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CCRN Questions & ANSWERS 2024
A patient has had a large anterior myocardial infarction last month and developed a ventricular aneurysm. He now has episodes of ventricular tachycardia that are not prevented or converted with antidysrhythmic agents. An implantable cardioverter-defibrillator (ICD) is implanted. Four days after surgery he develops ventricular tachycardia. The ICD has delivered three shocks but has not converted the rhythm. He is pulseless and apneic. Cardiopulmonary resuscitation is in progress. What is the priority action now? A. Administer epinephrine IV. B. Administer amiodarone. C. Defibrillate. D. Reset the ICD. โ
Defibrillate A 28-year-old woman is admitted to the critical care unit from the emergency department with a diagnosis of asthma. Her initial arterial blood gases on a 28% Venturi mask are as follows: pH 7. PaCO2 30 mm Hg HCO3 24 mEq/L PaO2 64 mm Hg Which of the following repeat arterial blood gases on 40% oxygen indicate that the patient's condition is worsening?
A.
pH 7.48, PaCO2 30 mm Hg, PaO2 68 mm Hg B. pH 7.46, PaCO2 32 mm Hg, PaO2 61 mm Hg C. pH 7.40, PaCO2 40 mm Hg, PaO2 62 mm Hg D. pH 7.39, PaCO2 30 mm Hg, PaO2 60 mm Hg โ
C. pH 7.40, PaCO2 40 mm Hg, PaO2 62 mm Hg The case study shows stage II asthma. Option c shows stage III asthma. The patient is still breathing at a fast rate, but carbon dioxide is starting to be retained as evidenced by the increase of the PaCO into normal range. Options a and b are still stage II. Option d shows a respiratory alkalosis with a metabolic acidosis because you would have expected the pH to be in an alkalotic range with the PaCO2 of 30. A patient experiencing alcohol withdrawal syndrome describes the swirls in the wallpaper as being worms. This is an example of which of the following? A. Delusion B. Hallucination C. Illusion D.
PaCO2 35 mm Hg HCO3 19 mEq/L PaO2 40 mm Hg Arterial oxygen saturation 75% Why does this patient have hypoxemia without hypercapnia? A. Because carbon dioxide is more diffusible than oxygen B. Because carbon dioxide has more driving pressure C. Because carbon dioxide is less diffusible than oxygen D. Because carbon dioxide excretion by the kidney is increased โ
Because carbon dioxide is more diffusible than oxygen Carbon dioxide is 20 times more diffusible than oxygen. In conditions that affect diffusion but do not affect ventilation, expect the PaO2 to be decreased and the PaCO2 to be normal (or decreased in hyperventilation, as in this patient). If ventilation were affected, such as if this patient were fatiguing, the PaCO2 then would increase. Driving pressure is the fraction of the gas in inspired air multiplied by the barometric pressure. Because carbon dioxide is ~0.5% of inspired air, the driving pressure would be very low. The kidney eliminates bicarbonate and hydrogen ions, but the lungs eliminate carbon dioxide. A 55-year-old patient has headache, nuchal rigidity, photophobia, and positive Kernig's and Brudzinski's signs. These are consistent with which of the following? A. Intracranial hemorrhage
B.
Subarachnoid hemorrhage C. Epidural hemorrhage D. Subdural hemorrhage โ
Subarachnoid hemorrhage When there is bleeding from an aneurysm, that blood irritates the meninges. The clinical presentation is very similar to meningitis. This clinical presentation is not consistent with intracranial, epidural, or subdural bleeding because the blood is not in contact with the meninges in those situations. An extra heart sound preceding S1 is most likely an S4 if the stethoscope's: A. diaphragm is over the apex. B. bell is over the aortic area. C. diaphragm is over the aortic area. D. bell is over the apex. โ
bell is over the apex.
B.
B waves C. C waves D. D waves โ
A waves, or plateau waves, are spontaneous, rapid increases in pressure between 50 and 200 mm Hg that last 5 minutes or more. A waves cause cerebral ischemia and are the most clinically significant ICP waveforms. Immediate intervention is necessary to prevent further brain injury and herniation. A waves are Awful Which of the following diagnostic tests would provide definitive evidence of a pneumothorax? A. Arterial blood gases B. Chest x-ray film C. Pulmonary function studies D. Spiral computed tomography โ
Chest x-ray film (Which is not really true.. but the test says so..
Which of the following does not shift the oxyhemoglobin dissociation curve to the left or the right? A. Blood pH B. 2,3-diphosphoglycerate (2,3-DPG) levels C. Body temperature D. Cardiac output โ
Cardiac output Body temperature, body pH, PaCO2 levels, and 2,3-DPG levels affect the oxyhemoglobin dissociation curve. Cardiac output does not directly affect the curve. Which of the following is the primary difference between a tracheostomy tube and a laryngectomy tube? A. The laryngectomy tube is longer. B. The laryngectomy tube does not have a cuff. C. Only the tracheostomy tube has an inner cannula. D. The tracheostomy tube has a larger lumen.
phosphate-binding antacids. C. calcium-containing antacids. D. histamine2 receptor antagonists. โ
magnesium-containing antacids. Magnesium-containing antacids can lead to magnesium intoxication in the patient with renal failure. A patient is complaining of dull, diffuse abdominal pain. Of the following possible causes, which is most likely to be the cause? A. Appendicitis B. Cholecystitis C. Ulcerative colitis D. Large intestinal obstruction โ
Large intestinal obstruction The rest are sharp pain Vt for extubation โ
5ml/kg
A 30-year-old man is in the surgical intensive care unit after exploratory laparotomy performed after he sustained a gunshot wound to the abdomen. He now has developed a pancreatic fistula. Which acid-base imbalance is this patient at risk for developing? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis โ
Metabolic acidosis The stomach is acidic, but the gastrointestinal tract below the stomach is alkaline. Pancreatic secretions are rich in bicarbonate, and these losses would cause metabolic acidosis. A 65-year-old man was admitted 2 hours ago after coronary artery bypass grafting. He has had the following vital sign changes: Admission 2 Hours Later Blood pressure (mm Hg) 110/80 96/ Heart rate (per minute) 85 100 Right atrial pressure (RAP; mm Hg) 6 2 Pulmonary artery pressure (PAP; mm Hg) 24/12 18/ Pulmonary artery occlusive pressure (PAOP; mm Hg) 10 5 Cardiac output (L/min) 6 4 Cardiac index (L/min/m2) 3.5 2.
Calcium D. Phosphate โ
Phosphate This often is called refeeding syndrome. Nutritional support allows the cells to begin making more adenosine triphosphate (ATP), and phosphate supplies are depleted. The same thing happens in diabetic ketoacidosis with treatment when insulin allows glucose to move into the cell increasing production of ATP and depletion of phosphate. Which of the following would be a contraindication to the use of fibrinolytic drugs, such as recombinant tissue plasminogen activator? A. Hypotension B. Heart block C. Uncontrolled hypertension D. Pain lasting more than 6 hours โ
Uncontrolled hypertension Pain of more than 6 hours duration is no longer a contraindication to the use of fibrinolytic drugs, although we certainly want to give fibrinolytic drugs as early as possible. Consider that pain indicates the presence of lactic acid and anaerobic metabolism. If the myocardial infarction is completed, there is no pain because dead myocardium does not metabolize aerobically or anaerobically. As long as there is pain, there is salvageable myocardium. Hypotension and heart block are not contraindications to fibrinolytic drugs, and they may improve with reperfusion of the myocardium. Uncontrolled hypertension increases the risk of hemorrhagic stroke.
A 72-year-old woman arrives at the emergency department after becoming unresponsive while watching television with her husband. The nurse observes paralysis of her right extremities, aphasia, and lethargy. The patient receives fibrinolytic therapy. After the patient is stabilized, a diet is offered. The nurse knows that before the patient eats, it is crucial to check which of the following cranial nerves? A. IX, X B. I, II C. III, VI D. VIII, XI โ
IX, X Cranial nerves IX and X control the gag and swallow response. These must be intact bilaterally to protect the patient's airway. glossopharngeal and vagus A 23-year-old man is admitted via the emergency department after a motorcycle collision. His Glasgow Coma Scale score was 12 in the emergency department, and it is still 12 upon his admission to the neurologic intensive care unit. Both eyes are ecchymotic and swollen shut, and he has multiple abrasions on his face. Which of the following is the most likely diagnosis? A. Linear skull fracture B.
A.
Educator B. Evaluator C. Facilitator D. Advocate โ
Advocate A patient develops carpopedal spasm and neuromuscular irritability manifested by Chvostek's and Trousseau's signs. Which electrolyte imbalance should you suspect? A. Hyperkalemia B. Hypercalcemia C. Hypermagnesemia D. Hyperphosphatemia โ
Hyperphosphatemia The patient's signs/symptoms are associated with hypocalcemia and its reciprocal condition, hyperphosphatemia. The same signs/symptoms also are seen in hypomagnesemia.
A patient with which of these conditions would have a normal serum lactate? A. Ventricular fibrillation B. Cardiogenic shock C. Severe anemia D. Renal failure โ
Renal failure All of these will cause metabolic acidosis, but in renal failure the acidosis is related to accumulation of nonvolatile acids (e.g., urea and uric acid). Ventricular fibrillation, cardiogenic shock, and severe anemia would decrease tissue oxygen delivery, resulting in the conversion of metabolism from aerobic to anaerobic and the buildup of lactic acid. Lactic acidosis is reflected as an increase in serum lactate level. A patient has a diagnosis of pulmonary embolism made by pulmonary arteriography. He now is receiving 100% oxygen via a non-rebreathing mask for 24 hours. The nurse is concerned about the possibility of oxygen toxicity. What is a common, early sign of oxygen toxicity? A. Cyanosis B. Hypercapnia C. Substernal chest pain
A decrease in static compliance would occur in which of the following? A. Pneumothorax B. Flail chest C. Bronchospasm D. Mucous plug โ
Pneumothorax Static compliance is the compliance of the lung when no air is moving, so it reflects the compliance of the lung and the chest wall. Dynamic compliance is the compliance of the lung when air is moving, so it reflects the compliance of the lung and chest wall plus airway resistance. Pneumothorax causes a sudden decrease in static compliance, whereas acute respiratory syndrome causes a gradual decrease in static compliance. Bronchospasm or mucous plug causes a decrease in dynamic compliance because it affects airway resistance. Flail chest actually would increase the static compliance because of the loss of intactness of the bony thorax. A 46-year-old woman is admitted to the critical care unit with acute respiratory failure as a result of pneumonia. Vital Signs Blood pressure 140/88 mm Hg Heart rate 108 beats/min Respiratory rate 26 breaths/min Temperature 39.8ยฐ C (103.8ยฐ F) Arterial Blood Gases
pH 7. PaCO2 54 mm Hg HCO3 24 mEq/L PaO2 60 mm Hg What effect would these alterations have on the oxyhemoglobin curve and oxygen saturation? A. A shift to the right and arterial oxygen saturation (SaO2) greater than 90% for the PaO2 of 60 mm Hg B. A shift to the left and SaO2 greater than 90% for the PaO2 of 60 mm Hg C. A shift to the left and SaO2 less than 90% for the PaO2 of 60 mm Hg D. A shift to the right and SaO2 less than 90% for the PaO2 of 60 mm Hg โ
This patient has hyperthermia and acidosis. Both of these cause a shift in the oxyhemoglobin dissociation curve to the right. Shift to the right causes a lower saturation for a given PaO2 because of a lower affinity between oxygen and hemoglobin. Though a PaO2 of 60 mm Hg usually is associated with an oxygen saturation of 90%, this patient would have a saturation of less than 90% for the PaO2 of 60 mm Hg. When the curve is shifted to the right, affinity is decreased. This means that the pickup of oxygen at the lung level is impaired but drop-off at the tissue level is improved. A shift of the curve to the left improves pickup of oxygen at the lung level but impairs drop-off at the tissue level. A 70-kg male patient with acute respiratory failure is being weaned from mechanical ventilation using the intermittent mandatory ventilation (IMV) method. Ventilator settings and current arterial blood gas results are as follows: Ventilator Settings Arterial Blood Gases Fraction of inspired oxygen, 0.35 pH, 7. Tidal volume, 700 mL HCO3, 22 mEq/L
