CCRN Test Bank Practice 2 Exam
Questions And Answers Recently
Updated Solution
A patient's blood pressure is 82/48 after an infusion of 30 mL/kg of 0.9 NS over the past hour. The heart
rate is 126 beats/minute, the temperature is 35°C, the hemoglobin is 8.9 g/dL, the WBC count is 4,000,
and the bands are 22%. A pulmonary artery catheter was inserted, and the following measurements
were obtained: pulmonary artery pressure 22/8 mmHg, central venous pressure 1 mmHg, pulmonary
artery occlusion pressure 4 mmHg, cardiac output 7.0 L/minute, and systemic vascular resistance 600
dynes/s/cm-5.bet. This patient needs:
(A) continued fluids, a blood transfusion, and pressor.
(B) discontinuation of fluids, a blood transfusion, and warming.
(C) reduction in the fluid rate, positive inotropes, and preload reducers.
(D) continued fluids, vasopressors, and antibiotics. - ANSWER ✔ - (D) continued fluids, vasopressors, and
antibiotics.
A nurse notices that patients who are receiving PCA therapy have had more adverse effects and have
generated a lot of safety reports over the past month. She asks the clinical nurse specialist whether
anyone else has noticed these increases, and the CNS says "No." What would be the ideal strategy for
the nurse to follow at this point?
(A) Poll the unit nurses and 2 noncritical care units about whether an increase in adverse effects has
been noticed.
(B) Discuss the finding with the author of the hospital PCA Standing Orders. (C) Undertake a chart audit
of all patients who have received PCA therapy in the previous 6 months.
(D) List all future adverse effects for the next 30 days. - ANSWER ✔ - (C) Undertake a chart audit of all
patients who have received PCA therapy in the previous 6 months.
The physician asks the nurse to call if there are any signs of increased intracranial pressure. Clinical
changes that are indicative of an increase in the ICP for the majority of neurological problems are seen
in which order of progression (early to late) of those listed below?
(A) pupillary inequality, change in the level of consciousness, vital sign changes
(B) change in the level of consciousness, vital sign changes, pupillary inequality
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,(C) vital sign changes, pupillary inequality, pupils fixed and dilated
(D) change in the level of consciousness, pupillary inequality, vital sign changes - ANSWER ✔ - (D) change
in the level of consciousness, pupillary inequality, vital sign changes
Which of the following sets of assessments indicates organ dysfunction according to the qSOFA score?
(A) BP 96/48, respiratory rate 28 breaths/minute, Glasgow Coma Scale (GCS) 12
(B) temperature 39°C, heart rate 104 beats/minute, respiratory rate 24breaths/minutes
(C) BP 104/48, heart rate 106 beats/minute, WBC count 18,000
(D) temperature 34°C, respiratory rate 24 breaths/minute, bands 12% - ANSWER ✔ - (A) BP 96/48,
respiratory rate 28 breaths/minute, Glasgow Coma Scale (GCS) 12
Which of the following would a nurse anticipate with the initiation of a nitroprusside (Nipride) infusion?
(A) decreased contractility
(B) increased pulmonary vascular resistance
(C) decreased afterload
(D) increased preload. - ANSWER ✔ - (C) decreased afterload
A patient was admitted 12 hours ago with an acute inferior wall MI. Which of the following would be
expected on the 12-lead ECG?
(A) ST elevation and deep Q-waves in I, II, and aVL
(B) ST depression in I and aVL
(C) ST elevation and deep Q-waves in V2, V3, and V4
(D) ST depression in II, III, and aVF - ANSWER ✔ - (D) ST depression in II, III, and aVF
Which of the following is NOT a negative outcome of immobility?
(A) increased resting heart rate
(B) dementia
(C) pain
(D) urinary retention - ANSWER ✔ - (B) dementia
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,A patient was admitted status post fall from a third-story roof. A chest X-ray reveals a fracture of left ribs
4 through 6, and chest excursion on the left side is diminished. The patient's vital signs include: BP
84/54, heart rate 130 beats/minute, and respiratory rate 32 breaths/minute. Which of the following
immediate interventions is indicated?
(A) oxygen, a fluid bolus, left-sided chest tube insertion
(B) intubation, pressors, left-sided chest tube insertion
(C) oxygen, a fluid bolus, pericardiocentesis
(D) intubation, fluids, emergency surgery - ANSWER ✔ - (A) oxygen, a fluid bolus, left-sided chest tube
insertion
Which of the following is an evidence-based indication of the need for an indwelling urinary catheter?
(A) the presence of an infection
(B) an acute pelvic fracture
(C) the presence of a stage 1 pressure injury
(D) a provider order for shift intake and output - ANSWER ✔ - (B) an acute pelvic fracture
A type 1 diabetic is training for a 10K run and develops tachycardia, slurred speech, and confusion.
Which of the following does this patient most likely need?
(A) an immediate glucose source
(B) insulin
(C) a CT scan of the head
(D) fluids - ANSWER ✔ - (A) an immediate glucose source
Fluid and electrolyte balance require close monitoring for a patient with acute pancreatitis due to which
of the following?
(A) increased diuresis secondary to pancreatic enzyme release
(B) increased incidences of hypercalcemia
(C) increased capillary permeability, resulting in fluid loss from the vascular space
(D) hypoglycemia due to pancreatic cell destruction - ANSWER ✔ - (C) increased capillary permeability,
resulting in fluid loss from the vascular space
A patient is status post percutaneous coronary intervention, and labs reveal a PTT of 210 seconds.
Which of the following is indicated?
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, (A) heparin
(B) vitamin K
(C) protamine sulfate
(D) fresh frozen plasma - ANSWER ✔ - (C) protamine sulfate
A nurse notices that a patient who was admitted with acute pancreatitis demonstrates a left hand
spasm when she inflates the BP cuff on the patient's left arm. Which of the following is the most likely
assessment?
(A) positive Chvostek sign, hypophosphatemia
(B) positive Trousseau sign, hypocalcemia
(C) positive Kernig's sign, hypermagnesemia
(D) positive Cullen's sign, hypercalcemia - ANSWER ✔ - (B) positive Trousseau sign, hypocalcemia
A nurse is interested in getting approval for a protocol that he learned from a nationally known expert at
a nursing conference he recently attended. Which of the following strategies would be most effective in
convincing hospital leadership that the new protocol is financially worthwhile?
(A) Send copies of the protocol and the conference presentation to the nursing leadership.
(B) Present a summary of research (that relates the protocol to a decreased
length of patient stay) to the nursing leadership.
(C) Outline favorable patient outcomes that have been demonstrated at other hospitals that adopted
the protocol.
(D) Ask for a meeting with the unit medical director to request adoption of the
to be protocol. - ANSWER ✔ - (B) Present a summary of research (that relates the protocol to a
decreased length of patient stay) to the nursing leadership.
A patient develops an acute onset of inspiratory and expiratory wheezing throughout the lung fields.
Which of the following statements about this patient is CORRECT?
(A) The patient has acute heart failure and requires morphine.
(B) The patient has an asthma exacerbation and immediately requires bronchodilators.
(C) The patient has an asthma exacerbation and immediately requires corticosteroids.
(D) The patient has acute heart failure and requires a diuretic. - ANSWER ✔ - (B) The patient has an
asthma exacerbation and immediately requires bronchodilators.
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Questions And Answers Recently
Updated Solution
A patient's blood pressure is 82/48 after an infusion of 30 mL/kg of 0.9 NS over the past hour. The heart
rate is 126 beats/minute, the temperature is 35°C, the hemoglobin is 8.9 g/dL, the WBC count is 4,000,
and the bands are 22%. A pulmonary artery catheter was inserted, and the following measurements
were obtained: pulmonary artery pressure 22/8 mmHg, central venous pressure 1 mmHg, pulmonary
artery occlusion pressure 4 mmHg, cardiac output 7.0 L/minute, and systemic vascular resistance 600
dynes/s/cm-5.bet. This patient needs:
(A) continued fluids, a blood transfusion, and pressor.
(B) discontinuation of fluids, a blood transfusion, and warming.
(C) reduction in the fluid rate, positive inotropes, and preload reducers.
(D) continued fluids, vasopressors, and antibiotics. - ANSWER ✔ - (D) continued fluids, vasopressors, and
antibiotics.
A nurse notices that patients who are receiving PCA therapy have had more adverse effects and have
generated a lot of safety reports over the past month. She asks the clinical nurse specialist whether
anyone else has noticed these increases, and the CNS says "No." What would be the ideal strategy for
the nurse to follow at this point?
(A) Poll the unit nurses and 2 noncritical care units about whether an increase in adverse effects has
been noticed.
(B) Discuss the finding with the author of the hospital PCA Standing Orders. (C) Undertake a chart audit
of all patients who have received PCA therapy in the previous 6 months.
(D) List all future adverse effects for the next 30 days. - ANSWER ✔ - (C) Undertake a chart audit of all
patients who have received PCA therapy in the previous 6 months.
The physician asks the nurse to call if there are any signs of increased intracranial pressure. Clinical
changes that are indicative of an increase in the ICP for the majority of neurological problems are seen
in which order of progression (early to late) of those listed below?
(A) pupillary inequality, change in the level of consciousness, vital sign changes
(B) change in the level of consciousness, vital sign changes, pupillary inequality
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,(C) vital sign changes, pupillary inequality, pupils fixed and dilated
(D) change in the level of consciousness, pupillary inequality, vital sign changes - ANSWER ✔ - (D) change
in the level of consciousness, pupillary inequality, vital sign changes
Which of the following sets of assessments indicates organ dysfunction according to the qSOFA score?
(A) BP 96/48, respiratory rate 28 breaths/minute, Glasgow Coma Scale (GCS) 12
(B) temperature 39°C, heart rate 104 beats/minute, respiratory rate 24breaths/minutes
(C) BP 104/48, heart rate 106 beats/minute, WBC count 18,000
(D) temperature 34°C, respiratory rate 24 breaths/minute, bands 12% - ANSWER ✔ - (A) BP 96/48,
respiratory rate 28 breaths/minute, Glasgow Coma Scale (GCS) 12
Which of the following would a nurse anticipate with the initiation of a nitroprusside (Nipride) infusion?
(A) decreased contractility
(B) increased pulmonary vascular resistance
(C) decreased afterload
(D) increased preload. - ANSWER ✔ - (C) decreased afterload
A patient was admitted 12 hours ago with an acute inferior wall MI. Which of the following would be
expected on the 12-lead ECG?
(A) ST elevation and deep Q-waves in I, II, and aVL
(B) ST depression in I and aVL
(C) ST elevation and deep Q-waves in V2, V3, and V4
(D) ST depression in II, III, and aVF - ANSWER ✔ - (D) ST depression in II, III, and aVF
Which of the following is NOT a negative outcome of immobility?
(A) increased resting heart rate
(B) dementia
(C) pain
(D) urinary retention - ANSWER ✔ - (B) dementia
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,A patient was admitted status post fall from a third-story roof. A chest X-ray reveals a fracture of left ribs
4 through 6, and chest excursion on the left side is diminished. The patient's vital signs include: BP
84/54, heart rate 130 beats/minute, and respiratory rate 32 breaths/minute. Which of the following
immediate interventions is indicated?
(A) oxygen, a fluid bolus, left-sided chest tube insertion
(B) intubation, pressors, left-sided chest tube insertion
(C) oxygen, a fluid bolus, pericardiocentesis
(D) intubation, fluids, emergency surgery - ANSWER ✔ - (A) oxygen, a fluid bolus, left-sided chest tube
insertion
Which of the following is an evidence-based indication of the need for an indwelling urinary catheter?
(A) the presence of an infection
(B) an acute pelvic fracture
(C) the presence of a stage 1 pressure injury
(D) a provider order for shift intake and output - ANSWER ✔ - (B) an acute pelvic fracture
A type 1 diabetic is training for a 10K run and develops tachycardia, slurred speech, and confusion.
Which of the following does this patient most likely need?
(A) an immediate glucose source
(B) insulin
(C) a CT scan of the head
(D) fluids - ANSWER ✔ - (A) an immediate glucose source
Fluid and electrolyte balance require close monitoring for a patient with acute pancreatitis due to which
of the following?
(A) increased diuresis secondary to pancreatic enzyme release
(B) increased incidences of hypercalcemia
(C) increased capillary permeability, resulting in fluid loss from the vascular space
(D) hypoglycemia due to pancreatic cell destruction - ANSWER ✔ - (C) increased capillary permeability,
resulting in fluid loss from the vascular space
A patient is status post percutaneous coronary intervention, and labs reveal a PTT of 210 seconds.
Which of the following is indicated?
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, (A) heparin
(B) vitamin K
(C) protamine sulfate
(D) fresh frozen plasma - ANSWER ✔ - (C) protamine sulfate
A nurse notices that a patient who was admitted with acute pancreatitis demonstrates a left hand
spasm when she inflates the BP cuff on the patient's left arm. Which of the following is the most likely
assessment?
(A) positive Chvostek sign, hypophosphatemia
(B) positive Trousseau sign, hypocalcemia
(C) positive Kernig's sign, hypermagnesemia
(D) positive Cullen's sign, hypercalcemia - ANSWER ✔ - (B) positive Trousseau sign, hypocalcemia
A nurse is interested in getting approval for a protocol that he learned from a nationally known expert at
a nursing conference he recently attended. Which of the following strategies would be most effective in
convincing hospital leadership that the new protocol is financially worthwhile?
(A) Send copies of the protocol and the conference presentation to the nursing leadership.
(B) Present a summary of research (that relates the protocol to a decreased
length of patient stay) to the nursing leadership.
(C) Outline favorable patient outcomes that have been demonstrated at other hospitals that adopted
the protocol.
(D) Ask for a meeting with the unit medical director to request adoption of the
to be protocol. - ANSWER ✔ - (B) Present a summary of research (that relates the protocol to a
decreased length of patient stay) to the nursing leadership.
A patient develops an acute onset of inspiratory and expiratory wheezing throughout the lung fields.
Which of the following statements about this patient is CORRECT?
(A) The patient has acute heart failure and requires morphine.
(B) The patient has an asthma exacerbation and immediately requires bronchodilators.
(C) The patient has an asthma exacerbation and immediately requires corticosteroids.
(D) The patient has acute heart failure and requires a diuretic. - ANSWER ✔ - (B) The patient has an
asthma exacerbation and immediately requires bronchodilators.
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