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Quiz Session - Attempts With Random Questions

AACN CCRN (Adult) Exam Questions

Page 8 of 50

141.

Which of the following factors directly affects myocardial oxygen demand?

  • Heart rate

  • Preload

  • Afterload

  • Right ventricular pressure

Correct answer: Heart rate

Major physiologic factors that determine the heart’s demand for oxygen include the heart size, the left ventricular (LV) systolic pressure, the heart rate, and the level of myocardial inotropic state. Heart rate and contractility affect myocardial oxygen consumption. Any therapeutic intervention that diminishes heart size, LV pressure, heart rate, and inotropic state will decrease myocardial oxygen demand.

Preload, also known as the left ventricular end-diastolic pressure (LVEDP), is the amount of ventricular stretch at the end of diastole. Think of it as the heart loading up for the next big squeeze of the ventricles during systole. Some people remember this by using an analogy of a balloon. Blow air into the balloon and it stretches. The more air you blow in, the greater the stretch.

Afterload, also known as the systemic vascular resistance (SVR), is the amount of resistance the heart must overcome to open the aortic valve and push the blood volume out into the systemic circulation. It is the pressure that the ventricles must overcome to open the aortic and pulmonic valves and to pump blood into the systemic and pulmonary vasculature. If you think about the balloon analogy, afterload is represented by the knot at the end of the balloon. To get the air out, the balloon must work against that knot.

142.

A 69-year-old female patient in with a diagnosis of hepatic failure is admitted due to an extremely reduced appetite for the last two weeks, fatigue, and weakness. Her son, who cares for her, is very concerned about her nutritional status.

The critical care nurse expects the following laboratory testing to be done to evaluate for malnutrition:

  • albumin

  • electrolytes

  • bilirubin

  • complete blood count

Correct answer: albumin

The most helpful laboratory studies in assessing malnutrition in an adult are laboratory studies evaluating protein status, followed by hematological studies. Measures of protein nutritional status include serum albumin, prealbumin, transferrin, creatinine, CRP, cholesterol, and BUN levels. The best measure of long-term malnutrition is serum albumin because of its longer half-life.

The other answer choices may also be relevant to provide other clues to the patient's malnutrition, but albumin is expected for laboratory testing in malnutrition cases.

143.

When a patient with flail chest inspires, which of the following should the nurse expect to see?

  • The flail chest segment will move inwards

  • The flail chest segment will move outwards

  • The trachea will move away from the affected side

  • The trachea will move towards from the affected side

Correct answer: The flail chest segment will move inwards

Flail chest occurs when three or more contiguous ribs are fractured in at least two places, causing a free-floating flail chest segment of the chest wall. This segment will move inward during the negative pressure caused by inspiration and outwards with the positive pressure of expiration. This causes "paradoxical breathing", creating a less effective ventilatory pattern. Tracheal movement is not a common finding with flail chest.

144.

A patient who underwent kidney transplantation one week ago is found to have increased creatinine levels, fever, and graft tenderness. These symptoms MOST likely suggest which of the following?

  • Acute rejection

  • Hyperacute rejection

  • Chronic rejection

  • Cyclosporine A toxicity

Correct answer: Acute rejection

These symptoms suggest acute rejection, which can occur days to months after transplantation. Hyperacute rejection would have occurred within minutes to hours after transplantation. Chronic rejection usually occurs months to years post-transplantation and often presents subtly. Cyclosporine A toxicity typically presents with neurotoxicity, hirsutism, or gum hyperplasia, not graft tenderness.

145.

The gold standard for determining left ventricular function is:

  • ejection fraction

  • Cardiac Index (CI)

  • Cardiac Output (CO)

  • Left Ventricular End-Diastolic Pressure (LVEDP)

Correct answer: ejection fraction

Ejection fraction, the percentage of blood volume ejected from the left ventricle with each contraction, is the gold standard for determining left ventricular function and is helpful in selecting treatment strategies. A normal Left Ventricular Ejection Fraction (LVEF) is 55% to 60% and is one of the most important predictors of long-term outcome following acute MI.

146.

Which of the following would be considered a physiologic manifestation of anxiety?

  • Increased heart rate

  • Apprehension

  • Fidgeting

  • Crying

Correct answer: Increased heart rate

Chest pain would be considered a physiologic manifestation of anxiety.

Fidgeting and crying would be a behavioral manifestation of anxiety. Apprehension would be a cognitive manifestation of anxiety. 

147.

Which of the following valves can be replaced using a TAVR?

  • Only the aortic valve

  • The aortic and pulmonic valves

  • The mitral and tricuspid valves 

  • Only the mitral valve

Correct answer: Only the aortic valve

A Transcatheter Aortic Valve Replacement (TAVR) is a minimally invasive procedure used to replace the aortic valve using an approach that involves accessing the valve using transvenous catheters. Only the aortic valve can be accessed using this method.

148.

The MOST common form of intrarenal failure is:

  • Acute Tubular Necrosis (ATN)

  • Contrast-Induced Nephropathy (CIN)

  • pancreatitis

  • interstitial nephritis

Correct answer: Acute Tubular Necrosis (ATN)

Intrarenal failure is a disease of the kidney itself: the nephron, glomeruli, tubules, interstitium, or vasculature within the cortex or medulla. The underlying pathophysiologic abnormality in intrarenal failure is renal cellular damage. ATN involves medullary damage and is the most common form of intrarenal failure. Glomerular Filtration Rate (GFR) and tubular function cease; it is an injury secondary to decreased renal blood flow, causing hypoxia of the medullary area. Hypoperfusion causes structural damage, and the basement membrane is disrupted. Capillaries swell and slough off, and the glomerulus and tubules become obstructed.

CIN is seen in approximately 10% of patients receiving contrast media, and the idea is that the contrast media causes renal vasoconstriction. It is defined as a 25% increase in creatinine or an absolute increase of 0.5 mg/dL. At-risk patients include diabetics, the elderly, or those with underlying renal insufficiency. Pancreatitis and interstitial nephritis are both causes of ATN.

149.

Intravenous (IV) sodium bicarbonate is indicated in diabetic ketoacidosis (DKA) in which clinical situation? 

  • pH less than 7

  • pH greater than 7

  • Low anion gap

  • High anion gap 

Correct answer: pH less than 7

The most common precipitating scenarios associated with DKA are underlying or concomitant infection (40%), missed insulin (25%), and newly diagnosed, previously unknown diabetes (15%). Other causes make up about 20%, including MI, stroke, trauma, and pancreatitis. DKA is primarily a complication of type 1 diabetes, but can (rarely) occur in some forms of type 2 diabetes.

It is a biochemical triad of hyperglycemia, ketonemia, and metabolic acidosis with a large anion gap. DKA can develop in less than 24 hours, making prompt recognition of symptoms and treatment critical. The administration of adequate IV fluids, insulin, and potassium replacement is sufficient to reverse acidosis in most cases. 

Use of sodium bicarbonate is not recommended for patients with a pH > 7.0 in DKA. 

150.

In a patient with heart failure, which abnormal heart sound would the nurse expect to be MOST LIKELY? 

  • S3

  • S4

  • S1

  • S2

Correct answer: S3

In healthy adults, there are two normal heart sounds, often described as a lub and a dub, that occur in sequence with each heartbeat. These are the first heart sound (S1) and second heart sound (S2), produced by the closing of the atrioventricular valves and semilunar valves. S3 is an abnormal gallop that occurs during early diastole and is frequently caused by ventricular overload. It is an early sign of right heart failure and can also be heard in left heart failure. 

S4 is associated with angina more so than heart failure. While it may occur with heart failure, an S3 is more common.

151.

The LEADING complication post-hemorrhage or post-surgical repair of a Subarachnoid Hemorrhage (SAH) is:

  • cerebral vasospasm

  • deep vein thrombosis

  • diabetes insipidus

  • increased cerebral perfusion pressure

Correct answer: cerebral vasospasm

A Subarachnoid Hemorrhage (SAH) is bleeding into the space between the brain and the tissue covering the brain. Cerebral vasospasm after subarachnoid hemorrhage is a well-described phenomenon that is defined as narrowing of the large and medium-sized intracranial arteries; most often, it affects the anterior circulation supplied by the internal carotid arteries. Cerebral vasospasm leading to Delayed Cerebral Ischemia (DCI) continues to be a major complication and source of morbidity in cases of SAH.

152.

Arterial blood gases (ABGs) are frequently used as a diagnostic tool to assess many factors in a critically ill patient. Of the following, which does NOT address an ABG directly? 

  • Hemoglobin and hematocrit (H&H) values 

  • Oxygenation

  • Ventilatory status

  • Acid-base balance

Correct answer: Hemoglobin and hematocrit (H&H) values 

ABGs are frequently used to assess oxygenation, ventilatory status, and acid-base balance. Hemoglobin and hematocrit (H&H) values are interpreted (not directly assessed) for their impact on oxygenation and fluid balance. 

If the patient's condition warrants, the oxygen saturation values may be continuously monitored via connection to a noninvasive oxygen saturation monitor or via SvO2 through a pulmonary artery (PA) catheter device. 

153.

Which of the following clinical presentations is MOST suggestive of a subarachnoid hemorrhage?

  • Sudden severe headache with neck stiffness

  • Gradual onset of headache with confusion

  • Cyclical loss of consciousness followed by lucid intervals

  • Fluctuating level of consciousness with dilated pupils

Correct answer: Sudden severe headache with neck stiffness

Sudden severe headache with neck stiffness, often described as a "thunderclap" headache, is a characteristic presentation of subarachnoid hemorrhage. Gradual onset of headache with confusion is more typical of conditions like brain tumors or encephalitis. Loss of consciousness followed by a lucid interval is characteristic of an epidural hematoma, while a fluctuating level of consciousness with dilated pupils may suggest increased intracranial pressure or traumatic brain injury. Transient or prolonged loss of consciousness may occur; however, this is not as characteristic of a subarachnoid hemorrhage as a thunderclap headache.

154.

Which of the following is the BEST method to assess pain in a critically ill patient who is intubated and nonresponsive?

  • Behavioral pain scale 

  • Visual analog scale (VAS)

  • Vital signs

  • FLACC pain scale

Correct answer: Behavioral pain scale 

When a critically ill patient is unable to indicate their pain intensity either verbally or nonverbally, nurses must often use other criteria to assess the patient's pain. Using a behavioral pain scale provides a guide for identifying and assessing pain in nonverbal patients. Two examples include the Detroit Medical Center Behavioral Pain Scale and the Behavioral Pain Assessment Tool (BPAT). These scales measure facial signs and expressions, restlessness, muscle tone, vocalization, and consolability.  

Vital signs alone should not be used for pain assessment in a critically ill patient. The FLACC (Face, Legs, Activity, Cry, Consolability) pain scale is used in children, not adults. The VAS is used with patients who are not verbal but can still communicate nonverbally.

155.

Diagnostic testing for encephalitis encompasses all the following EXCEPT:

  • CT with contrast

  • MRI

  • EEG

  • CSF analysis

Correct answer: CT with contrast 

Encephalitis is inflammation of the brain parenchyma. There are many types of encephalitis, including arboviruses such as West Nile, but the most common type seen in most ICUs in the United States is encephalitis due to the herpes simplex virus (HSV). 

HSV encephalitis can result from a new infection, or can represent a reactivation of a preexisting infection. 

Signs and symptoms include fever, focal or diffuse neurologic changes, headache, and seizures. Diagnostic testing includes MRI, EEG, and CSF analysis. The diagnosis is often presumed, pending specialized testing of the CSF. Empiric therapy is started with an antiviral agent. 

CT with contrast is not an encephalitis diagnostic.

156.

The critical care nurse just received report on a female patient with new-onset generalized tonic-clonic (grand mal) seizures. While at her bedside, the nurse witnesses a seizure. 

What should the nurse's FIRST action be?

  • Position the patient on her side and provide supplemental oxygen 

  • Position the patient on her side and call a rapid response team (RRT)

  • Position the patient on her side and place pillows and blankets around the bed rails for padding 

  • Position the patient on her side and insert an oral airway 

Correct answer: Position the patient on her side and provide supplemental oxygen 

From a nursing perspective, the first priority is to protect the patient from injury. Ensure a safe environment during the seizure by clearing objects out of the area. Position the patient on her side to decrease aspiration risk, and provide supplemental oxygen to assist with maintaining adequate cerebral oxygenation. 

Padded side rails are no longer considered routine care and are indicated only for patients at high risk. Because the seizure has already started, it is impossible to insert an oral airway safely. Never try to restrain a seizing patient; movement is strong and involuntary, and you and the patient could be harmed. Hitting the code button or calling an RRT can be done, but will not immediately help the patient.

The nurse should also assess for precipitating events, aura, onset, duration, medication or interventions that stopped the seizure, if any, and postictal state. All should be documented in the nursing note after the seizure has ended. 

157.

If not managed properly, a major complication for the patient with Diabetes Insipidus (DI) is:

  • hypovolemic shock

  • bradycardia

  • hyponatremia

  • hypothermia

Correct answer: hypovolemic shock

The management of the patient in DI is aimed at correcting the profound fluid volume deficit and electrolyte imbalances associated with this condition. If fluid losses are not replaced, hypovolemic shock can develop rapidly. In addition to administering IV hypotonic solutions, the nurse must carefully record and monitor fluid status, vital signs, electrolytes, and neurologic status.

Hyponatremia and hypothermia are complications of Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH). Tachycardia (not bradycardia) is a complication of fluid volume deficit associated with DI.

158.

A patient has just been admitted to the critical care unit with a diagnosis of gastrointestinal bleeding. She is alert and oriented; however, she is very nauseated and adamant about needing to call her sister. The nurse says that she will call the sister to notify her of the admission. During the admission history, the nurse would like to assess the patient’s belief related to her admitting diagnosis.

What question would provide the nurse with information for understanding the patient’s cultural beliefs related to her diagnosis?

  • Why do you think you are sick?

  • When did you experience your first symptoms?

  •  Do you consume alcohol on a regular basis?

  • Does anyone else in your family have this bleeding problem?

Correct answer: Why do you think you are sick? 

All cultures have systems of health beliefs to explain what causes illness, how it can be cured or treated, and who should be involved in the process. Cultural issues play a major role in patient understanding and compliance with their specific diagnosis. Thus, the best way to assess the patient's cultural beliefs related to the diagnosis is to simply ask why she believes she is sick.

The other questions are an appropriate and relevant part of their medical history, but they will not address her cultural beliefs.

159.

Which of the following drugs is MOST LIKELY to cause rhabdomyolysis when overdosed on?

  • Phencyclidine

  • Acetaminophen

  • Heroin

  • Barbituates

Correct answer: Phencyclidine

Phencyclidine (PCP) is a hallucinogenic drug that can cause rhabdomyolysis when overdosed. Barbituates and heroin overdoses typically leads to respiratory depression and CNS Suppression. Acetaminophen overdoses lead to liver failure.

160.

Which of the following situations BEST demonstrates clinical inquiry?

  • A nurse asks a practice committee for the rationale behind why Homans' sign is part of the critical care unit's standard assessment

  • A patient asks the nurse about the proper technique for administering Lovenox

  • A nursing student asks for guidance on how to change a wound dressing

  • A charge nurse asks a critical care nurse if they can work an extra four hours to make up a hole in the unit's staffing

Correct answer: A nurse asks a practice committee for the rationale behind why Homans' sign is part of the critical care unit's standard assessment

Clinical inquiry refers to the ongoing process of questioning and evaluating practice and providing informed practice. Asking a practice committee about the rationale for an outdated assessment technique does demonstrate clinical inquiry. A patient or nursing student asking for teaching on how to perform a care task is teaching-related and is not an inquiry that is focused on improving care, but on learning a skill. Asking a nurse to work late is not an example of clinical inquiry.

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