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Quiz Session - Attempts With Random Questions

AACN CCRN (Adult) Exam Questions

Page 9 of 50

161.

In regards to patient restraints, which of the following is an example of a nurse demonstrating the principle of nonmaleficence?

  • The nurse tries alternatives to restraints, such as pain relief 

  • The nurse administers a sedative to help the patient get to sleep 

  • The nurse over-sedates the patient to avoid using physical restraints 

  • The nurse provides 1:1 supervision to the patient to ensure the patient's safety 

Correct answer: The nurse tries alternatives to restraints, such as distractions

The principle of nonmaleficence imposes the duty to do no harm. This injunction suggests that the nurse should not knowingly inflict harm, and is responsible if negligent actions result in detrimental consequences. 

The use of restraints violates the patient's autonomy, even when they are used for the benefit of the patient's safety (nonmaleficence). There must be a physician's order for the use of restraints. Alternative treatments, such as scheduled toileting, offering food and drink, pain relief, and distractions (e.g., presence of family), should be considered before choosing to apply physical restraints.

Sedation is appropriate when it helps calm the patient (not for the sole purpose of putting the patient to sleep). Over-sedation is considered a chemical restraint, and should never take the place of nursing assessment and appropriate intervention(s). One-to-one (1:1) supervision is only warranted if it is ordered by the physician. While this is an example of nonmaleficence, since it is not a specific physician order, this could potentially cause the nurse to neglect her other patients, thus causing harm to them unintentionally. Therefore, it is not a solution in this scenario. 

162.

What is the rationale for elevating the affected limb above the heart in a patient who is developing compartment syndrome?  

  • The affected limb should not be elevated

  • Venous return will be enhanced, reducing fluid volumes accumulating in the compartment

  • Elevation of the extremity enhance lymphatic system function using gravitational forces

  • Elevating the extremity reduces blood flow to the affected area, slowing development of compartment syndrome

Correct answer: The affected limb should not be elevated

Compartment syndrome causes fluid to accumulate in the interstitial space of a muscle compartment. Enhancing venous return does not reduce interstitial edema in the compartment. Lymphatic function will not be significantly improved by increased gravitational force. Elevating the extremity does reduce blood flow to the affected area, but this does not slow the development of compartment syndrome. It instead decreases circulation to the area, worsening the condition. This is why elevation of the extremity is contraindicated.

163.

How often should vital signs and neurological assessment be performed for a patient who has received Recombinant Tissue Plasminogen Activator (rtPA) for acute ischemic stroke?

  • Every 15 minutes for the first two hours, then every 30 minutes for six hours, then hourly until 24 hours following initial treatment

  • Every 30 minutes for six hours, then hourly until 24 hours following initial treatment

  • Every 15 minutes for the first hour, then every 30 minutes for two hours, then every four hours until 24 hours following initial treatment

  • Every 30 minutes for four hours, then hourly until 24 hours following initial treatment

Correct answer: Every 15 minutes for the first two hours, then every 30 minutes for six hours, then hourly until 24 hours following initial treatment 

Fibrinolytic therapy is administered for acute ischemic stroke in an attempt to restore perfusion to the affected area. IV administration of rtPA is considered in all patients who meet criteria and can be treated within three hours of the onset of symptoms. Due to the increased risk of Intracerebral Hemorrhage (ICH) following rtPA administration, frequent vital signs and neurologic assessments are essential. Vital signs and neurologic checks are done every 15 minutes for the first two hours after rtPA is administered, then every 30 minutes for an additional six hours, then every hour until 24 hours have passed since rtPA was given. If neurologic deterioration occurs, rtPA is stopped (if still infusing), the physician is notified, and a stat head CT is performed to assess for bleeding. 

164.

Which of the following infection pattern is MOST LIKELY in a patient who develops pneumonia that has a hematogenous origin?

  • Diffuse distribution in both lungs

  • Diffuse distribution in one lung

  • Localized in the right lower lobe

  • Localized in the right upper lobe

Correct answer: Diffuse distribution in both lungs

Pneumonia with a hematogenous origin is caused by infectious organisms that access the bloodstream from another part of the body, then lodge in the pulmonary vasculature. The mechanism of the origin for this form of pneumonia results in an infection that is spread evenly throughout both lungs.

165.

The critical care nurse is caring for a 35-year-old female admitted to the ICU with a recurring bowel obstruction. She has been experiencing uncontrolled vomiting for the last several hours despite the use of antiemetics. Her ABG results are as follows: 

  • pH: 7.49
  • PaCO2: 41 mmHg
  • HCO3: 32 mEq/L

What type of acid-base imbalance is this patient currently experiencing?

  • Acute (uncompensated) metabolic alkalosis

  • Acute (uncompensated) respiratory alkalosis

  • Partially compensated metabolic alkalosis

  • Partially compensated respiratory alkalosis

Correct answer: Acute (uncompensated) metabolic alkalosis 

Normal pH ranges from 7.35–7.45. Since this patient's pH is above 7.45, she is alkalotic. Normal CO2 (carbon dioxide) levels range from 35–45 mmHg, and normal HCO3 (bicarbonate) levels range from 22–26 mEq/L. CO2 is the respiratory component and HCO3 is the metabolic component. The component that matches the pH is the system controlling the ABG (Arterial Blood Gases).

In this scenario, the pH is high, indicating alkalosis; the primary source of the acid-base imbalance is metabolic, as evidenced by the elevated bicarbonate level, but the compensatory buffering system value remains in the normal range (CO2 of 41). Thus, there is no evidence of compensation occurring. Treatment of this patient might include the administration of IV fluids and measures to reduce the excess base.

166.

Thyroid hormone secretion is regulated by hormones from which of the following glands?

  • Anterior pituitary, hypothalamus

  • Anterior pituitary, thalamus

  • Posterior pituitary, parathyroid

  • Posterior pituitary, adrenal

Correct answer: Anterior pituitary, hypothalamus

Thyroid-Releasing Hormone (TRH) from the hypothalamus stimulates TSH (Thyroid Stimulating Hormone) from the anterior pituitary, which stimulates thyroid hormone release and secretion. The parathyroid gland produces parathyroid hormone, not thyroid hormones. The posterior pituitary gland and adrenal glands do not regulate thyroid hormone secretion.

167.

A patient with acute respiratory distress syndrome (ARDS) is on a volume mechanical ventilator. The nurse notes a high peak inspiratory pressure (PIP), and knows that this finding is associated with which of the following? 

  • The patient has developed a pneumothorax

  • Lung compliance is improving

  • The patient likely has an airway infection

  • The ventilator system is likely malfunctioning

Correct answer: The patient has developed a pneumothorax

PIP increases with any airway resistance. Factors that may increase PIP could be increased secretions, bronchospasm, biting down on ventilation tubing, and decreased lung compliance. A decreasing or worsening lung compliance is associated with pneumothorax. 

Lung compliance, or pulmonary compliance, is a measure of the lung's ability to stretch and expand (distensibility of elastic tissue). A decrease in lung compliance requires more pressure to achieve the same ventilation.

A high PIP does not indicate improving lung compliance, airway infection, or a malfunctioning ventilator system.  

168.

A 78-year-old man with a hearing impairment is admitted to the critical care unit with acute heart failure. What is the BEST communication method to use in this case?

  • Assess his preferred method of communication prior to attempting communication

  • Speak loudly and exaggerate your lip movements

  • Use written communication to ensure he understands

  • Use sign language to communicate with the patient

Correct answer: Assess his preferred method of communication prior to attempting communication

The patient's method of communication should be assessed prior to attempting a particular communication method. Speaking loudly or exaggerating lip movements can distort communication and may not be effective if the patient's hearing loss is severe. Sign language can be an effective method, but only if the patient is proficient in sign language. Written communication can be effective if the patient can read; however, this should not be assumed.

169.

Nursing strategies to prevent delirium in a critically ill patient include all of the following EXCEPT:

  • strictly enforcing visiting hours

  • early mobility

  • frequent reorientation

  • treating pain

Correct answer: strictly enforcing visiting hours

Nursing strategies to prevent delirium and decrease its effects include early mobilization, reorientation, modulating stimulation, providing appropriate cognitive activities, promoting normal sleep-wake cycles, ensuring assistive devices are readily available, treating pain, and family presence.

Visitors, particularly family members and close support people, are crucial to the patient's recovery process. Discretion should be utilized when visitors want to visit, but should not be turned away if the patient desires to have them present.

170.

In which type of shock is the heart UNABLE to pump enough blood to meet the oxygen and metabolic needs of the body?

  • Cardiogenic

  • Hypovolemic

  • Distributive

  • Neurogenic

Correct answer: Cardiogenic

Cardiogenic shock occurs when the heart cannot pump enough blood to meet the oxygen and metabolic needs of the body. Coronary artery disease and severe heart attack are common causes of pump failure. In every case of cardiogenic shock, the heart fails to function effectively as a pump, leading to decreases in stroke volume, cardiac output, blood pressure, and tissue perfusion.

Hypovolemic shock occurs when there is inadequate volume in the vascular space, as in the cases of acute blood loss or shifting of fluid out of the vascular space into other body fluid spaces.

Distributive shock is characterized by an abnormal placement or distribution of vascular volume and occurs in three situations: sepsis, neurologic damage, anaphylaxis. Of the distributive shock syndromes, septic shock is most commonly seen in critical care settings.

Neurogenic shock occurs when neurological injury affects the ability to maintain vascular tone.

171.

Causes of Acute Renal Failure (ARF) may include all of the following EXCEPT:

  • acetaminophen toxicity

  • septic shock

  • antihypertensive medications

  • excessive use of diuretics

Correct answer: acetaminophen toxicity

Acetaminophen toxicity would most likely cause liver damage (not kidney damage) as the bulk of acetaminophen metabolism takes place in the liver.

A few causes of Acute Renal Failure (ARF) include septic shock, antihypertensive medications and excessive use of diuretics.

172.

Which of the following components of the AACN's Synergy Model describes working with others to achieve the BEST possible goal for a patient?

  • Collaboration

  • Systems thinking

  • Caring practices

  • Complexity

Correct answer: Collaboration

The AACN Synergy Model for Patient Care delineates core patient characteristics and needs that drive the core nurse competencies required to care for patients and families. Collaboration is essential for a critical care nurse's practice, and describes working with others in a way that promotes each person's contributions toward achieving optimal patient/family goals.

Systems thinking refers to the body of knowledge that helps the nurse to manage the system through which patient care is provided. Caring practices are activities that promote a therapeutic environment. Complexity is a patient characteristic referring to the intricate entanglement of two or more systems. 

173.

The ICU nurse is caring for a critically ill patient. The patient's daughter, a nurse in another hospital, insists on performing care tasks for her father. What is the appropriate response for the ICU nurse?

  • Allow the daughter to be involved in the care to the extent permitted according to hospital policy

  • Allow the daughter to perform all tasks, as she is a nurse

  • Deny her involvement in care as it could create a legally compromising situation for the hospital

  • Verify the daughter is actually licensed as a nurse

Correct answer: Allow the daughter to be involved in the care to the extent permitted according to hospital policy

Any family member should be as involved in their family member's care as permitted and desired by the patient. Allow the daughter to be involved in the care to the extent permitted according to hospital policy, respecting both her professional knowledge and her role as a family member. It is important to ensure that the care provided is safe and adheres to hospital policy. Completely denying her involvement or letting her perform all tasks could interfere with appropriate care provision and breach professional boundaries. Verifying her licensure is not necessary, as care requiring a nursing license specifically will not be assignable to a family member while the patient is still hospitalized.

174.

A patient with meningitis has a purple blotchy rash. Which type of meningitis is this MOST LIKELY to be?

  • Bacterial

  • Viral

  • Fungal

  • Parasitic 

Correct answer: Bacterial

Meningitis that causes a petechial rash that progresses to pupal blotches is meningococcal meningitis, caused by Neisseria meningitidis, a bacteria. Meningococcal meningitis is one of the most serious types of meningitis and requires immediate treatment.

175.

A 43-year-old male patient is admitted to the ICU following a high-speed motor vehicle collision. He has sustained multiple fractures, a lacerated liver, and blunt chest trauma. His blood pressure is 84/49 mmHg, heart rate 112/min, and his respiratory rate is 25/min. He is becoming increasingly agitated and hypoxemic despite receiving 100% oxygen via non-rebreather mask. Which of the following actions should the nurse prioritize?

  • Prepare for immediate intubation 

  • Start aggressive fluid resuscitation

  • Administer pain medication

  • Expedite the insertion of an arterial line

Correct answer: Prepare for immediate intubation 

The patient's increasing agitation and hypoxemia despite 100% FiO2 and the mechanisms of his injuries all indicate impending respiratory failure, which necessitates immediate intubation. While fluid resuscitation may be beneficial, it does not directly address the patient's compromised breathing and is a secondary concern to facilitating improved oxygenation. Administering pain medication is secondary to addressing the respiratory status. Insertion of an arterial line may be an important intervention but would be secondary to intubation.

176.

The recommended tidal volume with which to ventilate a patient with Acute Respiratory Distress Syndrome (ARDS) who weighs 65 kg is:

  • 260–390 mL

  • 130–260 mL

  • 390–520 mL

  • 520–780 mL

Correct answer: 260–390 mL

It is vital to achieve and maintain adequate oxygenation in the patient with a diagnosis of Acute Respiratory Distress Syndrome (ARDS), while also avoiding barotrauma. Research supports lung protective mechanical ventilation consisting of using small tidal volumes of 4–6 mL/kg to prevent volutrauma, and higher PEEP (Positive End-Expiratory Pressure) levels to recruit alveoli. Thus, in this instance, 65 kg x 4 mL = 260 mL to 65 kg x 6 mL = 390 mL of air is recommended to ventilate the patient.

177.

Which of the following factors is NOT used to diagnose AMI?

  • ST-segment depression

  • History of ischemic-like symptoms

  • Changes on serial EKGs

  • Elevation and fall in level of serum cardiac biomarkers

Correct answer: ST-segment depression

ST-segment depression itself is not used to diagnose AMI (Acute Myocardial Infarction) unless it is noted as a change on a serial EKG. While ST-segment depression indicates an NSTEMI (Non-ST-Elevation Myocardial Infarction), it must be new or worse compared to a prior EKG. A history of ischemic-like symptoms, changes on serial EKGs, and an elevation and fall in the level of serum cardiac biomarkers are the three factors on which a diagnosis of AMI is made, with at least two of the findings needing to be present to make the diagnosis.

178.

Of the following nursing actions, which MIGHT decrease a patient's self-esteem?

  • Requiring the patient to participate in all treatments

  • Discussing negative aspects of the patient's condition

  • Providing opportunities to discuss issues important to the patient

  • Allowing the patient to do his or her own dressing changes if desired

Correct answer: Requiring the patient to participate in all treatments

Though patient participation in all treatments is highly encouraged and recommended, the nurse cannot require an adult to do anything. Discussing negative consequences of the patient's condition and providing opportunities to discuss issues important to the patient may cause the patient to feel sad or upset, but will not lower self-esteem. Allowing the patient to do their own dressing changes if the patient wishes will help to increase the patient's self-esteem and confidence.

179.

In disseminated intravascular coagulation (DIC), activation of fibrinolysis releases which of the following coagulation factors? 

  • Plasmin

  • Platelets

  • Fibrin

  • D-dimer

Correct answer: Plasmin

Fibrinolysis is the natural process that breaks down clots from fibrin (a protein formed from fibrinogen during the clotting of blood). It is the result of the production of plasmin, a coagulation factor and enzyme that breaks down some of the fibrin in a physiologic attempt to open the microcirculation. This produces fibrin degradation products, including D-dimer. 

D-dimer levels are elevated in thrombotic disorders such as deep vein thrombosis (DVT) and pulmonary emboli. Platelets play a role in the initiation of blood coagulation at the site of damaged blood vessel walls.

Fibrinogen is a soluble protein in the plasma that is broken down to fibrin by the enzyme thrombin, to form clots. The fibrinogen level is tested during evaluation for bleeding disorders. Plasma levels of fibrinogen may be increased during an inflammatory response, acute infection, or pregnancy. Decreased levels are present with liver disease and DIC.

180.

Signs of volume overload in a critically ill patient may include all the following EXCEPT:

  • Weak peripheral pulses

  • Jugular vein distention (JVD)

  • Dyspena 

  • S3 heart sound

Correct answer: Weak peripheral pulses 

Signs of volume overload may include: 

  • Pulmonary crackles and dyspnea
  • JVD
  • Peripheral edema
  • S3 heart sound

Volume deficit may be noted by the presence of dry mucous membranes and weak peripheral pulses. There would more likely be bounding peripheral pulses in a volume overloaded patient. 

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