CCRN Exam QUESTIONS,Answers And
Rationale Recently Updated Practice
Save
Terms in this set (194)
The nurse is caring for a Continuously monitor the patient in lead II
patient with acute inferior
wall MI, post-coronary It is best practice to monitor the patient status post
artery stent deployment, PCI with stent, in the lead that was most abnormal
For optimal care of the during the acute occlusion.
patient, the nurse should:
The ECG demonstrates Complication likely to occur after an acute inferior
ST elevation in leads II, III wall MI include bradycardia secondary to ischemia
and aVF. The nurse needs to the SA and/or AV node, and papillary muscle
to monitor the patient rupture or dysfunction due to the anatomical
closely for which of the distance between the RCA and the papillary muscle.
following?
Which of the following B. the hemodynamic profile of RAP 5, PAOP 7, SVR
hemodynamic profiles 400 is typical of septic shock, and choice B would
would benefit from the be the best approach.
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
,Which of the following is The decrease in PaCO2 is evidence of respiratory
indicative of a mixed alkalosis and the decreased HCO3 is evidenced of a
acid-base disorder? metabolic acidosis. The pt with severe sepsis or
septic shock may present with this mixed acid-base
A. pH 7.18; PaCO2 25; disorder.
PaO2 64; HCO3 11
B. pH 7.33; PaCO2 29;
PaO2 72; HCO3 15
The patient with a Failure to capture (pacemaker without a QRS) may
temporary pacemaker be corrected by repositioning the patient to the
develops pacemaker side.
malfunction. The oriented
is instructed to reposition
the patient to try and
correct the problem. The
cardiac monitor most
likely demonstrates?
coronary artery perfusion.
Diastolic heart failure results in a problem with left
The patient with diastolic
ventricular FILLING secondary to ventricular
heart develops SVT, heart
thickening, and contractility and ejection are
rate 220/min. The most
maintained in diastolic failure. The rapid heart rate
dangerous hemodynamic
will decrease filling time, worsen left ventricular
effect is a decrease in:
filling and because coronary artery perfusion
occurs during diastole, this arrhythmia may be life-
threatening.
The patient is receiving Discontinue heparin and being argatroban.
heparin infusion for the
treatment of pulmonary The patient most likely has HIT. Exposure to heparin
embolism. There has needs to discontinued and a direct thrombin
been a 60% decrease in inhibitor started for continued anticoagulation.
the platelet count and no
clinical change. Which of
the following is
indicated?
,The patient with oat cell Phenytoin (Dilantin), 3% saline.
carcinoma has the
following clinical findings: The patient has signs of SIADH which results in
low urine output, low production of excessive ADH. Dilantin will inhibit
serum osmolality, ADH secretion and 3% saline will increase serum
hyponatremia, and sodium.
elevated urine sodium.
The nurse anticipates
which of the following as
part of the treatment
plan?
Peep therapy and Barotrauma
mechanical ventilation
are ordered for the The addition of positive end-expiratory pressure will
patient with acute increase alveolar recruitment, prevent atelectasis
respiratory failure. Which and improve oxygenation. However, the increase in
of the following is a intrathoracic pressure may lead to pneumothorax or
possible complication? subcutaneous emphysema.
The postoperative avoid high airway pressures
thoracic surgery patient
has bubbling in the water Bubbling in the water seal chamber is due to a
seal drainage chamber of pleural air leak, and high airway pressure will either
the chest tube. Which of prevent resolution of the current air leak or make it
the following worse.
interventions is
indicated?
Lung crackles
Which clinical sign might
patients with both
Both a problem with systolic (ejection problem) and
systolic and diastolic
diastolic (filling problem) will increase left heart
heart failure have in
pressure and cause cardiogenic pulmonary edema
common?
(lung crackles).
, Which of the following is Fever
most likely to result in a
low Sv02? Fever increases metabolic rate and consumption,
which may lead to a drop in mixed venous oxygen
A. Hypotermia saturation.
B. Fever
C. Severe sepsis
The nurse needs to Perform a square wave test
assess adequacy of the
tubing/catheter system
for the arterial line. Which
of the following
interventions will best
assess this?
The patient requires fluid Warm blood products and crystalloids
resuscitation and 8 units
of PRBC's status post Warming fluids and blood needed for traumatic
traumatic injury. Which of injury will prevent hypothermia and its related
the following adverse effects.
interventions is most
appropriate?
high dose vasopressors
Which of the following
therapies should be
Vasopressors increase left ventricular after load,
avoided for the patient
which would increase myocardial work of a failing
with cardiogenic shock?
heart.
The patient is status post Nimodipine (Nimotop)
repair of an aneurysm for
subarachnoid is a calcium channel blocker that is started
hemorrhage. Which of immediately post-op to prevent arterial spasm of
the following the brain.
interventions is indicated
to prevent vasospasm?
Rationale Recently Updated Practice
Save
Terms in this set (194)
The nurse is caring for a Continuously monitor the patient in lead II
patient with acute inferior
wall MI, post-coronary It is best practice to monitor the patient status post
artery stent deployment, PCI with stent, in the lead that was most abnormal
For optimal care of the during the acute occlusion.
patient, the nurse should:
The ECG demonstrates Complication likely to occur after an acute inferior
ST elevation in leads II, III wall MI include bradycardia secondary to ischemia
and aVF. The nurse needs to the SA and/or AV node, and papillary muscle
to monitor the patient rupture or dysfunction due to the anatomical
closely for which of the distance between the RCA and the papillary muscle.
following?
Which of the following B. the hemodynamic profile of RAP 5, PAOP 7, SVR
hemodynamic profiles 400 is typical of septic shock, and choice B would
would benefit from the be the best approach.
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
,Which of the following is The decrease in PaCO2 is evidence of respiratory
indicative of a mixed alkalosis and the decreased HCO3 is evidenced of a
acid-base disorder? metabolic acidosis. The pt with severe sepsis or
septic shock may present with this mixed acid-base
A. pH 7.18; PaCO2 25; disorder.
PaO2 64; HCO3 11
B. pH 7.33; PaCO2 29;
PaO2 72; HCO3 15
The patient with a Failure to capture (pacemaker without a QRS) may
temporary pacemaker be corrected by repositioning the patient to the
develops pacemaker side.
malfunction. The oriented
is instructed to reposition
the patient to try and
correct the problem. The
cardiac monitor most
likely demonstrates?
coronary artery perfusion.
Diastolic heart failure results in a problem with left
The patient with diastolic
ventricular FILLING secondary to ventricular
heart develops SVT, heart
thickening, and contractility and ejection are
rate 220/min. The most
maintained in diastolic failure. The rapid heart rate
dangerous hemodynamic
will decrease filling time, worsen left ventricular
effect is a decrease in:
filling and because coronary artery perfusion
occurs during diastole, this arrhythmia may be life-
threatening.
The patient is receiving Discontinue heparin and being argatroban.
heparin infusion for the
treatment of pulmonary The patient most likely has HIT. Exposure to heparin
embolism. There has needs to discontinued and a direct thrombin
been a 60% decrease in inhibitor started for continued anticoagulation.
the platelet count and no
clinical change. Which of
the following is
indicated?
,The patient with oat cell Phenytoin (Dilantin), 3% saline.
carcinoma has the
following clinical findings: The patient has signs of SIADH which results in
low urine output, low production of excessive ADH. Dilantin will inhibit
serum osmolality, ADH secretion and 3% saline will increase serum
hyponatremia, and sodium.
elevated urine sodium.
The nurse anticipates
which of the following as
part of the treatment
plan?
Peep therapy and Barotrauma
mechanical ventilation
are ordered for the The addition of positive end-expiratory pressure will
patient with acute increase alveolar recruitment, prevent atelectasis
respiratory failure. Which and improve oxygenation. However, the increase in
of the following is a intrathoracic pressure may lead to pneumothorax or
possible complication? subcutaneous emphysema.
The postoperative avoid high airway pressures
thoracic surgery patient
has bubbling in the water Bubbling in the water seal chamber is due to a
seal drainage chamber of pleural air leak, and high airway pressure will either
the chest tube. Which of prevent resolution of the current air leak or make it
the following worse.
interventions is
indicated?
Lung crackles
Which clinical sign might
patients with both
Both a problem with systolic (ejection problem) and
systolic and diastolic
diastolic (filling problem) will increase left heart
heart failure have in
pressure and cause cardiogenic pulmonary edema
common?
(lung crackles).
, Which of the following is Fever
most likely to result in a
low Sv02? Fever increases metabolic rate and consumption,
which may lead to a drop in mixed venous oxygen
A. Hypotermia saturation.
B. Fever
C. Severe sepsis
The nurse needs to Perform a square wave test
assess adequacy of the
tubing/catheter system
for the arterial line. Which
of the following
interventions will best
assess this?
The patient requires fluid Warm blood products and crystalloids
resuscitation and 8 units
of PRBC's status post Warming fluids and blood needed for traumatic
traumatic injury. Which of injury will prevent hypothermia and its related
the following adverse effects.
interventions is most
appropriate?
high dose vasopressors
Which of the following
therapies should be
Vasopressors increase left ventricular after load,
avoided for the patient
which would increase myocardial work of a failing
with cardiogenic shock?
heart.
The patient is status post Nimodipine (Nimotop)
repair of an aneurysm for
subarachnoid is a calcium channel blocker that is started
hemorrhage. Which of immediately post-op to prevent arterial spasm of
the following the brain.
interventions is indicated
to prevent vasospasm?
