PCCN EXAM 2025/2026 VERIFIED
QUESTIONS AND ANSWERS GRADED A+
LATEST!!
Which of the ff findings is most indicative of a ruptured aortic aneurysm
A. Back pain
B. bounding peripheral pulses
C. intermittent claudication
D. warm, flushed skin
A. An aneurysm is the localized dilation of an artery. Should an aneurysm rupture,
blood will build up under pressure in the tissues surrounding the aorta, which can
result in acute pain and tenderness in theses areas. This is particularly the case if
the aneurysm leaks from the back of the aorta. Ruptured AAA presents with a
classic triad of pain in the flank or back, hypotension and a pulsatile abdominal
mass; however, only about half of the full triad. The pt will complain of the pain
and may feel cold, sweaty and faint on standing. The pt may also report abdominal
pain. A small percentage may have vomiting
According to recommendations based on research findings, pain assessment should
occur
A. based on changes in vital signs
B. only when the pt movements indicate the pt is seeking attention
C. routinely, regardless of physical findings
D. only when the presence of pain can be validated
,C. Pain is considered the fifth vital sign and must be assessed regularly. Presence
of physical findings may be part of the comprehensive assessment of pain.
However, physical findings may not be present in all patients with pain
A pt with a tracheostomy requires frequent suctioning for thick sputum, A nurse
finds a colleague instilling saline in the endotracheal tube prior to suctioning. The
most appropriate response by the nurse would be to
A. report the colleague to the charge nurse or manager
B. noted the practice on the pt chart to ensure consistency of suctioning techniques
C. ask the attending physician to review the suctioning policy.
D. collaborate with the colleague to review the evidence about this practice.
D. In addition to an unappreciable increase in sputum recovery, use of NS
adversely affects arterial and global tissue oxygenation and dislodges bacterial
colonies, thus contributing to lower airway contamination. Other harmful pt
outcomes have been reported in the nursing literature, including delays in return to
baseline vital signs, Spo2 and intracranial pressure. Because no solid scientifically
based benefits for routine use of normal saline have been shown, it is highly
recommended that this potentially harmful practice be abandoned. Instead,
treatment considerations should center on ways to prevent the development of
thick tenacious secretions. A review of these data should take place with the
colleague to help mitigate continuation of this dangerous practice
Upon admission to the PCU, you screen a pt to determine whether to administer an
influenza vaccine. Which of the following is a contraindication to the vaccine?
A. Guillian-Barre syndrome
B. chronic renal failure
,C. COPD
D. cirrhosis
A. Persons who developed Guillain-Barre syndrome after receiving an influenza
vaccine should not receive the influenza vaccine without checking with their
provider
Emergency treatment of ventricular dysrhythmias for the pt who has an ICD
pacemaker includes which of the following
A. If a pt develops vfib, the nurse should not defibrillate with external paddles
B. if the ICD is firing correctly and the pt does not have pulse, CPR is not
indicated
C. when preparing for external defibrillation, avoid placing the paddle directly over
the ICD pulse generator
D. when you need to turn off all functions of the ICD or pacemaker, apply a
magnet
C. Defibrillation has been known to cause malfunction of an ICD or pacemaker.
Care should be taken to ensure the defibrillation paddle/ pads are applied at least 4-
finger breaths away from the device. The anterior-lateral and anterior-posterior
positions for paddle/pad placement are acceptable in a pt with a permanent ICD or
pacemaker. The pads may also be placed safely away from the ICD with 1 pad at
the apex left mid-axillary, 5th ICS., and the other pad right of the sternum just
below the clavicle.
Based on the device implanted and the manufacturer, application of a magnet may
turn device off or reset to the default settings.
, A pt is admitted following mitral valve replacement. Which of the following
should most likely be included in the patent's plan of care
A. positive inotropic agent
B. anticoagulant
C. prophylactic antibiotic
D. ACE inhibitor
B. Anticoagulatn therapy recommendations are based on the valve apparatus and
the pt risk factors (afib, LV dyfunction, previous thromboembolism, and
hypercoagulable condition). Mechanical valve replacement require lifelong
anticoagulant therapy, while most pt with bioprosthetic valve replacement require
short term anti-coagulation (3 months). In pt with NSR and no risk factors for
thrombus, only aspirin therapy is recommended after bioprosthetic valve
replacement.
Two days following a near-drowning accident, a pt is dyspneic, using accessory
muscles, expectorating large amounts of secretions and reporting feeling of
impending death. Changes to the assessment data include
RR- 24 TO 36
CXR clear to bilateral diffuse infiltrates
ABG 40% face mask or 100% non-rebreather mask
pO2 120 mm Hg to 56 mm Hg
pCO2 33 mmHg to 56 mmHg
pH 7.42 to 7.35
HCO3 24 meq/L to 27 mEq/L
QUESTIONS AND ANSWERS GRADED A+
LATEST!!
Which of the ff findings is most indicative of a ruptured aortic aneurysm
A. Back pain
B. bounding peripheral pulses
C. intermittent claudication
D. warm, flushed skin
A. An aneurysm is the localized dilation of an artery. Should an aneurysm rupture,
blood will build up under pressure in the tissues surrounding the aorta, which can
result in acute pain and tenderness in theses areas. This is particularly the case if
the aneurysm leaks from the back of the aorta. Ruptured AAA presents with a
classic triad of pain in the flank or back, hypotension and a pulsatile abdominal
mass; however, only about half of the full triad. The pt will complain of the pain
and may feel cold, sweaty and faint on standing. The pt may also report abdominal
pain. A small percentage may have vomiting
According to recommendations based on research findings, pain assessment should
occur
A. based on changes in vital signs
B. only when the pt movements indicate the pt is seeking attention
C. routinely, regardless of physical findings
D. only when the presence of pain can be validated
,C. Pain is considered the fifth vital sign and must be assessed regularly. Presence
of physical findings may be part of the comprehensive assessment of pain.
However, physical findings may not be present in all patients with pain
A pt with a tracheostomy requires frequent suctioning for thick sputum, A nurse
finds a colleague instilling saline in the endotracheal tube prior to suctioning. The
most appropriate response by the nurse would be to
A. report the colleague to the charge nurse or manager
B. noted the practice on the pt chart to ensure consistency of suctioning techniques
C. ask the attending physician to review the suctioning policy.
D. collaborate with the colleague to review the evidence about this practice.
D. In addition to an unappreciable increase in sputum recovery, use of NS
adversely affects arterial and global tissue oxygenation and dislodges bacterial
colonies, thus contributing to lower airway contamination. Other harmful pt
outcomes have been reported in the nursing literature, including delays in return to
baseline vital signs, Spo2 and intracranial pressure. Because no solid scientifically
based benefits for routine use of normal saline have been shown, it is highly
recommended that this potentially harmful practice be abandoned. Instead,
treatment considerations should center on ways to prevent the development of
thick tenacious secretions. A review of these data should take place with the
colleague to help mitigate continuation of this dangerous practice
Upon admission to the PCU, you screen a pt to determine whether to administer an
influenza vaccine. Which of the following is a contraindication to the vaccine?
A. Guillian-Barre syndrome
B. chronic renal failure
,C. COPD
D. cirrhosis
A. Persons who developed Guillain-Barre syndrome after receiving an influenza
vaccine should not receive the influenza vaccine without checking with their
provider
Emergency treatment of ventricular dysrhythmias for the pt who has an ICD
pacemaker includes which of the following
A. If a pt develops vfib, the nurse should not defibrillate with external paddles
B. if the ICD is firing correctly and the pt does not have pulse, CPR is not
indicated
C. when preparing for external defibrillation, avoid placing the paddle directly over
the ICD pulse generator
D. when you need to turn off all functions of the ICD or pacemaker, apply a
magnet
C. Defibrillation has been known to cause malfunction of an ICD or pacemaker.
Care should be taken to ensure the defibrillation paddle/ pads are applied at least 4-
finger breaths away from the device. The anterior-lateral and anterior-posterior
positions for paddle/pad placement are acceptable in a pt with a permanent ICD or
pacemaker. The pads may also be placed safely away from the ICD with 1 pad at
the apex left mid-axillary, 5th ICS., and the other pad right of the sternum just
below the clavicle.
Based on the device implanted and the manufacturer, application of a magnet may
turn device off or reset to the default settings.
, A pt is admitted following mitral valve replacement. Which of the following
should most likely be included in the patent's plan of care
A. positive inotropic agent
B. anticoagulant
C. prophylactic antibiotic
D. ACE inhibitor
B. Anticoagulatn therapy recommendations are based on the valve apparatus and
the pt risk factors (afib, LV dyfunction, previous thromboembolism, and
hypercoagulable condition). Mechanical valve replacement require lifelong
anticoagulant therapy, while most pt with bioprosthetic valve replacement require
short term anti-coagulation (3 months). In pt with NSR and no risk factors for
thrombus, only aspirin therapy is recommended after bioprosthetic valve
replacement.
Two days following a near-drowning accident, a pt is dyspneic, using accessory
muscles, expectorating large amounts of secretions and reporting feeling of
impending death. Changes to the assessment data include
RR- 24 TO 36
CXR clear to bilateral diffuse infiltrates
ABG 40% face mask or 100% non-rebreather mask
pO2 120 mm Hg to 56 mm Hg
pCO2 33 mmHg to 56 mmHg
pH 7.42 to 7.35
HCO3 24 meq/L to 27 mEq/L
