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Quiz Session - Attempts With Random Questions

AACN PCCN July 2024 Exam Hanbook version 2.1.0 Exam Questions

Page 8 of 33

141.

A 45-year-old male patient is brought to the emergency department after being found unconscious. His laboratory results reveal elevated liver enzymes, high ammonia levels, and normal blood glucose. 

Which of the following is the MOST likely cause of his condition?

  • Hepatic encephalopathy

  • Diabetic ketoacidosis

  • Hypoxic-ischemic encephalopathy

  • Severe sepsis

Correct answer: Hepatic encephalopathy

The patient’s elevated liver enzymes and high ammonia levels strongly indicate hepatic encephalopathy. This condition occurs when the liver is unable to adequately remove toxins from the blood, resulting in their accumulation and subsequent effects on the brain. High ammonia levels are particularly characteristic of hepatic encephalopathy, and the absence of hypoglycemia further supports this diagnosis.

Diabetic Ketoacidosis (DKA) typically presents with hyperglycemia, elevated ketone levels, and acidosis. The patient's normal blood glucose level makes DKA less likely as the cause of his unconscious state.

Hypoxic-ischemic encephalopathy is due to reduced oxygen and blood flow to the brain, usually following a significant event like cardiac arrest. While this can cause unconsciousness, the laboratory findings of elevated liver enzymes and ammonia levels point away from this diagnosis.

Severe sepsis is a systemic infection that can lead to altered mental status. It is typically associated with signs of infection, such as fever, leukocytosis, or hypotension. 

142.

What organ is the primary controller of bicarbonate levels?

  • Kidneys

  • Liver

  • Heart

  • Pancreas

Correct answer: Kidneys

Bicarbonate (HCO₃⁻) levels in the body are primarily regulated by the kidneys. The kidneys play a crucial role in maintaining acid-base balance by either reabsorbing bicarbonate or excreting it in the urine, depending on the body's pH. This process is essential to buffering acids and maintaining the blood's pH within a narrow range.

While it is involved in numerous metabolic processes, the liver does not directly control bicarbonate levels or acid-base balance.

The heart pumps blood throughout the body but does not regulate bicarbonate levels or acid-base balance.

The pancreas produces digestive enzymes and hormones such as insulin but does not control bicarbonate levels in the blood.

143.

Which of the following spinal cord injury syndromes involves injury to the central gray matter with preservation of the outer white matter? 

  • Central cord syndrome

  • Anterior cord syndrome

  • Posterior cord syndrome

  • Brown-Sequard syndrome

Correct answer: Central cord syndrome

Central cord syndrome results from an injury primarily affecting the central gray matter of the spinal cord, with some preservation of the outer white matter. This type of injury often leads to more severe motor deficits in the upper extremities than in the lower extremities due to the somatotopic organization of the corticospinal tracts, in which the fibers controlling the upper extremities are located more centrally.

Anterior cord syndrome involves injury to the anterior two-thirds of the spinal cord, affecting the anterior gray matter and the anterior white matter, including the motor tracts. This typically results in loss of motor function and pain/temperature sensation below the level of the injury, with preservation of proprioception and vibration sense.

Posterior cord syndrome involves injury to the posterior columns of the spinal cord, leading to loss of proprioception and vibration sense below the level of injury, while motor function and pain/temperature sensation are typically preserved.

Brown-Sequard syndrome results from a hemisection (one-sided injury) of the spinal cord. It leads to ipsilateral (same side) loss of motor function and proprioception, with contralateral (opposite side) loss of pain and temperature sensation.

144.

A 67-year-old female patient with End-Stage Renal Disease (ESRD) presents with confusion, muscle cramps, and a potassium level of 6.3 mEq/L. 

What is the MOST appropriate initial intervention?

  • Administer intravenous calcium gluconate

  • Give oral potassium chloride

  • Increase dietary potassium

  • Administer isotonic saline

Correct answer: Administer intravenous calcium gluconate

Intravenous calcium gluconate stabilizes the cardiac membranes in hyperkalemia, protecting against life-threatening arrhythmias while other interventions to lower potassium are initiated.

Giving potassium chloride would worsen hyperkalemia. Increasing dietary potassium would exacerbate the problem. Administering isotonic saline would not address hyperkalemia directly and could increase fluid overload in ESRD patients.

145.

A 57-year-old male patient with a history of type 2 diabetes mellitus presents with extreme thirst, polyuria, and confusion.

Which of the following laboratory findings is MOST characteristic of Hyperosmolar Hyperglycemic State (HHS)?

  • Plasma glucose > 600 mg/dL

  • Serum bicarbonate < 15 mEq/L

  • Elevated serum ketones

  • Arterial pH < 7.3

Correct answer: Plasma glucose > 600 mg/dL

HHS is defined by significant hyperglycemia, often exceeding 600 mg/dL, without the presence of significant ketoacidosis. Dehydration, hyperosmolarity, and altered mental status are also characteristic of this state.

Serum bicarbonate < 15 mEq/L is typically seen in Diabetic Ketoacidosis (DKA), not HHS, as acidosis is not a prominent feature of HHS. Elevated serum ketones are more indicative of DKA, as ketogenesis is not a primary concern in HHS. Arterial pH < 7.3 also occurs in DKA due to acidosis, while HHS patients usually have a pH > 7.3.

146.

A 57-year-old male patient with a history of connective tissue disease has been diagnosed with Pulmonary Arterial Hypertension (PAH). 

Which of the following medications is MOST commonly used as first-line treatment for this condition?

  • Epoprostenol

  • Sildenafil

  • Amiodarone

  • Furosemide

Correct answer: Epoprostenol

Epoprostenol is a prostacyclin analog and is often considered first-line therapy in patients with severe PAH. It works by dilating pulmonary arteries and decreasing the pressure in the lungs.

Sildenafil, a phosphodiesterase-5 inhibitor, is also used for PAH but is typically prescribed after prostacyclin therapy or in less severe cases.
Amiodarone is used to treat arrhythmias, not pulmonary hypertension. Furosemide is a diuretic that helps reduce fluid overload, but it does not directly treat pulmonary arterial hypertension.

147.

You are faced with a situation in which your patient refuses a recommended treatment plan due to personal beliefs. According to the American Nurses Association (ANA) Code of Ethics, what is your PRIMARY responsibility in this scenario?

  • Respect the patient's autonomy and support their decision even if it conflicts with your personal beliefs

  • Persuade the patient to accept the treatment plan for their well-being

  • Report the patient's refusal to the hospital ethics committee for further action

  • Discharge the patient from care due to noncompliance with medical advice

Correct answer: Respect the patient's autonomy and support their decision even if it conflicts with your personal beliefs

The ANA Code of Ethics emphasizes the importance of respecting patients' rights to make their own healthcare decisions. Nurses must honor the principle of autonomy, which allows patients to make informed choices about their own care based on their values and beliefs. This ethical obligation requires nurses to support and advocate for their patients' decisions even if they personally disagree with them.

Persuading the patient to accept the treatment plan undermines their autonomy and does not align with the ethical principle of respect for the patient's right to self-determination.

Reporting the refusal to the ethics committee might be necessary in certain complex ethical dilemmas, but the primary responsibility remains to respect and support the patient's decision.

Discharging the patient for noncompliance is not an appropriate response and could be considered punitive and unethical.

148.

A 68-year-old male patient with a history of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) presents to the emergency department with shortness of breath, wheezing, and increased work of breathing. He has a productive cough with green sputum for the past three days. On physical examination, the patient is tachypneic with a respiratory rate of 28 breaths per minute, and auscultation reveals bilateral wheezes. His oxygen saturation is 88% on room air. The attending physician orders an Arterial Blood Gas (ABG) to assess the patient’s respiratory status.

The ABG results are as follows:

  • pH: 7.32
  • PaCO2: 55 mmHg
  • PaO2: 60 mmHg
  • HCO3-: 30 mEq/L

Based on these results and the clinical presentation, what does the patient's PaCO2 level indicate?

  • The patient is likely experiencing respiratory acidosis due to CO2 retention from COPD exacerbation

  • The patient's PaCO2 is within normal limits, suggesting no acute respiratory issue

  • The patient's elevated PaCO2 indicates metabolic acidosis

  • The patient's PaCO2 is slightly elevated, which is normal for a COPD patient and does not indicate an acute problem

Correct answer: The patient is likely experiencing respiratory acidosis due to CO2 retention from COPD exacerbation

Normal blood carbon dioxide tension (PaCO2) is 35–45 mmHg. In this scenario, the patient’s PaCO2 is elevated at 55 mmHg, which, along with a low pH of 7.32, indicates respiratory acidosis. This is consistent with CO2 retention common in COPD exacerbations. 

The other options are incorrect as they either misrepresent the normal PaCO2 range or incorrectly interpret the clinical implications of the ABG results.

149.

Which of the following interventions is appropriate management of a patient with a thoracic aortic aneurysm?

  • Maintain Systolic Blood Pressure (SBP) < 120 mmHg

  • Titrate vasoconstrictors to maintain the patient's blood pressure as low as possible

  • Administer replacement blood products to maintain adequate hemoglobin and hematocrit levels

  • Maintain heart rate > 90 beats/minute

Correct answer: Maintain Systolic Blood Pressure (SBP) < 120 mmHg

The primary objectives in the management of aortic aneurysm are relieving pain and anxiety, lowering BP and thereby decreasing stress on the aneurysm, performing surgical repair if necessary, teaching the patient, and preventing complications. Maintaining SBP at 120 mmHg or lower will prevent further dissection or rupture of the aneurysm. 

Vasodilators, not vasoconstrictors, should be titrated to maintain the patient's blood pressure as low as possible (90–120 mmHg if tolerated). This decreases the pressure on the aneurysm. Blood products are indicated in the case of acute dissection or rupture. Heart rate should be monitored but does not necessarily need to be kept below 90 beats/min. 

150.

Which of the following sets of symptoms would MOST likely indicate cardiac tamponade secondary to pericardial effusion?

  • Tachycardia, dyspnea, hypotension

  • Pulsus paradoxus, widened pulse pressure, hypotension

  • Pulsus paradoxus, narrowed pulse pressure, hypertension 

  • Bradycardia, narrowed pulse pressure, hypotension

Correct answer: Tachycardia, dyspnea, hypotension

Cardiac tamponade is characterized by a triad of symptoms known as Beck's triad: hypotension, muffled heart sounds, and jugular venous distension. In addition, tachycardia is a common compensatory response, and dyspnea results from reduced cardiac output and poor perfusion. 

Pulsus paradoxus (an exaggerated decrease in systolic blood pressure during inspiration) is indeed associated with cardiac tamponade, but widened pulse pressure is not; instead, a narrowed pulse pressure is more typical due to reduced stroke volume. Hypertension is not typical; hypotension is more consistent with this condition. Bradycardia is less common; tachycardia is typically observed when the body attempts to maintain cardiac output.

151.

A 74-year-old male patient with a history of heart failure presents with tachycardia, hypotension, and decreased urine output. His blood pressure remains low despite initial fluid resuscitation. 

Which factor should be MOST prioritized when deciding to start vasopressors in this patient with compensatory shock?

  • Ability to maintain adequate cardiac output with fluids alone

  • Urine output over the last hour

  • Electrolyte levels

  • Respiratory rate and effort

Correct answer: Ability to maintain adequate cardiac output with fluids alone

The decision to initiate vasopressor therapy in compensatory shock hinges on whether the patient can maintain adequate cardiac output and blood pressure with fluids alone. If hypotension persists despite fluid resuscitation, vasopressors may be needed to support blood pressure and perfusion to vital organs.

While urine output is an important indicator of organ perfusion, it is secondary to overall cardiac output and blood pressure stabilization when deciding to start vasopressors.

While electrolyte imbalances should be corrected, they do not directly determine the need for vasopressors. The primary concern in shock management is ensuring adequate perfusion.

Although respiratory status is crucial to monitor, the primary factor in vasopressor initiation is hemodynamic stability. Respiratory status may guide other supportive measures, but it does not directly determine the need for vasopressors.

152.

A 49-year-old female patient presents to the emergency department complaining of palpitations. Her vital signs are blood pressure 118/75 mmHg, heart rate 108 beats per minute, respiratory rate 18 breaths per minute, and SpO2 96%. An EKG shows atrial fibrillation. 

Which of the following is the MOST common initial symptom of atrial fibrillation?

  • Palpitations

  • Chest pain

  • Syncope

  • Fatigue

Correct answer: Palpitations

Atrial fibrillation presents with palpitations as the most common initial symptom. Palpitations occur because of the irregular and rapid beating of the atria, which patients often feel as an abnormal heart rhythm. Early recognition of this symptom is critical to timely intervention.

Fatigue is another common symptom of atrial fibrillation but typically develops after the arrhythmia has been sustained for a period. Chest pain can occur in patients with underlying ischemia or when the heart is working harder to compensate, but it is not the most common initial symptom. Syncope, or fainting, is a less frequent presentation of atrial fibrillation and usually occurs in more severe cases with associated hemodynamic instability.

153.

A 67-year-old female patient with restrictive cardiomyopathy presents with symptoms of heart failure. Her echocardiogram shows normal left ventricular size with severe diastolic dysfunction. 

Which finding on her physical exam is MOST likely indicative of restrictive cardiomyopathy?

  • Jugular venous distension

  • S3 heart sound

  • Bounding peripheral pulses

  • Displaced apical impulse

Correct answer: Jugular venous distension

Jugular venous distension (distended neck veins) is a common finding in patients with restrictive cardiomyopathy due to elevated right atrial pressures resulting from impaired ventricular filling. This condition leads to increased central venous pressure, which is visible as distension of the jugular veins.

An S3 heart sound is more commonly associated with systolic heart failure and dilated cardiomyopathy than with restrictive cardiomyopathy. Bounding peripheral pulses are typically associated with conditions like aortic regurgitation. A displaced apical impulse is often seen in patients with dilated cardiomyopathy due to ventricular enlargement, which is not characteristic of restrictive cardiomyopathy.

154.

A 39-year-old female patient is being treated for atrial fibrillation with Coumadin (warfarin). 

Which of the following laboratory tests is MOST important to monitor in this patient?

  • International Normalized Ratio (INR)

  • Partial Thromboplastin Time (PTT)

  • D-dimer

  • Fibrinogen level

Correct answer: International Normalized Ratio (INR)

Warfarin (Coumadin) is a vitamin K antagonist that helps prevent blood clots and is commonly prescribed for conditions like atrial fibrillation. The effectiveness of warfarin is monitored using the INR, which assesses the patient’s anticoagulation status. Keeping the INR within the therapeutic range is crucial to prevent bleeding or clotting complications.

PTT is used to monitor heparin, not warfarin. While the D-dimer test can identify clot formation, it does not assess the efficacy of warfarin. Fibrinogen is a clotting factor, but its levels are not typically monitored in patients receiving warfarin.

155.

A 68-year-old male patient with diabetes is learning to self-administer insulin injections. Which action by the nurse is MOST likely to facilitate the patient’s learning and ensure accurate self-administration?

  • Demonstrating the injection technique and then having the patient practice it

  • Providing written instructions for how to administer insulin 

  • Showing a video of the injection process 

  • Telling the patient to follow the instructions on the insulin packaging

Correct answer: Demonstrating the injection technique and then having the patient practice it

Hands-on practice with direct demonstration is most likely to facilitate effective learning for self-administering insulin. This method allows the patient to observe, practice, and receive immediate feedback, ensuring proper technique and confidence.

Providing written instructions alone might not be sufficient for all patients, as some might need visual and practical demonstrations to grasp the technique fully.

Showing a video can be helpful, but it does not allow for real-time practice and immediate correction, which are critical for learning a new skill like injection administration.

Telling the patient to follow the instructions on the insulin packaging is inadequate, as it assumes the patient can understand and execute the technique correctly without personalized instruction or practice.

156.

A patient with a tracheostomy spontaneously opens their eyes to verbal stimuli and obeys verbal commands. What is the patient's Glasgow Coma Scale (GCS) score?

  • 9T

  • 11

  • 10

  • 0 or NA

Correct answer: 9T

The GCS is used to assess a patient’s level of consciousness. It is scored based on three components: Eye opening (E), Verbal response (V), and Motor response (M). Since the patient has a tracheostomy, they cannot give a verbal response, so the Verbal response score is replaced with T (for Tracheostomy), and the Verbal response component is not included in the score.

The components in this scenario are scored as follows:

  • Eye Opening (E): Spontaneously to verbal stimuli = three points
  • Verbal Response (V): T (Tracheostomy), not scored numerically
  • Motor Response (M): Obeys verbal commands = six points

The GCS score in this scenario is calculated as follows:

3 (E) + 6 (M) = 9

However, because the Verbal response cannot be assessed due to the tracheostomy, the GCS score is recorded as 9T, indicating the inability to score the verbal component.

157.

Supplementation of which of the following is most often indicated in patients with Acute Kidney Injury (AKI)?

  • Folic acid, pyridoxine, and water-soluble vitamins

  • Folic acid, niacin, and water-soluble vitamins

  • Pyridoxine, phosphorus, and water-soluble vitamins

  • Folic acid, ascorbic acid, and fat-soluble vitamins

Correct answer: Folic acid, pyridoxine, and water-soluble vitamins

In patients with AKI, supplementation of folic acid (a B vitamin), pyridoxine (vitamin B6), and other water-soluble vitamins is often indicated. This is because patients with AKI, particularly those who are undergoing renal replacement therapies such as dialysis, can lose water-soluble vitamins through the dialysis process. Additionally, these patients may have dietary restrictions that limit their intake of certain nutrients, making supplementation necessary to prevent deficiencies.

Niacin (vitamin B3) and fat-soluble vitamins are not typically required as part of the supplementation regimen in AKI unless there is a specific deficiency. Phosphorus is generally restricted in AKI because impaired kidney function can lead to hyperphosphatemia, which can cause additional complications. Ascorbic acid (vitamin C) is a water-soluble vitamin that may be supplemented, but the focus is usually on a broad spectrum of water-soluble vitamins, particularly the B vitamins like folic acid and pyridoxine.

158.

What is the MOST essential principle of collaboration in a multidisciplinary team?

  • Effective communication

  • Mutual respect

  • Shared goals

  • Leadership support

Correct answer: Effective communication

Effective communication is the foundation of successful collaboration in healthcare. Without clear communication, even the most skilled team may face challenges in providing coordinated care. Sharing information accurately and within an ideal time frame helps to prevent misunderstandings and ensures that all members are aligned toward the same patient care goals.

Mutual respect is important but builds on communication. Shared goals are the desired outcome of collaboration, but without communication, these goals cannot be achieved. Leadership support is crucial to collaboration but does not directly reflect the practice of collaboration itself.

159.

A 68-year-old male patient with a history of Chronic Obstructive Pulmonary Disease (COPD) and alcohol use disorder is admitted to the PCU for acute respiratory failure. The patient is intubated and placed on mechanical ventilation. Due to his history of alcohol withdrawal, a continuous infusion of a benzodiazepine is initiated to prevent withdrawal symptoms and ensure sedation. Over the course of several days, the patient's respiratory status improves, and the medical team decides to wean him off sedation. However, after discontinuing the sedative infusion, the patient remains unresponsive, and attempts to awaken him are slow.

Which of the following medications, when used as a continuous infusion in this patient, is MOST likely responsible for the prolonged awakening time?

  • Lorazepam

  • Diazepam

  • Chlordiazepoxide

  • Midazolam

Correct answer: Lorazepam

Lorazepam is a benzodiazepine that, when used as a continuous infusion (over 24 hours), has a relatively long half-life and a prolonged effect, especially in patients with compromised liver function or those who have been on the medication for an extended period. In this scenario, the patient's history of alcohol use disorder and the need for continuous sedation may have led to the accumulation of lorazepam, resulting in a slow and prolonged awakening process. It can take hours to days for the patient to fully awaken after discontinuing the infusion.

Diazepam also has a long half-life, but it is less commonly used as a continuous infusion for sedation in critical care settings. 

Chlordiazepoxide is typically used for alcohol withdrawal management but is not commonly administered as a continuous infusion in the ICU setting. 

Midazolam is a shorter-acting benzodiazepine often used for sedation in ICU settings; its effects usually wear off relatively quickly after discontinuation, making prolonged sedation less likely with this medication.

160.

What principle is violated by decisions to withhold cardiopulmonary resuscitation without involving patients or their surrogates?

  • Patient autonomy

  • Privacy and confidentiality

  • Nonmaleficence

  • Justice

Correct answer: Patient autonomy

Decisions to withhold cardiopulmonary resuscitation without involving patients or their surrogates violate the principle of patient autonomy. Critically ill patients often experience sudden changes in their cardiopulmonary status, and it is presumed unless stated otherwise that CPR will be initiated immediately upon cardiac arrest. If documentation does not exist related to CPR status, appropriate discussions with the patient or surrogate must be held before the decision to forgo cardiopulmonary resuscitation is made to uphold patient autonomy.

The other answer choices do not apply to this example. Privacy and confidentiality are derived from the virtue of fidelity, the obligation to uphold promises, obligations, and commitments. Confidentiality is the protection of information, and privacy is a patient's right to be free from unnecessary access by others. Nonmaleficence is the obligation of the healthcare professional not to harm the patient. Justice implies that patients have a right to fair and impartial treatment.

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