CCRN (Adult) Certification Exam — Questions and Answers

Question 1: A critical care nurse is performing a neurological assessment on a patient with a large epidural hematoma. The nurse notes the development of a fixed and dilated pupil on the right side, bradycardia, and systolic hypertension. These findings are most indicative of which neurological emergency?

Central neurogenic hyperventilation.
Onset of a generalized tonic-clonic seizure.
Development of cerebral salt wasting.
Uncal herniation with brainstem compression. (Correct answer)

Correct answer: Uncal herniation with brainstem compression.

The triad of bradycardia, systolic hypertension (with a widening pulse pressure), and an abnormal respiratory pattern (not always present) is known as Cushing's triad, a late sign of severely increased ICP. When combined with a unilateral fixed and dilated pupil (ipsilateral to the lesion), it strongly suggests uncal herniation, where the uncus of the temporal lobe shifts downward, compressing the third cranial nerve (oculomotor) and the brainstem. This is a life-threatening emergency requiring immediate intervention.

Question 2: The thermodilution method for measuring cardiac output can be falsely elevated by:

Slow injection technique
A large left-to-right shunt
Tricuspid regurgitation
Injectate volume less than required (Correct answer)

Correct answer: Injectate volume less than required

Too little injectate produces a smaller temperature change, falsely indicating higher output.

Question 3: Which finding is an absolute contraindication to fibrinolytic therapy?

Age over 75
Controlled hypertension
Current anticoagulant use
Recent ischemic stroke within 3 months (Correct answer)

Correct answer: Recent ischemic stroke within 3 months

Recent ischemic stroke within 3 months is an absolute contraindication due to high bleeding/conversion risk.

Question 4: A patient with severe sepsis begins bleeding from venipuncture sites and around their central line. Laboratory results show a platelet count of 45,000/mm³, prolonged PT and aPTT, a fibrinogen level of 80 mg/dL, and an elevated D-dimer. These findings are most indicative of which hematologic complication?

Vitamin K Deficiency
Heparin-Induced Thrombocytopenia (HIT)
Thrombotic Thrombocytopenic Purpura (TTP)
Disseminated Intravascular Coagulation (DIC) (Correct answer)

Correct answer: Disseminated Intravascular Coagulation (DIC)

Disseminated Intravascular Coagulation (DIC) is a complex syndrome characterized by widespread systemic activation of coagulation, leading to the formation of microthrombi and consumption of clotting factors and platelets. This consumptive coagulopathy results in the paradoxical combination of thrombosis and hemorrhage. The lab profile presented—thrombocytopenia, prolonged clotting times, low fibrinogen, and elevated D-dimer (a fibrin degradation product)—is the classic presentation of DIC, especially in the context of sepsis.

Question 5: A patient with acute decompensated heart failure has an SpO2 of 84% and crackles throughout. What is the priority intervention?

Administer a fluid bolus
Place the patient flat
Start a beta-blocker
Provide supplemental oxygen and consider noninvasive positive pressure ventilation (Correct answer)

Correct answer: Provide supplemental oxygen and consider noninvasive positive pressure ventilation

Oxygenation and positive pressure ventilation improve gas exchange and reduce preload in acute pulmonary edema.

Question 6: A patient is intubated and mechanically ventilated for Acute Respiratory Distress Syndrome (ARDS). The ventilator settings are: FiO2 0.8, PEEP 12 cm H2O, Tidal Volume 350 mL, and Respiratory Rate 22 breaths/min. The most recent PaO2 is 70 mmHg. What is the patient's PaO2/FiO2 (P/F) ratio?

112
314
87.5 (Correct answer)
250

Correct answer: 87.5

The PaO2/FiO2 (P/F) ratio is calculated by dividing the PaO2 by the FiO2 (expressed as a decimal). In this case, PaO2 = 70 mmHg and FiO2 = 0.8. Therefore, the calculation is 70 / 0.8 = 87.5. This value indicates severe ARDS.

Question 7: A patient with diabetic ketoacidosis has a serum potassium of 5.8 mEq/L. Why must potassium be monitored closely during insulin therapy?

Insulin raises serum potassium
Potassium does not change with insulin
Insulin drives potassium into cells, causing rapid hypokalemia (Correct answer)
Insulin causes potassium retention by the kidneys

Correct answer: Insulin drives potassium into cells, causing rapid hypokalemia

Insulin shifts potassium intracellularly, so serum levels can fall quickly during DKA treatment.

Question 8: A post-operative patient has a sudden drop in blood pressure, tachycardia, and cool clammy skin. Which type of shock is most likely?

Hypovolemic shock (Correct answer)
Cardiogenic shock from tamponade
Neurogenic shock
Anaphylactic shock

Correct answer: Hypovolemic shock

Hemorrhage causing hypovolemia presents with hypotension, tachycardia, and cool clammy skin.

Question 9: A widened alveolar-arterial (A-a) oxygen gradient with hypoxemia suggests which mechanism?

High altitude exposure
Low inspired oxygen concentration
Pure hypoventilation
Ventilation-perfusion mismatch or shunt (Correct answer)

Correct answer: Ventilation-perfusion mismatch or shunt

A widened A-a gradient indicates a gas-exchange problem such as V/Q mismatch, shunt, or diffusion impairment.

Question 10: A patient with severe acute pancreatitis develops sudden, severe flank pain and ecchymosis around the left flank. The nurse recognizes this finding as Grey Turner's sign. This sign is indicative of which life-threatening complication?

Ruptured pancreatic pseudocyst
Retroperitoneal hemorrhage (Correct answer)
Peripancreatic abscess formation
Splenic vein thrombosis

Correct answer: Retroperitoneal hemorrhage

Grey Turner's sign (flank ecchymosis) and Cullen's sign (periumbilical ecchymosis) are clinical signs of retroperitoneal hemorrhage. In severe acute pancreatitis, inflammatory and enzymatic processes can erode blood vessels, leading to significant bleeding into the retroperitoneal space.

Question 11: Which finding would be an absolute contraindication to IV thrombolytic therapy in an ischemic stroke patient?

Blood glucose of 110 mg/dL
Age of 70 years
Active internal bleeding (Correct answer)
Blood pressure of 150/90 mmHg

Correct answer: Active internal bleeding

Active internal bleeding is an absolute contraindication because thrombolytics greatly worsen hemorrhage.

Question 12: A 68-year-old patient is admitted from the emergency department with a diagnosis of community-acquired pneumonia. The patient has a temperature of 38.9°C, heart rate of 120 bpm, respiratory rate of 28/min, and a blood pressure of 88/50 mmHg. According to the Surviving Sepsis Campaign's Hour-1 Bundle, which of the following is a priority intervention?

Administer broad-spectrum antibiotics. (Correct answer)
Insert a pulmonary artery catheter.
Obtain a procalcitonin level.
Administer low-dose corticosteroids.

Correct answer: Administer broad-spectrum antibiotics.

The Surviving Sepsis Campaign Hour-1 Bundle emphasizes five critical, time-sensitive interventions: 1) Measure lactate level, 2) Obtain blood cultures, 3) Administer broad-spectrum antibiotics, 4) Begin rapid administration of crystalloid fluids for hypotension or high lactate, and 5) Apply vasopressors if hypotensive during or after fluid resuscitation. Administering antibiotics as soon as possible, ideally within the first hour of recognition, is a cornerstone of treatment to control the source of infection and has been shown to improve survival. The other options are not initial priorities in the first hour; procalcitonin is a diagnostic aid, a PA catheter is an advanced monitoring tool not used for initial resuscitation, and corticosteroids are considered later for refractory shock.

Question 13: A patient is diagnosed with brain death. Which finding is consistent with this diagnosis?

Absent brainstem reflexes including no corneal or gag response (Correct answer)
Spontaneous respirations on apnea testing
Reactive pupils to light
Decorticate posturing to pain

Correct answer: Absent brainstem reflexes including no corneal or gag response

Brain death requires absence of all brainstem reflexes, including corneal, gag, and pupillary responses.

Question 14: Which component of the 'lethal triad' of trauma worsens as a result of large-volume crystalloid resuscitation?

Hypercoagulability
Hypothermia and coagulopathy (Correct answer)
Alkalosis
Hyperthermia

Correct answer: Hypothermia and coagulopathy

The lethal triad is hypothermia, acidosis, and coagulopathy, all aggravated by excessive crystalloid.

Question 15: A patient with a TBI suddenly develops polyuria with dilute urine, hypernatremia, and rising serum osmolality. Which condition is most likely?

Acute tubular necrosis
Diabetes insipidus (Correct answer)
Cerebral salt wasting
SIADH

Correct answer: Diabetes insipidus

Diabetes insipidus causes large volumes of dilute urine with hypernatremia from ADH deficiency.

Question 16: What is the priority intervention for a neutropenic patient who develops a fever of 38.5C?

Obtain cultures and start broad-spectrum antibiotics promptly (Correct answer)
Place the patient in droplet isolation only
Administer acetaminophen and recheck in 4 hours
Hold all antibiotics until culture results return

Correct answer: Obtain cultures and start broad-spectrum antibiotics promptly

Neutropenic fever is an emergency requiring blood cultures and empiric broad-spectrum antibiotics within an hour to prevent sepsis.

Question 17: In treating PEA, identifying and reversing underlying causes is essential. Which is a common reversible cause?

Hypovolemia (Correct answer)
Hyperthyroidism
Hypernatremia
Hypercalcemia

Correct answer: Hypovolemia

Hypovolemia is one of the reversible 'H's' causing PEA and is treated with volume resuscitation.

Question 18: A patient in septic shock remains hypotensive after adequate fluid resuscitation. Which vasopressor is the recommended first-line agent?

Vasopressin
Phenylephrine
Norepinephrine (Correct answer)
Dopamine

Correct answer: Norepinephrine

Norepinephrine is the first-line vasopressor for septic shock per current guidelines.

Question 19: A ventilated patient suddenly desaturates with absent breath sounds on the right and tracheal deviation to the left. The priority action is:

Increase the FiO2 and observe
Order a routine chest x-ray and wait
Needle decompression for tension pneumothorax (Correct answer)
Administer a bronchodilator

Correct answer: Needle decompression for tension pneumothorax

Tracheal deviation with unilateral absent breath sounds and desaturation indicates a tension pneumothorax requiring immediate decompression.

Question 20: A 12-lead ECG demonstrates a short PR interval, a slurring at the beginning of the QRS (delta wave), and a wide QRS complex. This pattern is characteristic of:

Regular sawtooth atrial flutter pattern
First-degree AV block with aberrant conduction
Wolff-Parkinson-White (WPW) syndrome (Correct answer)
Multifocal atrial tachycardia

Correct answer: Wolff-Parkinson-White (WPW) syndrome

WPW is identified by the triad of a short PR interval, delta wave (pre-excitation slurring), and widened QRS caused by an accessory pathway bypassing the AV node.

Question 21: Which lung-protective tidal volume target is recommended for a patient with ARDS?

6 mL/kg of predicted body weight (Correct answer)
15 mL/kg of predicted body weight
12 mL/kg of actual body weight
3 mL/kg of predicted body weight

Correct answer: 6 mL/kg of predicted body weight

Low tidal volume ventilation at 6 mL/kg predicted body weight reduces ventilator-induced lung injury.

Question 22: A patient with esophageal varices is actively bleeding. Which medication reduces portal pressure?

Dopamine
Octreotide (Correct answer)
Norepinephrine
Heparin

Correct answer: Octreotide

Octreotide causes splanchnic vasoconstriction, lowering portal pressure and reducing variceal bleeding.

Question 23: A persistently low SvO2 (45%) most likely reflects:

Increased oxygen extraction from inadequate delivery (Correct answer)
A wedged catheter
Sepsis with impaired extraction
Excess supplemental oxygen

Correct answer: Increased oxygen extraction from inadequate delivery

Low SvO2 indicates tissues are extracting more oxygen because delivery is inadequate.

Question 24: A patient with thrombotic thrombocytopenic purpura (TTP) presents with the classic pentad. Which finding is part of it?

Hypernatremia
Hypercalcemia
Microangiopathic hemolytic anemia (Correct answer)
Hyperglycemia

Correct answer: Microangiopathic hemolytic anemia

TTP features microangiopathic hemolytic anemia, thrombocytopenia, neurologic changes, renal dysfunction, and fever.

Question 25: A competent patient refuses a recommended dialysis treatment. What is the nurse's primary ethical obligation?

Respect the patient's autonomous decision after ensuring informed understanding (Correct answer)
Notify the family to override the decision
Proceed with treatment to preserve life
Have the patient declared incompetent

Correct answer: Respect the patient's autonomous decision after ensuring informed understanding

Autonomy requires respecting a competent patient's informed refusal of treatment.

Question 26: During an active generalized tonic-clonic seizure, which nursing action is the priority?

Protect the airway and prevent injury (Correct answer)
Restrain the extremities firmly
Insert a bite block between the teeth
Administer oral fluids

Correct answer: Protect the airway and prevent injury

Maintaining the airway and preventing injury are the priorities during an active seizure.

Question 27: Oxygen delivery (DO2) to the tissues depends primarily on cardiac output and:

Systemic vascular resistance
Central venous pressure
Heart rate alone
Arterial oxygen content (Correct answer)

Correct answer: Arterial oxygen content

DO2 equals cardiac output multiplied by arterial oxygen content.

Question 28: A heart failure patient's BNP is markedly elevated. What does this indicate?

Myocardial ischemia
Pulmonary embolism
Increased ventricular wall stretch and volume overload (Correct answer)
Renal failure

Correct answer: Increased ventricular wall stretch and volume overload

BNP is released in response to ventricular stretch, so elevation reflects volume overload and heart failure severity.

Question 29: Which component of the ABCDEF bundle specifically addresses family engagement and empowerment?

B — Breathing trials
D — Delirium assessment
F — Family engagement and empowerment (Correct answer)
A — Assess and manage pain

Correct answer: F — Family engagement and empowerment

The 'F' in the ABCDEF bundle stands for Family Engagement and Empowerment, recognizing family as partners in care to reduce patient distress and delirium.

Question 30: A patient with acute kidney injury has a fractional excretion of sodium (FENa) less than 1%. What does this suggest?

Postrenal obstruction
Prerenal cause (Correct answer)
Acute tubular necrosis
Glomerulonephritis

Correct answer: Prerenal cause

A FENa below 1% indicates sodium retention from a prerenal cause such as hypoperfusion.

Question 31: The underlying pathophysiology that drives MODS in sepsis is primarily:

Isolated electrolyte imbalance
Dysregulated systemic inflammation and microcirculatory failure (Correct answer)
A localized bacterial abscess
Pure cardiogenic pump failure

Correct answer: Dysregulated systemic inflammation and microcirculatory failure

Uncontrolled inflammation and impaired microcirculation cause widespread organ injury.

Question 32: A 68-year-old male with a history of COPD is brought to the emergency department with increased shortness of breath, wheezing, and purulent sputum. His ABG reveals: pH 7.28, PaCO2 65 mmHg, PaO2 58 mmHg, HCO3 28 mEq/L. Which intervention should the critical care nurse anticipate as the most appropriate initial treatment?

Administration of high-flow oxygen via a non-rebreather mask
Non-invasive positive pressure ventilation (NIPPV) (Correct answer)
Immediate endotracheal intubation and mechanical ventilation
Intravenous sodium bicarbonate administration

Correct answer: Non-invasive positive pressure ventilation (NIPPV)

Non-invasive positive pressure ventilation (NIPPV) is the recommended first-line therapy for hypercapnic respiratory failure secondary to a COPD exacerbation. It helps decrease the work of breathing, improve gas exchange, and has been shown to reduce the need for intubation and mortality. Immediate intubation is reserved for patients who fail NIPPV, have contraindications, or are in respiratory arrest. High-flow oxygen could worsen hypercapnia, and sodium bicarbonate does not address the underlying ventilatory problem.

Question 33: A nurse caring for a stroke patient should screen for which complication before allowing oral intake?

Hyperglycemia
Dysphagia (Correct answer)
Atrial fibrillation
Deep vein thrombosis

Correct answer: Dysphagia

A swallow screen detects dysphagia, preventing aspiration in stroke patients.

Question 34: A patient with hemophilia A is bleeding. Which factor must be replaced?

Factor VII
Factor XIII
Factor IX
Factor VIII (Correct answer)

Correct answer: Factor VIII

Hemophilia A is a deficiency of factor VIII, which must be replaced to control bleeding.

Question 35: Which of the following findings is most consistent with a diagnosis of Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?

Serum sodium 125 mEq/L, decreased urine osmolality, signs of dehydration
Serum sodium 150 mEq/L, serum osmolality 315 mOsm/kg, polyuria
Serum sodium 138 mEq/L, urine specific gravity 1.002, intense thirst
Serum sodium 122 mEq/L, serum osmolality 260 mOsm/kg, urine specific gravity 1.030 (Correct answer)

Correct answer: Serum sodium 122 mEq/L, serum osmolality 260 mOsm/kg, urine specific gravity 1.030

SIADH is characterized by excessive ADH release, leading to renal water retention. This causes dilutional hyponatremia (low serum sodium), low serum osmolality, and the excretion of inappropriately concentrated urine (high urine specific gravity and high urine osmolality) in a euvolemic state. [9, 35] The other options describe dehydration/DI (A and C) or are contradictory (D).

Question 36: Which finding suggests that a trauma patient is progressing from compensated to decompensated shock?

Improving mental status
Slowing heart rate to normal
Rising blood pressure
Narrowing pulse pressure with falling blood pressure (Correct answer)

Correct answer: Narrowing pulse pressure with falling blood pressure

A narrowing pulse pressure followed by falling blood pressure signals failing compensation and decompensated shock.

Question 37: An intra-aortic balloon pump should inflate at which point in the cardiac cycle?

During systolic ejection
At the dicrotic notch (onset of diastole) (Correct answer)
During the QRS complex
At end-diastole

Correct answer: At the dicrotic notch (onset of diastole)

Inflation at the dicrotic notch augments diastolic coronary perfusion.

Question 38: A high CVP with hypotension, jugular venous distension, and muffled heart sounds suggests:

Cardiac tamponade (Correct answer)
Hypovolemic shock
Septic shock
Anaphylaxis

Correct answer: Cardiac tamponade

Beck's triad of elevated venous pressure, hypotension, and muffled heart sounds defines tamponade.

Question 39: What is the definitive treatment for thrombotic thrombocytopenic purpura?

Platelet transfusion
Splenectomy as first line
High-dose heparin
Plasma exchange (plasmapheresis) (Correct answer)

Correct answer: Plasma exchange (plasmapheresis)

Plasma exchange removes autoantibodies and replaces ADAMTS13, and is the urgent treatment of choice for TTP.

Question 40: What is the primary physiologic benefit of applying PEEP?

Recruiting collapsed alveoli to improve oxygenation (Correct answer)
Increasing cardiac output
Lowering arterial CO2
Decreasing airway resistance

Correct answer: Recruiting collapsed alveoli to improve oxygenation

PEEP keeps alveoli open at end-expiration, increasing functional residual capacity and improving oxygenation.

Question 41: A postoperative neurosurgical patient develops urine output of 800 mL/hr with rising serum sodium. What condition should the nurse suspect?

Cerebral salt wasting with hyponatremia
Diabetes insipidus (Correct answer)
Acute kidney injury
SIADH

Correct answer: Diabetes insipidus

High-volume dilute urine with hypernatremia after pituitary/brain surgery strongly suggests central diabetes insipidus.

Question 42: Cardiac index is calculated by dividing cardiac output by:

Mean arterial pressure
Heart rate
Body surface area (Correct answer)
Body weight

Correct answer: Body surface area

Cardiac index normalizes cardiac output to body surface area for comparison across patients.

Question 43: Which of the following is NOT the most appropriate first intervention if a patient is suspected of having an episode of acute hypoglycemia?

Give the patient a ½ glass of orange juice.
Draw a STAT blood glucose level. (Correct answer)
Give the patient IV dextrose or IM glucagon.
Check the blood glucose with a glucometer.

Correct answer: Draw a STAT blood glucose level.

In a suspected acute hypoglycemic episode, the immediate priority is to rapidly raise the patient's blood glucose level to prevent neurological damage. Administering oral glucose (like orange juice) or IV/IM glucose is the first therapeutic intervention. While checking blood glucose with a glucometer is important for rapid confirmation, drawing a STAT lab blood glucose delays critical treatment and is not the most appropriate first intervention.

Question 44: Fidelity as an ethical principle refers to:

Distributing resources fairly
Avoiding harm
Telling the truth
Keeping commitments and promises to the patient (Correct answer)

Correct answer: Keeping commitments and promises to the patient

Fidelity is the duty to remain faithful to commitments made to patients.

Question 45: A RASS score of -2 indicates which level of sedation?

Alert and calm
Moderate sedation — movement or eye opening without eye contact (Correct answer)
Light sedation — briefly awakens to voice
Deep sedation — no response to voice

Correct answer: Moderate sedation — movement or eye opening without eye contact

A RASS of -2 indicates light sedation, where the patient briefly awakens (eye opening and contact) to voice for less than 10 seconds.

Question 46: The nurse is caring for a patient on mechanical ventilation when the low-pressure alarm sounds. The nurse assesses the patient and finds them with a decreased level of consciousness and diminished breath sounds on the left side. Which of the following is the most likely cause?

The patient is biting the endotracheal tube.
There is a mucus plug in the mainstem bronchus.
The ventilator tubing has become disconnected from the endotracheal tube. (Correct answer)
The patient has developed a tension pneumothorax.

Correct answer: The ventilator tubing has become disconnected from the endotracheal tube.

A low-pressure alarm indicates a loss of pressure in the ventilator circuit. The most common cause is a leak or disconnection somewhere between the ventilator and the patient's airway, such as the ventilator tubing becoming disconnected from the endotracheal tube. Mucus plugs, biting the tube, and tension pneumothorax would all cause a HIGH-pressure alarm due to increased resistance or decreased compliance.

Question 47: A patient presents with tearing chest pain radiating to the back and a blood pressure difference between arms. What is the most likely diagnosis?

Aortic dissection (Correct answer)
Unstable angina
Acute MI
Pericarditis

Correct answer: Aortic dissection

Tearing pain radiating to the back with unequal arm blood pressures strongly suggests aortic dissection.

Question 48: According to the PADIS bundle, which approach should be used first when managing pain in ICU patients (analgesia-first strategy)?

Use neuromuscular blockade before analgesia
Treat pain before titrating sedation (Correct answer)
Start sedation before assessing pain
Administer benzodiazepines before opioids

Correct answer: Treat pain before titrating sedation

The analgesia-first (analgo-sedation) approach recommends treating pain first, as untreated pain is a major driver of agitation and over-sedation.

Question 49: A junctional escape rhythm in a post-cardiac surgery patient is best identified by which ECG finding?

Absent or retrograde P waves with narrow QRS complexes at 40–60 bpm (Correct answer)
Sawtooth flutter waves between narrow QRS complexes
Wide QRS complexes with AV dissociation at 60–100 bpm
Irregularly irregular rhythm with fibrillatory baseline

Correct answer: Absent or retrograde P waves with narrow QRS complexes at 40–60 bpm

Junctional escape rhythms originate in the AV node/junction, producing narrow QRS complexes at 40–60 bpm; P waves are absent, inverted, or retrograde depending on where conduction spreads.

Question 50: When using a daily spontaneous awakening trial (SAT), which patient condition is an absolute contraindication?

Active seizures (Correct answer)
Heart rate of 90 bpm
FiO2 requirement of 40%
Mild sedation (RASS -1)

Correct answer: Active seizures

Active seizures are an absolute contraindication to SAT because interrupting sedation could precipitate further neurological deterioration.

Question 51: A mechanically ventilated patient suddenly desaturates with high peak pressures and absent breath sounds on the right. What is the most likely cause?

Tension pneumothorax (Correct answer)
Pulmonary edema
Endotracheal tube migration into the esophagus
Atelectasis

Correct answer: Tension pneumothorax

Sudden desaturation with high pressures and unilateral absent breath sounds suggests tension pneumothorax.

Question 52: For glycemic control in critically ill septic patients, insulin therapy is typically started when blood glucose exceeds:

250 mg/dL
140 mg/dL
110 mg/dL
180 mg/dL (Correct answer)

Correct answer: 180 mg/dL

Insulin is initiated when glucose exceeds 180 mg/dL, targeting roughly 140-180 mg/dL.

Question 53: An elevated systemic vascular resistance (SVR) with low cardiac output is most consistent with:

Septic shock
Cardiogenic shock (Correct answer)
Anaphylactic shock
Neurogenic shock

Correct answer: Cardiogenic shock

Compensatory vasoconstriction raises SVR while a failing heart lowers output in cardiogenic shock.

Question 54: The ethical principle of justice in critical care primarily concerns:

Doing no harm to patients
Honoring patient wishes
Fair and equitable allocation of resources and care (Correct answer)
Keeping promises to patients

Correct answer: Fair and equitable allocation of resources and care

Justice addresses fairness in distributing care and resources among patients.

Question 55: What is the most reliable indicator of correct endotracheal tube placement after intubation?

Pulse oximetry reading
Chest rise
Auscultation of breath sounds alone
Waveform capnography confirming end-tidal CO2 (Correct answer)

Correct answer: Waveform capnography confirming end-tidal CO2

Continuous waveform capnography is the most reliable method to confirm ET tube placement.

Question 56: HIPPA laws require which of the following ethical principles?

Patient confidentiality (Correct answer)
Patient fidelity
Patient veracity
Patient justice

Correct answer: Patient confidentiality

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law primarily enacted to protect the privacy and security of individuals' protected health information (PHI). A core ethical and legal principle mandated by HIPAA is patient confidentiality, ensuring that sensitive medical information is handled securely and disclosed only with proper authorization or under specific legal circumstances.

Question 57: Nonmaleficence is best demonstrated when a nurse:

Tells the patient the full truth
Double-checks a high-alert medication dose before administration (Correct answer)
Advocates for equal resource distribution
Honors a patient's treatment refusal

Correct answer: Double-checks a high-alert medication dose before administration

Nonmaleficence means avoiding harm, exemplified by preventing medication errors.

Question 58: The CPOT (Critical-Care Pain Observation Tool) assesses pain using which four behavioral indicators?

Eye opening, verbal response, motor response, and reflexes
Heart rate, blood pressure, respiratory rate, and oxygen saturation
Vital signs, pupil response, skin color, and diaphoresis
Facial expression, body movements, muscle tension, and ventilator compliance/vocalization (Correct answer)

Correct answer: Facial expression, body movements, muscle tension, and ventilator compliance/vocalization

The CPOT evaluates four domains: facial expression, body movements, muscle tension, and compliance with ventilator or vocalization in extubated patients.

Question 59: A patient presents with sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxia after recent surgery. Which cardiovascular emergency is most likely?

Aortic stenosis
Pulmonary embolism (Correct answer)
Acute MI
Pericarditis

Correct answer: Pulmonary embolism

Sudden dyspnea, pleuritic pain, tachycardia, and hypoxia after surgery strongly suggest pulmonary embolism.

Question 60: Which ECG change is most consistent with an acute anterior ST-elevation myocardial infarction (STEMI)?

ST elevation in leads V1 through V4 (Correct answer)
PR interval prolongation greater than 0.20 seconds
ST depression in leads II, III, and aVF
New right bundle branch block pattern

Correct answer: ST elevation in leads V1 through V4

The left anterior descending artery supplies the anterior wall; its occlusion causes ST elevation in the precordial leads V1–V4, the territory those leads overlie.

Question 61: What is the normal range for QRS complex duration in an adult?

0.16–0.20 seconds
0.12–0.16 seconds
0.06–0.12 seconds (Correct answer)
Less than 0.06 seconds

Correct answer: 0.06–0.12 seconds

A normal QRS duration is 0.06–0.12 seconds; a QRS wider than 0.12 seconds indicates intraventricular conduction delay such as bundle branch block or ventricular origin.

Question 62: Moral distress in critical care nurses most often results from:

Excessive overtime hours
Disagreement with hospital pay scales
Knowing the right action but being constrained from taking it (Correct answer)
Lack of clinical knowledge

Correct answer: Knowing the right action but being constrained from taking it

Moral distress occurs when nurses cannot act on what they believe is ethically correct.

Question 63: A trauma patient on massive transfusion develops oozing from IV sites and mucous membranes. Which condition should be suspected?

Disseminated intravascular coagulation (Correct answer)
Von Willebrand disease
Hemophilia A
Vitamin K deficiency

Correct answer: Disseminated intravascular coagulation

Diffuse bleeding from multiple sites during major trauma suggests disseminated intravascular coagulation (DIC).

Question 64: A patient with a high cervical spinal cord injury develops hypotension and bradycardia shortly after injury. This is most consistent with which condition?

Neurogenic shock (Correct answer)
Anaphylactic shock
Septic shock
Hypovolemic shock

Correct answer: Neurogenic shock

Neurogenic shock causes hypotension with bradycardia from loss of sympathetic tone after cord injury.

Question 65: In ARDS lung-protective ventilation, plateau pressure should generally be kept below:

30 cm H2O (Correct answer)
15 cm H2O
50 cm H2O
60 cm H2O

Correct answer: 30 cm H2O

Keeping plateau pressure < 30 cm H2O limits alveolar overdistension and barotrauma.

Question 66: A nurse acts as a patient advocate primarily by:

Prioritizing the institution's interests
Following physician orders without question
Making decisions on the patient's behalf
Supporting the patient's expressed wishes and values (Correct answer)

Correct answer: Supporting the patient's expressed wishes and values

Advocacy means supporting and representing the patient's own values and choices.

Question 67: Which physiologic change explains why central venous oxygen saturation (ScvO2) may be elevated in late sepsis?

Impaired cellular oxygen extraction at the tissue level (Correct answer)
Hyperventilation
Increased oxygen demand by tissues
Profound anemia

Correct answer: Impaired cellular oxygen extraction at the tissue level

Cytopathic injury prevents tissues from extracting oxygen, raising venous saturation.

Question 68: A patient in the ICU for five days with severe sepsis from peritonitis now exhibits jaundice, a total bilirubin level of 4.5 mg/dL (77 µmol/L), and an INR of 1.8. These findings are most indicative of the onset of dysfunction in which organ system as part of MODS?

Renal.
Hematologic.
Hepatic. (Correct answer)
Cardiovascular.

Correct answer: Hepatic.

Multiple Organ Dysfunction Syndrome (MODS) is the progressive failure of two or more organ systems. The clinical signs of jaundice (icterus), a significantly elevated total bilirubin (normal <1.2 mg/dL), and a prolonged INR (reflecting impaired synthesis of clotting factors by the liver) are hallmark indicators of acute hepatic (liver) dysfunction.

Question 69: A patient in stable narrow-complex SVT does not respond to vagal maneuvers. What is the first-line medication?

Diltiazem infusion
Lidocaine
Amiodarone
Adenosine (Correct answer)

Correct answer: Adenosine

Adenosine is first-line for stable narrow-complex SVT because it briefly blocks AV node conduction to terminate reentry.

Question 70: A nurse is asked to perform a procedure outside their scope of practice. The correct action is to:

Perform it and document carefully
Delegate it to an aide
Decline and notify the supervisor, as it falls outside legal scope (Correct answer)
Perform it since a physician ordered it

Correct answer: Decline and notify the supervisor, as it falls outside legal scope

Nurses must not exceed their legal scope of practice even when ordered to do so.

Question 71: Refractory hypoxemia despite optimal ventilator settings and prone positioning may warrant which advanced therapy?

Discontinuing PEEP
Increasing tidal volume to 12 mL/kg
Venovenous ECMO (Correct answer)
Routine bronchoscopy

Correct answer: Venovenous ECMO

VV-ECMO provides extracorporeal gas exchange for severe ARDS unresponsive to conventional management.

Question 72: Plateau pressure should be maintained below which value to limit ventilator-induced lung injury?

30 cm H2O (Correct answer)
50 cm H2O
40 cm H2O
20 cm H2O

Correct answer: 30 cm H2O

Keeping plateau pressure under 30 cm H2O reduces alveolar overdistension and barotrauma.

Question 73: In ARDS, lung-protective ventilation targets which tidal volume?

6 mL/kg of predicted body weight (Correct answer)
10 mL/kg of actual body weight
4 mL/kg of actual body weight
12 mL/kg of predicted body weight

Correct answer: 6 mL/kg of predicted body weight

ARDSNet protocol uses 6 mL/kg of predicted body weight to limit volutrauma.

Question 74: Passive leg raise is used in septic resuscitation primarily to assess:

Deep vein thrombosis risk
Level of consciousness
Peripheral edema
Fluid responsiveness before giving more volume (Correct answer)

Correct answer: Fluid responsiveness before giving more volume

A passive leg raise provides a reversible autotransfusion to predict fluid responsiveness.

Question 75: What is the primary goal of maintaining normocapnia (PaCO2 35-45 mmHg) in a patient with elevated ICP?

To avoid cerebral vasoconstriction or vasodilation that worsens perfusion or pressure (Correct answer)
To increase cerebral oxygen consumption
To promote metabolic alkalosis
To stimulate the respiratory drive

Correct answer: To avoid cerebral vasoconstriction or vasodilation that worsens perfusion or pressure

CO2 strongly affects cerebral vessel caliber, so normocapnia prevents harmful vasoconstriction or vasodilation.

Question 76: Stroke volume variation (SVV) is a useful predictor of fluid responsiveness primarily in patients who are:

Spontaneously breathing
In atrial fibrillation
Receiving high-dose vasopressors
Mechanically ventilated in sinus rhythm (Correct answer)

Correct answer: Mechanically ventilated in sinus rhythm

SVV reliability depends on positive-pressure ventilation and regular cardiac rhythm.

Question 77: Before administering IV alteplase (tPA) for ischemic stroke, which study must be completed to exclude hemorrhage?

Noncontrast CT of the head (Correct answer)
EEG
Carotid ultrasound
Lumbar puncture

Correct answer: Noncontrast CT of the head

A noncontrast head CT must confirm there is no hemorrhage before giving tPA.

Question 78: A critical care nurse is caring for a patient with severe ARDS who has been placed in a prone position. The nurse understands that the primary goal of this intervention is to:

Improve oxygenation by recruiting dependent alveoli and improving V/Q matching. (Correct answer)
Increase lung compliance and functional residual capacity.
Decrease the patient's sedation requirements.
Improve secretion clearance and prevent ventilator-associated pneumonia.

Correct answer: Improve oxygenation by recruiting dependent alveoli and improving V/Q matching.

The main physiological rationale for prone positioning in ARDS is to improve oxygenation. It does so by recruiting collapsed alveoli in the dependent (posterior) lung regions, promoting more uniform lung inflation, improving ventilation-perfusion (V/Q) matching, and facilitating the drainage of secretions. While it may help with secretion clearance, its primary purpose is to enhance gas exchange.

Question 79: A 58-year-old male is admitted with a hypertensive emergency. His blood pressure is 220/140 mmHg, and he is complaining of a severe headache and confusion. Which of the following is the most appropriate initial nursing action?

Administer a potent oral antihypertensive agent for rapid effect.
Administer a rapid IV bolus of 0.9% normal saline.
Initiate an IV infusion of sodium nitroprusside and titrate to a goal mean arterial pressure (MAP). (Correct answer)
Prepare for immediate endotracheal intubation.

Correct answer: Initiate an IV infusion of sodium nitroprusside and titrate to a goal mean arterial pressure (MAP).

In a hypertensive emergency with signs of end-organ damage (e.g., encephalopathy), the priority is to lower the blood pressure in a controlled manner using a titratable intravenous agent. Sodium nitroprusside is a potent vasodilator that allows for precise, rapid control of blood pressure. The goal is not to normalize the blood pressure immediately but to reduce it by no more than 25% in the first hour to prevent cerebral hypoperfusion. Administering a fluid bolus would worsen hypertension. Intubation is not indicated unless there is respiratory failure. Oral agents are not used for emergencies because their absorption and effect are less predictable and controllable.

Question 80: A 78-year-old male with a history of type 2 diabetes is brought to the ICU with altered mental status. His vital signs are: BP 90/60 mmHg, HR 125 bpm, RR 24, Temp 38.5°C. Laboratory results show: Glucose 1,150 mg/dL, Serum Osmolality 345 mOsm/kg, Arterial pH 7.36, Serum Bicarbonate 25 mEq/L, and small ketones in the urine. Which condition do these findings most strongly indicate?

Myxedema Coma
Diabetic Ketoacidosis (DKA)
Thyroid Storm
Hyperosmolar Hyperglycemic State (HHS) (Correct answer)

Correct answer: Hyperosmolar Hyperglycemic State (HHS)

The patient's presentation of profound hyperglycemia (>600 mg/dL), high serum osmolality (>320 mOsm/kg), and altered mental status without significant acidosis (pH > 7.30, Bicarb > 18) is characteristic of Hyperosmolar Hyperglycemic State (HHS). [10, 15] DKA would present with significant metabolic acidosis and large serum ketones. Myxedema coma and thyroid storm are not primarily characterized by extreme hyperglycemia.

Question 81: Why are ACE inhibitors a cornerstone of chronic heart failure management?

They increase heart rate
They directly increase contractility
They are potent diuretics
They reduce afterload and prevent ventricular remodeling (Correct answer)

Correct answer: They reduce afterload and prevent ventricular remodeling

ACE inhibitors lower afterload and inhibit the RAAS, slowing maladaptive ventricular remodeling.

Question 82: When leveling an arterial line transducer to obtain an accurate reading, the nurse should place it at the phlebostatic axis. This anatomical landmark is located at the intersection of:

The fifth intercostal space and the anterior axillary line
The second intercostal space and the mid-axillary line
The fourth intercostal space and the mid-clavicular line
The fourth intercostal space and the mid-axillary line (Correct answer)

Correct answer: The fourth intercostal space and the mid-axillary line

The phlebostatic axis is the correct reference point for leveling a transducer for hemodynamic monitoring. It is located at the intersection of the fourth intercostal space and the mid-axillary line. This position approximates the level of the right atrium, ensuring accurate pressure measurements.

Question 83: Which crystalloid is generally preferred for large-volume resuscitation in sepsis to avoid hyperchloremic acidosis?

0.9% normal saline
Balanced solutions like lactated Ringer's (Correct answer)
0.45% half-normal saline
Dextrose 5% in water

Correct answer: Balanced solutions like lactated Ringer's

Balanced crystalloids are favored over normal saline to reduce hyperchloremic metabolic acidosis.

Question 84: The Berlin criteria require that ARDS-related respiratory failure is NOT fully explained by:

Aspiration
Sepsis
Cardiac failure or fluid overload (Correct answer)
Pneumonia

Correct answer: Cardiac failure or fluid overload

Hydrostatic edema from cardiac failure or volume overload must be excluded as the primary cause.

Question 85: Which lab value is most specific for myocardial cell injury?

LDH
Myoglobin
CK total
Troponin I (Correct answer)

Correct answer: Troponin I

Troponin I is the most cardiac-specific and sensitive marker of myocardial injury.

Question 86: A patient receiving mannitol for elevated ICP should be monitored most closely for which complication?

Hyperkalemia
Serum hyperosmolality and dehydration (Correct answer)
Metabolic acidosis
Fluid overload and hyponatremia

Correct answer: Serum hyperosmolality and dehydration

Mannitol's osmotic diuresis can cause dehydration and dangerously high serum osmolality.

Question 87: A patient with SAH develops hyponatremia, hypovolemia, and high urine sodium with signs of dehydration. Which diagnosis is most consistent?

SIADH
Acute kidney injury
Diabetes insipidus
Cerebral salt wasting (Correct answer)

Correct answer: Cerebral salt wasting

Cerebral salt wasting causes hyponatremia with volume depletion and renal sodium loss.

Question 88: What is the recommended ventilation strategy for a trauma patient with ARDS?

Tidal volume 10-12 mL/kg
Low tidal volume 6 mL/kg of predicted body weight (Correct answer)
High tidal volume to recruit alveoli
Zero PEEP

Correct answer: Low tidal volume 6 mL/kg of predicted body weight

Low tidal volume (6 mL/kg PBW) lung-protective ventilation reduces ventilator-induced injury in ARDS.

Question 89: A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg and a mean arterial pressure (MAP) of 70 mmHg. The nurse calculates the cerebral perfusion pressure (CPP) and recognizes the need for which immediate intervention?

Administering an antihypertensive agent to lower MAP.
Increasing the head of the bed to 90 degrees.
Performing a deep suctioning of the endotracheal tube.
Administering a prescribed vasopressor to increase MAP. (Correct answer)

Correct answer: Administering a prescribed vasopressor to increase MAP.

The cerebral perfusion pressure (CPP) is calculated as MAP - ICP. In this case, CPP is 70 - 22 = 48 mmHg. The goal CPP for TBI patients is typically 60-70 mmHg. A CPP below 50 mmHg can lead to cerebral ischemia. The most direct way to improve a low CPP in this scenario is to increase the MAP using a vasopressor, as the ICP is already elevated. Lowering MAP would worsen cerebral ischemia. Increasing the head of the bed to 90 degrees could decrease MAP and CPP. Deep suctioning can transiently increase ICP.

Question 90: A patient with acute decompensated heart failure has a pulmonary artery wedge pressure of 24 mmHg. What does this elevated value indicate?

Increased left atrial/left ventricular filling pressure (Correct answer)
Right ventricular failure
Pulmonary embolism
Hypovolemia

Correct answer: Increased left atrial/left ventricular filling pressure

An elevated PAWP reflects increased left-sided filling pressures, typical of left heart failure.

Question 91: Cultural competence in ethical practice requires the nurse to:

Ignore cultural differences for consistency
Respect the patient's cultural and religious values in care decisions (Correct answer)
Assume all patients share mainstream values
Apply personal beliefs to all patients

Correct answer: Respect the patient's cultural and religious values in care decisions

Ethical, patient-centered care incorporates respect for cultural and religious values.

Question 92: A nurse is preparing to assist with an apnea test to determine brain death in a patient with a catastrophic brain injury. The nurse confirms that all prerequisites have been met. The test is considered positive, supporting a diagnosis of brain death, if what occurs?

The patient develops spontaneous respiratory effort.
The patient's heart rate increases by 20% from baseline.
The PaCO2 rises to ≥ 60 mmHg without respiratory effort. (Correct answer)
The SpO2 drops below 85% for more than 30 seconds.

Correct answer: The PaCO2 rises to ≥ 60 mmHg without respiratory effort.

A positive apnea test, which supports the clinical diagnosis of brain death, is defined by the absence of spontaneous respiratory movements despite a significant rise in PaCO2. The standard targets are a PaCO2 of 60 mmHg or higher, or a rise of at least 20 mmHg from a normal baseline PaCO2, in the absence of any breathing effort. The development of respiratory effort would be a negative test, indicating brainstem function. Severe desaturation or hemodynamic instability would lead to the test being aborted.

Question 93: During PA catheter insertion, a sustained right ventricular waveform indicates the tip is in the RV and the nurse should:

Flush vigorously and continue monitoring
Inflate the balloon and leave it
Document and take no action
Notify the provider to advance or withdraw to reduce arrhythmia risk (Correct answer)

Correct answer: Notify the provider to advance or withdraw to reduce arrhythmia risk

A catheter tip lodged in the RV can provoke ventricular arrhythmias and must be repositioned.

Question 94: Confidentiality may be ethically breached when:

There is a serious threat of harm to the patient or others (Correct answer)
The information is interesting
A coworker asks casually
A family member is curious

Correct answer: There is a serious threat of harm to the patient or others

Duty to warn or protect can override confidentiality when serious harm is threatened.

Question 95: A hemodynamically stable patient with atrial flutter and a ventricular rate of 150 bpm has no history of prior episodes. What is the most appropriate initial management?

Magnesium sulfate 2 g IV over 10 minutes
Temporary transvenous pacemaker insertion
Rate control with a beta-blocker or calcium channel blocker (Correct answer)
Immediate unsynchronized defibrillation at 200 joules

Correct answer: Rate control with a beta-blocker or calcium channel blocker

For hemodynamically stable atrial flutter, rate control with a beta-blocker (e.g., metoprolol) or non-dihydropyridine calcium channel blocker (e.g., diltiazem) is the initial priority.

Question 96: A patient has a PaO2 of 55 mmHg on room air with a normal PaCO2. This finding is most consistent with which type of respiratory failure?

Type II (hypercapnic) respiratory failure
Metabolic alkalosis
Type I (hypoxemic) respiratory failure (Correct answer)
Chronic compensated respiratory acidosis

Correct answer: Type I (hypoxemic) respiratory failure

Type I respiratory failure is defined by hypoxemia (PaO2 < 60 mmHg) with a normal or low PaCO2.

Question 97: The number of vertebrae in each section of the vertebral column is appropriately identified by which of the following?

7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccygeal (Correct answer)
7 cervical, 11 thoracic, 5 lumbar, 4 sacral, 5 coccygeal
8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 3 coccygeal
7 cervical, 12 thoracic, 7 lumbar, 6 sacral, 2 coccygeal

Correct answer: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccygeal

The human vertebral column is typically composed of 33 vertebrae, divided into five distinct regions. This arrangement includes 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, 5 fused sacral vertebrae, and typically 4 fused coccygeal vertebrae. This specific count for each section provides the structural support and flexibility of the spine.

Question 98: A patient with ascites and a tense, distended abdomen reports new fever and abdominal pain. What complication should be suspected?

Bowel obstruction
Spontaneous bacterial peritonitis (Correct answer)
Pancreatitis
Cholecystitis

Correct answer: Spontaneous bacterial peritonitis

Fever and abdominal pain in a patient with ascites suggest spontaneous bacterial peritonitis requiring paracentesis.

Question 99: Which arterial blood gas finding defines Type II respiratory failure?

Normal A-a gradient
PaCO2 < 35 mmHg
PaO2 > 80 mmHg with normal pH
PaCO2 > 45 mmHg with hypoxemia (Correct answer)

Correct answer: PaCO2 > 45 mmHg with hypoxemia

Type II (hypercapnic) failure is defined by alveolar hypoventilation with PaCO2 > 45 mmHg.

Question 100: A critical care nurse is monitoring a patient at high risk for abdominal compartment syndrome (ACS) following massive fluid resuscitation for trauma. According to the World Society of the Abdominal Compartment Syndrome (WSACS), ACS is defined as a sustained intra-abdominal pressure (IAP) greater than what threshold, accompanied by new organ dysfunction?

20 mmHg (Correct answer)
25 mmHg
16 mmHg
12 mmHg

Correct answer: 20 mmHg

The World Society of the Abdominal Compartment Syndrome (WSACS) defines abdominal compartment syndrome (ACS) as a sustained intra-abdominal pressure (IAP) greater than 20 mmHg that is associated with new organ dysfunction or failure. Intra-abdominal hypertension (IAH) is defined as a sustained IAP of 12 mmHg or greater.

Question 101: A patient arrives unconscious without an advance directive and needs emergency surgery. Consent is obtained through:

The charge nurse's authorization
Waiting until the patient regains consciousness
Implied consent under the emergency doctrine (Correct answer)
A court order before proceeding

Correct answer: Implied consent under the emergency doctrine

Implied (emergency) consent permits life-saving treatment when the patient cannot consent.

Question 102: The nurse expects that the foremost life-threatening occasion of adrenal crisis is:

Hypoglycemia
Hypernatremia
Vascular collapse (Correct answer)
Hypokalemia

Correct answer: Vascular collapse

Adrenal crisis, or Addisonian crisis, is a life-threatening emergency resulting from severe acute adrenal insufficiency, leading to profound deficiencies of cortisol and aldosterone. The lack of cortisol causes severe hypotension and shock, while aldosterone deficiency leads to critical electrolyte imbalances and hypovolemia. These combined effects culminate in severe vascular collapse, which is the most immediate and life-threatening complication.

Question 103: Which nursing action is most important to prevent ventilator-associated pneumonia?

Keeping the patient flat
Maintaining head-of-bed elevation at 30-45 degrees (Correct answer)
Routine saline lavage during suctioning
Changing ventilator circuits daily

Correct answer: Maintaining head-of-bed elevation at 30-45 degrees

Elevating the head of bed 30-45 degrees reduces aspiration risk and VAP incidence.

Question 104: A trauma patient develops dark, tea-colored urine after a crush injury. Which complication should be suspected?

Acute glomerulonephritis
Bladder rupture
Urinary tract infection
Rhabdomyolysis (Correct answer)

Correct answer: Rhabdomyolysis

Myoglobinuria from rhabdomyolysis produces tea-colored urine and can cause acute kidney injury.

Question 105: A patient who underwent a bone marrow transplant has an absolute neutrophil count (ANC) of 350/mm³. The patient's temperature is now 38.6° C (101.5° F). Which of the following physician orders should the nurse implement first?

Obtain blood cultures from two different sites.
Administer acetaminophen 650 mg PO.
Place the patient in protective isolation.
Administer a prescribed broad-spectrum antibiotic. (Correct answer)

Correct answer: Administer a prescribed broad-spectrum antibiotic.

Neutropenic fever is a medical emergency. An ANC less than 500/mm³ indicates severe neutropenia, and these patients cannot mount an effective immune response, making them highly susceptible to overwhelming infection. The standard of care is to administer broad-spectrum antibiotics as quickly as possible (ideally within one hour of fever presentation) to prevent sepsis and death. While obtaining blood cultures is crucial, it should not delay the administration of antibiotics. Antipyretics and isolation are important but are not the immediate life-saving priority.

Question 106: In neurogenic shock from a spinal cord injury, which combination of findings is expected?

Hypertension with bradycardia
Hypotension with bradycardia (Correct answer)
Hypertension with tachycardia
Hypotension with tachycardia

Correct answer: Hypotension with bradycardia

Neurogenic shock causes hypotension with bradycardia due to loss of sympathetic tone and unopposed vagal activity.

Question 107: Which position is most appropriate to optimize cerebral venous drainage in a patient with increased ICP?

Flat with the head turned to the side
Trendelenburg position
Head of bed at 30 degrees with the head midline (Correct answer)
Prone with head elevated

Correct answer: Head of bed at 30 degrees with the head midline

Elevating the head 30 degrees and keeping it midline promotes venous outflow and lowers ICP.

Question 108: Which type of shock is characterized by a low systemic vascular resistance and a high cardiac output in its early phase?

Obstructive shock
Septic (distributive) shock (Correct answer)
Hypovolemic shock
Cardiogenic shock

Correct answer: Septic (distributive) shock

Early septic shock produces vasodilation with low SVR and a compensatory high cardiac output ('warm shock').

Question 109: Which is an absolute contraindication to noninvasive ventilation?

Mild dyspnea
Inability to protect the airway (Correct answer)
Need for oxygen therapy
Anxiety

Correct answer: Inability to protect the airway

Patients who cannot protect their airway risk aspiration and require intubation rather than NIPPV.

Question 110: A patient presents with paroxysmal supraventricular tachycardia (PSVT) at 180 bpm. Vagal maneuvers have failed. What is the first pharmacological treatment of choice?

Adenosine 6 mg rapid IV push followed by a 20 mL saline flush (Correct answer)
Verapamil 5 mg IV over 2 minutes
Synchronized cardioversion at 50 joules
Amiodarone 150 mg IV over 10 minutes

Correct answer: Adenosine 6 mg rapid IV push followed by a 20 mL saline flush

Adenosine 6 mg rapid IV push with a saline flush is the first-line drug for PSVT; it briefly blocks AV conduction to terminate reentrant circuits.

Question 111: Which serum value is the most specific marker for acute pancreatitis?

Alkaline phosphatase
Amylase
Bilirubin
Lipase (Correct answer)

Correct answer: Lipase

Lipase is more specific and stays elevated longer than amylase in acute pancreatitis.

Question 112: Which sedative agent is preferred for ICU sedation in patients at high risk for delirium due to its analgo-sedation properties?

Midazolam
Lorazepam
Dexmedetomidine (Correct answer)
Propofol

Correct answer: Dexmedetomidine

Dexmedetomidine (an alpha-2 agonist) produces sedation without suppressing respiratory drive and is associated with lower rates of delirium compared to benzodiazepines.

Question 113: Which finding best indicates a neutropenic patient is at highest infection risk?

White blood cell count of 8,000/mm3
Hemoglobin of 10 g/dL
Absolute neutrophil count below 500/mm3 (Correct answer)
Platelet count of 90,000/mm3

Correct answer: Absolute neutrophil count below 500/mm3

An ANC below 500/mm3 defines severe neutropenia and markedly increases the risk of serious infection.

Question 114: A patient with syndrome of inappropriate antidiuretic hormone (SIADH) would be expected to have which sodium and fluid status?

Hyponatremia with fluid retention (Correct answer)
Hypernatremia with fluid overload
Hypernatremia with dehydration
Normal sodium with dehydration

Correct answer: Hyponatremia with fluid retention

Excess ADH causes water retention and dilutional hyponatremia with concentrated urine.

Question 115: Which electrolyte abnormality is most common in a patient with prolonged nasogastric suction?

Respiratory acidosis
Hyperchloremia
Metabolic alkalosis with hypokalemia (Correct answer)
Metabolic acidosis with hyperkalemia

Correct answer: Metabolic alkalosis with hypokalemia

Loss of gastric acid and potassium from NG suction produces hypokalemic metabolic alkalosis.

Question 116: A trauma patient presents with hypotension, jugular venous distention, and muffled heart sounds. Which condition is most likely?

Hemorrhagic shock
Tension pneumothorax
Pulmonary embolism
Cardiac tamponade (Correct answer)

Correct answer: Cardiac tamponade

Beck's triad (hypotension, JVD, muffled heart sounds) is the classic presentation of cardiac tamponade.

Question 117: Which drug interaction poses a risk of serotonin syndrome in ICU patients receiving fentanyl alongside?

Metoprolol
Vancomycin
Linezolid (an MAO inhibitor) (Correct answer)
Furosemide

Correct answer: Linezolid (an MAO inhibitor)

Linezolid has MAO-inhibiting properties; combining it with serotonergic opioids like fentanyl can precipitate serotonin syndrome.

Question 118: A patient is admitted with pneumonia and sepsis. Their arterial blood gas (ABG) on 60% FiO2 shows: pH 7.48, PaCO2 32 mmHg, PaO2 55 mmHg, HCO3 24 mEq/L. Which type of acute respiratory failure is this patient experiencing?

Hypercapnic respiratory failure
Ventilatory failure
Acute-on-chronic respiratory failure
Hypoxemic respiratory failure (Correct answer)

Correct answer: Hypoxemic respiratory failure

The patient's PaO2 is less than 60 mmHg, which is the defining characteristic of hypoxemic (Type 1) respiratory failure. The PaCO2 is low, and the pH is alkalotic, indicating the patient is hyperventilating to compensate for the hypoxemia, which is inconsistent with hypercapnic (Type 2) failure where PaCO2 would be elevated (>50 mmHg).

Question 119: A patient arrives in the ICU after a severe crush injury to both lower extremities. The urine is dark reddish-brown, and the serum Creatine Kinase (CK) level is 65,000 U/L. Which of the following interventions is the highest priority to prevent a common, life-threatening complication of this condition?

Initiating aggressive intravenous fluid resuscitation (Correct answer)
Applying a warming blanket to correct hypothermia
Preparing the patient for emergent fasciotomy
Administering sodium polystyrene sulfonate

Correct answer: Initiating aggressive intravenous fluid resuscitation

The patient is experiencing rhabdomyolysis, where myoglobin is released from damaged muscle tissue. Myoglobin is nephrotoxic and can cause acute kidney injury (AKI) by obstructing renal tubules. The priority intervention is aggressive intravenous fluid resuscitation to increase renal blood flow and flush the myoglobin through the kidneys, thereby preventing AKI.

Question 120: During a spontaneous breathing trial, which finding suggests the patient is failing and should be returned to full support?

SpO2 of 97%
RSBI below 80
Stable blood pressure
Rapid shallow breathing index (RSBI) above 105 (Correct answer)

Correct answer: Rapid shallow breathing index (RSBI) above 105

An RSBI (respiratory rate divided by tidal volume in liters) above 105 predicts weaning failure.

Question 121: A nurse disagrees with a physician's plan that may harm the patient. The first step is to:

Carry out the order without comment
Discuss the concern directly with the physician using the chain of command (Correct answer)
File a lawsuit
Refuse to provide any care

Correct answer: Discuss the concern directly with the physician using the chain of command

Communicating concerns and using the chain of command protects the patient and resolves conflict.

Question 122: A critical care nurse is caring for a patient who underwent an emergency laparotomy for a ruptured spleen. Over the past two hours, the nurse notes the patient's abdomen is becoming increasingly tense and distended, peak airway pressures are rising, and urine output has dropped to less than 10 mL/hr despite adequate MAP. These findings are most indicative of what complication?

Hemorrhagic shock
Septic shock
Acute mesenteric ischemia
Abdominal Compartment Syndrome (Correct answer)

Correct answer: Abdominal Compartment Syndrome

Abdominal Compartment Syndrome (ACS) is a life-threatening condition caused by increased intra-abdominal pressure. This pressure compromises blood flow to organs and impairs physiologic function. Key signs include a tense, distended abdomen, increased airway pressures (due to elevation of the diaphragm), and oliguria/anuria from renal vein compression and reduced perfusion, all of which are present in this patient.

Question 123: In a patient with an inferior wall MI, why should nitroglycerin be administered cautiously?

Right ventricular involvement makes the patient preload-dependent (Correct answer)
It increases myocardial oxygen demand
It may cause reflex tachycardia
It worsens ST elevation

Correct answer: Right ventricular involvement makes the patient preload-dependent

Inferior MIs often involve the right ventricle, and nitroglycerin-induced preload reduction can cause severe hypotension.

Question 124: Which value best reflects left ventricular preload?

Pulmonary capillary wedge pressure (Correct answer)
Central venous pressure
Systemic vascular resistance
Mean arterial pressure

Correct answer: Pulmonary capillary wedge pressure

PCWP estimates left atrial and left ventricular end-diastolic pressure, reflecting LV preload.

Question 125: Damage to the developing brain's motor control areas causes which of the following developmental conditions?

Prader-Willi syndrome
Williams syndrome
Fragile X syndrome
Cerebral palsy (Correct answer)

Correct answer: Cerebral palsy

Cerebral palsy (CP) is a group of permanent movement disorders that emerge in early childhood, resulting from non-progressive disturbances in the developing fetal or infant brain. These disturbances specifically affect the motor control areas of the brain, leading to challenges with muscle tone, movement, and posture. The other listed syndromes are genetic conditions with distinct etiologies.

Question 126: A 70 kg male patient is intubated for ARDS. To adhere to a lung-protective ventilation strategy, the nurse should anticipate setting the initial tidal volume to which of the following ranges?

560 - 700 mL (8-10 mL/kg)
150 - 250 mL (2-3.5 mL/kg)
700 - 840 mL (10-12 mL/kg)
280 - 420 mL (4-6 mL/kg) (Correct answer)

Correct answer: 280 - 420 mL (4-6 mL/kg)

The standard of care for ventilating patients with ARDS is a lung-protective strategy that utilizes low tidal volumes to prevent volutrauma and barotrauma. Current evidence and guidelines, such as those from the ARDSNet trials, recommend a tidal volume of 4 to 6 mL per kilogram of *predicted* body weight, not actual body weight, and maintaining a plateau pressure of less than 30 cm H2O.

Question 127: What is the earliest reliable sign of compensated shock in a young trauma patient?

Bradycardia
Tachycardia (Correct answer)
Decreased urine output
Hypotension

Correct answer: Tachycardia

Tachycardia is an early compensatory response, while hypotension is a late and ominous sign.

Question 128: A second vasopressor is often added to norepinephrine in refractory septic shock. Which agent is typically chosen?

Nitroprusside
Dobutamine
Vasopressin (Correct answer)
Esmolol

Correct answer: Vasopressin

Vasopressin is commonly added to norepinephrine to raise MAP and reduce catecholamine dose.

Question 129: A patient is admitted with decompensated right-sided heart failure. Which set of hemodynamic parameters would the nurse most expect to find?

Low CVP, low CO, high SVR
High CVP, high SVR, low PAWP
Low CVP, high PAWP, low SVR
High CVP, low PAWP, normal to high PVR (Correct answer)

Correct answer: High CVP, low PAWP, normal to high PVR

In right-sided heart failure, the right ventricle fails to pump effectively, leading to a backup of blood in the systemic venous circulation. This results in an elevated Central Venous Pressure (CVP). The Pulmonary Artery Wedge Pressure (PAWP), which reflects left-sided preload, would be low or normal unless there is concurrent left-sided failure. Pulmonary Vascular Resistance (PVR) may be elevated, as it is a common cause of right heart failure.

Question 130: A patient presents with acute ischemic stroke symptoms that began 2 hours ago. Which is the most important factor in determining eligibility for IV thrombolytics?

Presence of a headache
Blood glucose above 100 mg/dL
Patient age over 50
Time of symptom onset and absence of contraindications (Correct answer)

Correct answer: Time of symptom onset and absence of contraindications

Thrombolytic eligibility hinges on time since onset and ruling out bleeding contraindications.

Question 131: Which opioid is most commonly used for analgesia in mechanically ventilated ICU patients due to its titratability and short duration of action?

Meperidine
Codeine
Fentanyl (Correct answer)
Morphine

Correct answer: Fentanyl

Fentanyl is preferred in mechanically ventilated ICU patients due to its rapid onset, short duration of action, and ease of titration.

Question 132: Which finding indicates effective treatment of DKA?

Glucose returning to exactly 100 mg/dL
Closure of the anion gap and resolution of ketosis (Correct answer)
Disappearance of urine output
Increase in serum ketones

Correct answer: Closure of the anion gap and resolution of ketosis

Resolution of DKA is defined by closure of the anion gap and clearing of ketones, not glucose alone.

Question 133: A patient receiving heparin develops a platelet count drop of more than 50% on day 6. What condition should be suspected?

Aplastic anemia
Vitamin K deficiency
Heparin-induced thrombocytopenia (HIT) (Correct answer)
Idiopathic thrombocytopenic purpura

Correct answer: Heparin-induced thrombocytopenia (HIT)

HIT is an immune-mediated reaction occurring 5-10 days after heparin exposure, causing thrombocytopenia and a paradoxical thrombosis risk.

Question 134: The nurse examines Mr. David., a 45-year-old sportsman. His heart rate speeds up and slows down. In Lead II, he has upright P and R waves at 70 beats per minute. Most likely, his rhythm is an example of:

Digoxin toxicity
Increased intracranial pressure
Inferior wall MI
normal variation in EKG (Correct answer)

Correct answer: normal variation in EKG

The description of a heart rate that speeds up and slows down, upright P and R waves in Lead II, and a rate of 70 bpm is characteristic of sinus arrhythmia. Sinus arrhythmia is a normal physiological variation where the heart rate fluctuates with respiration, commonly observed in healthy individuals, especially athletes. It is a benign finding and not indicative of a pathological condition.

Question 135: Which assessment is most important after placement of a sengstaken-Blakemore (esophageal balloon) tube?

Monitor for airway obstruction from balloon migration (Correct answer)
Measure urine specific gravity
Assess for hypothermia
Check blood glucose hourly

Correct answer: Monitor for airway obstruction from balloon migration

An esophageal tamponade balloon can migrate and obstruct the airway, so airway protection is the priority.

Question 136: An advance directive becomes effective when:

The physician approves it
It is signed and witnessed
The patient is admitted to the ICU
The patient loses decision-making capacity (Correct answer)

Correct answer: The patient loses decision-making capacity

Advance directives guide care only once the patient can no longer make decisions.

Question 137: Which non-pharmacological intervention is a first-line strategy to prevent and treat ICU delirium?

Propofol infusion
Haloperidol administration
Early mobility and physical therapy (Correct answer)
Benzodiazepine taper

Correct answer: Early mobility and physical therapy

Early mobility and physical therapy are first-line non-pharmacological strategies proven to reduce the incidence and duration of ICU delirium.

Question 138: High peak airway pressure with a NORMAL plateau pressure most likely indicates:

Pneumothorax
Pulmonary edema
Decreased lung compliance
Increased airway resistance (e.g., secretions or bronchospasm) (Correct answer)

Correct answer: Increased airway resistance (e.g., secretions or bronchospasm)

A high peak with normal plateau reflects a resistance problem in the airways or circuit, not the lung parenchyma.

Question 139: A patient with a T4 spinal cord injury suddenly develops a pounding headache, severe hypertension, and flushing above the lesion. What is the priority action?

Administer a fluid bolus
Lay the patient flat and elevate the legs
Sit the patient upright and identify the noxious stimulus (Correct answer)
Apply firm abdominal pressure

Correct answer: Sit the patient upright and identify the noxious stimulus

Autonomic dysreflexia is treated by sitting the patient up and removing the triggering stimulus such as a full bladder.

Question 140: Central diabetes insipidus is most appropriately treated with which medication?

Furosemide
Desmopressin (DDAVP) (Correct answer)
Mannitol
Hydrochlorothiazide alone

Correct answer: Desmopressin (DDAVP)

Central DI results from ADH deficiency, so synthetic ADH (desmopressin) replaces the missing hormone.

Question 141: What is the gold standard diagnostic test to identify the source of an aneurysmal subarachnoid hemorrhage?

Electroencephalogram
Skull radiograph
Cerebral angiography (Correct answer)
Lumbar puncture

Correct answer: Cerebral angiography

Cerebral angiography is the gold standard for locating the aneurysm responsible for SAH.

Question 142: What is the most appropriate initial fluid for resuscitation of acute hemorrhagic shock when blood products are not yet available?

Dextrose 5% in water
Albumin 25%
Balanced crystalloid such as lactated Ringer's (Correct answer)
0.45% saline

Correct answer: Balanced crystalloid such as lactated Ringer's

Balanced isotonic crystalloids like lactated Ringer's are the initial fluid of choice while awaiting blood products.

Question 143: A critical care nurse is evaluating laboratory results to determine the cause of a patient's acute kidney injury (AKI). Which set of findings is most consistent with a prerenal cause, such as hypovolemia?

BUN:Creatinine ratio of 10:1, FENa > 2%
Urine sodium > 40 mEq/L, FENa > 2%
Urine sodium < 20 mEq/L, BUN:Creatinine ratio > 20:1 (Correct answer)
Presence of muddy brown casts in urine, urine sodium > 40 mEq/L

Correct answer: Urine sodium < 20 mEq/L, BUN:Creatinine ratio > 20:1

In prerenal AKI, the kidneys are responding to decreased perfusion by avidly conserving sodium and water. This results in a low urine sodium concentration (<20 mEq/L), a high BUN to creatinine ratio (>20:1) due to passive reabsorption of urea with water, and a fractional excretion of sodium (FENa) typically less than 1%.

Question 144: Source control in sepsis refers to:

Reducing the antibiotic dose
Controlling the patient's blood pressure
Limiting fluid intake
Identifying and eliminating the focus of infection (e.g., draining an abscess) (Correct answer)

Correct answer: Identifying and eliminating the focus of infection (e.g., draining an abscess)

Source control means physically removing or draining the infection source as soon as feasible.

Question 145: A patient with cirrhosis has worsening confusion and asterixis. Which intervention is most appropriate?

Give a proton pump inhibitor
Administer lactulose (Correct answer)
Restrict all protein permanently
Increase sodium intake

Correct answer: Administer lactulose

Lactulose reduces ammonia absorption, treating hepatic encephalopathy that causes confusion and asterixis.

Question 146: The principle of double effect may justify:

Sedating a patient against their will
Withholding pain relief to prolong life
Giving opioids for pain even if they may hasten death (Correct answer)
Intentionally ending a patient's life

Correct answer: Giving opioids for pain even if they may hasten death

Double effect permits a good action with a foreseen but unintended harmful side effect.

Question 147: The dicrotic notch on an arterial pressure waveform represents:

The closure of the aortic valve (Correct answer)
The opening of the aortic valve
The end of diastole
The peak systolic pressure

Correct answer: The closure of the aortic valve

The dicrotic notch is a small, downward deflection on the arterial waveform that follows the systolic peak. It signifies the closure of the aortic valve and the beginning of diastole. This closure causes a brief retrograde flow of blood, which creates the notch.

Question 148: Long QT syndrome predisposes a patient to which potentially fatal dysrhythmia?

Torsades de pointes (Correct answer)
Complete heart block
Accelerated idioventricular rhythm
Paroxysmal atrial fibrillation

Correct answer: Torsades de pointes

A prolonged QT interval represents delayed ventricular repolarization, creating a vulnerable window during which a premature beat can trigger torsades de pointes.

Question 149: What is the recommended endotracheal tube cuff pressure range to prevent both aspiration and tracheal mucosal injury?

35–45 cm H2O
50–60 cm H2O
5–10 cm H2O
20–30 cm H2O (Correct answer)

Correct answer: 20–30 cm H2O

Cuff pressures of 20–30 cm H2O seal the airway while avoiding ischemic mucosal damage.

Question 150: What is the primary pathophysiologic hallmark of the exudative phase of ARDS?

Increased alveolar-capillary membrane permeability with protein-rich edema (Correct answer)
Bronchospasm and air trapping
Pure cardiogenic pulmonary edema
Pleural effusion accumulation

Correct answer: Increased alveolar-capillary membrane permeability with protein-rich edema

Diffuse alveolar damage increases capillary permeability, flooding alveoli with protein-rich fluid.

Question 151: Which benzodiazepine is associated with the highest risk of ICU delirium and prolonged mechanical ventilation?

Clonazepam
Midazolam
Diazepam
Lorazepam (Correct answer)

Correct answer: Lorazepam

Lorazepam has been identified in studies as an independent risk factor for transitioning to delirium in ICU patients, particularly due to its active metabolites and long half-life.

CCRN (Adult) Certification Exam

The CCRN (Adult) certification exam, administered by the AACN, validates a registered nurse’s knowledge and clinical judgment in acute and critical care nursing for adult patients.

150

Questions

180 min

Time Limit

66%

To Pass

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