and unrelated to Status Asthmaticus Which of the following alterations in pulmonary status is most likely to occur in a pt with status asthmaticus? - -Correct Answer-Hyperinflation Which acid-base problem is mostly seen in pts with renal failure? - -Correct Answer- metabolic acidosis A pt develops extreme dyspnea, anxiety and coughing, with expectoration of pink frothy sputum. Also has s3 gallop. What do you think this is? - -Correct Answer-Pulmonary edema Use of histamine blockers can increase the risk of? - -Correct Answer-nosocomial pneumonia A patient with a history of a-fib developed arm weakness, blurred vision, and facial droop 5 hours ago. What should the nurse initially anticipate? - -Correct Answer-a non- contrast CT scan to determine if it is ischemic or hemorrhagic stroke What signs would indicate that the pt is not tolerating the ventriculostomy? - -Correct Answer-Leakage from the ventriculostomy site.
Opposite would be gallbladder problem Ruptured spleen has what signs? - -Correct Answer-Kehrs sign - left shoulder pain What does diuretics do to someone with liver dz? - -Correct Answer-Lowers their potassium Pre renal failure: - -Correct Answer-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: - -Correct Answer-Kidney damage - most common cause is acute tubular necrosis Nephrotoxicity is caused by: - -Correct Answer-eating heavy metals/Meds/street drugs/ rhabdomyolysis How to tell Pre renal vs Renal? - -Correct Answer-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? - -Correct Answer-Calcium chloride and insulin and glucose and sodium bicarbonate People with kidney dz always have a low what? - -Correct Answer-Calcium or high phosphate levels. This will lead to C&T signs. Low potassium levels S&S? - -Correct Answer-U wave and ST depressions Sympathetic Nervous System increases what? - -Correct Answer-Heart rate and contractility which maintains B/P Compensatory Phase of Shock: - -Correct Answer-B/P maintained Tachycardia Skin pale, cool (except in early sepsis) Progressive Phase of Shock: - -Correct Answer-Hypotension Clammy, mottled skin Further change in LOC
Refractory Phase of Shock: - -Correct Answer-Multisystem organ dysfunction Hypovolemic Shock effects on pulse pressure: - -Correct Answer-NARROW pulse pressure Systolic decreases, diastolic maintains or elevates Do you give pressors for Hypovolemic shock? - -Correct Answer-No! SVR is already high due to compensatory mechanism SIRS criteria: - -Correct Answer-Must have 2 or more of the following: Temp > 38C or < 36C Heart rate > 90 Resp > 20 bpm WBC > 12,000 or < 4,000 OR bands > 10% (shift to the left) Sepsis clinical manifestations: - -Correct Answer-must include 2 or more of the SIRS criteria plus a documented infection (culture) or suspected infection. Suspected infection is the presence of one or more of the following: *positive culture results from blood, sputum, urine, etc. *receiving antibiotic, anti fungal, or other anti-infective therapy *altered mental status in elderly *possible pneumonia (infiltrate on chest radiograph) Severe Sepsis: - -Correct Answer-sepsis PLUS markers of organ dysfunction. Examples of organ dysfunction: Hypotension Acute hypoxemia Lactate greater than 2 Platelets below 100, Septic shock: - -Correct Answer-septic shock is severe sepsis plus one of the following: *Systemic MAP < 65mmHg despite adequate fluid resuscitation *Maintaining the MAP>65 requires a pressor, e.g., levo, dopamine, epi. S&S of early Septic Shock: S&S of late Septic Shock: - -Correct Answer-Tachycardia, bounding pulse B/P normal or low Skin warm, flushed Respirations deep, somewhat fast Fever (temp>38C) Hypotension Tachycardia, pulse weak and thready
Heparin: - -Correct Answer-Heparin inhibits the conversion of prothrombin into thrombin Heparin inactivates circulating thrombin Heparin inhibits the conversion of fibrinogen into fibrin Heparin Induced Thrombocytopenia: - -Correct Answer-In patients who do not have anti-thrombin III. Heparin may have the opposite effect, thus causing blood to clot. Idiopathic (immune) Thrombocytopenic Purpura: - -Correct Answer-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 - -Correct Answer-Platelets are less than 50, Both Hb and HCT are decreased Pallor, petchiae, purpura, ecchymoses, and oozing of blood from venipuncture sites Difference between DIC and ITP: - -Correct Answer-DIC has increased fibrin splits products whereas ITP does not Multisystem Trauma: Know what? - -Correct Answer-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? - - Correct Answer-Tissue thromboplastin The beneficial effects of heparin in DIC are thought to be due to its: - -Correct Answer- Neutralizing of free-circulating thrombin Complications of PEEP? - -Correct Answer-Barotrauma (rupture of lung tissue) Renal transplant acute rejection occurs within? - -Correct Answer-1-2 weeks A-sline, dicrotic notch is the closure of? - -Correct Answer-aortic valve.
ARDS...Keep patient what? Acidosis causes what? - -Correct Answer-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? - -Correct Answer-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? - -Correct Answer-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? - -Correct Answer- True How would carbon dioxide levels change with an increase in minute ventilation? - - Correct Answer-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? - -Correct Answer-True The primary result of carbon monoxide poisoning is: - -Correct Answer-Hypoxia Which of the following sign or symptom is most specific to a small-bowel obstruction? - - Correct Answer-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? - -Correct Answer-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? - -Correct Answer-Increase milliamperage
Tx for DKA: - -Correct Answer-Insulin, fluids 0.9 saline, 0.45 saline (if sodium high and B/P normal or high) Decrease blood sugar by 50-100 mg/hr Add dextrose to IV fluids after serum glucose reaches - 250mg Continue insulin infusion until acidosis is resolved Characteristics of HHNK: - -Correct Answer-Older Type 2 diabetes Pancreatitis
600 blood sugar Insulin production: Yes Serum K: Often elevated due to insulin deficiency Tx for HHNK: - -Correct Answer-Fluids, insulin 0.9 saline Decrease blood sugar by 50-100mg/hr Add dextrose to IV fluids Definitive test for DIC: - -Correct Answer-FSP Normal: < Fibrinogen is 200- Tx for DIC: - -Correct Answer-Eliminate the cause Vit K Platelets FFP (Fresh frozen plasma) Cryoprecipitate Heparin (low dose) is controversial so may not see it on test. S&S of HIT: - -Correct Answer-Platelets < 150,000 or drop 30% to 50% Early sign - PETECHIAE Clots may lead to PE, MI, stroke, amputation Tx for HIT: - -Correct Answer-Stop HEPARIN (fractionated as well as unfractionated)
Test for presence of heparin antibodies, ELISA, but do not wait for test results to stop heparin and start treatment Start warfarin Platelets < 10,000, monitor for changes in LOC (intracranial bleed) What is decreased in Cardiogenic shock: - -Correct Answer-BP CI/CO SvO Everything else is increased: RAP/PAOP/PAP/SVR/PVR What is increased in hypovolemic shock? - -Correct Answer-SVR Everything else is decreased What is increased in Septic shock (early)? - -Correct Answer-CO/CI/SV/SvO What is increased in Septic shock (late)? - -Correct Answer-Just SVR and maybe PAOP What is decreased in pulmonary edema? - -Correct Answer-CO/CI/SV/SvO What does dopamine do in medium (4-10) dose and high (11-20) dose do? Also, Levo/Neo and EPI doses? - -Correct Answer-It increases everything: B/P CO/CI SVR/PVR HR PAP/RAP/PAOP What does Nitro do? - -Correct Answer-It decreases everything except in cases of high dosage which could increase CO/CI/HR indirectly by decreasing Afterload What does Dobutamine do? - -Correct Answer-It decreases PAOP/SVR It increases CO/CI/HR Preload therapies: Increases? - -Correct Answer-Volume expanders: Crystalloids Colloids Pressors Preload therapies: Decreases? - -Correct Answer-Diuretics Dilators: nitrates/nitroprusside/nesiritide Morphine
