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Quiz Session - Attempts With Random Questions

AACN PCCN NOV 2023 Exam Hanbook version 1.1.1 Exam Questions

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41.

Which of the following statements about epidural analgesia is TRUE?

  • When administered in combination, epidural opioids and local anesthetics work synergistically, and less of each agent is needed to produce analgesia

  • The risk of respiratory depression is greater with the administration of epidural opioids than with IV administration

  • Higher infusion rates of local anesthetic-containing solutions increase the density of the epidural blockade

  • Higher local anesthetic concentrations result in an increased spread of the epidural blockade

Correct answer: When administered in combination, epidural opioids and local anesthetics work synergistically, and less of each agent is needed to produce analgesia

Epidural opioids can be combined with dilute concentrations of Local Anesthetics (LAs) to achieve analgesia. Opioids, which are administered epidurally, work in the dorsal horn of the spinal cord, and epidural LAs primarily block the conduction of afferent sensory fibers at the dorsal nerve root.

Higher infusion rates of local anesthetic-containing solutions increase the spread of the blockade, whereas higher LA concentrations result in an increased density of the blockade.

Epidural opioids were once feared to be linked to an increased risk of respiratory depression, but clinical studies have not confirmed this.

42.

View the SUPPORTING DETAILS to answer the following question:

Based on the patient's Arterial Blood Gas (ABG) results provided, which of the following do you suspect?

  • Respiratory acidosis, no compensation, with hypoxemia

  • Metabolic acidosis, no compensation, without hypoxemia

  • Respiratory acidosis, full compensation, with hypoxemia

  • Respiratory alkalosis, no compensation, with hypoxemia

Correct answer: Respiratory acidosis, no compensation, with hypoxemia

Based on these ABG results, the patient is experiencing uncompensated respiratory acidosis with hypoxemia. The elevated PaCO2 indicates that the acidosis is due to a respiratory issue, as there is no metabolic compensation (normal HCO3 and base excess). The low PaO2 and SaO2 indicate that the patient also has hypoxemia, likely due to the respiratory condition.

43.

You are caring for a patient who just suffered a Myocardial Infarction (MI). Which of the following is likely to benefit the patient the MOST? 

  • Visits from the patient's supportive daughter

  • Telephone communication from the family

  • A detailed explanation of the area of the patient's heart affected by the infarction

  • The opportunity to watch television uninterrupted

Correct answer: Visits from the patient's supportive daughter

Following an MI, emotional support is crucial for the patient's recovery. A visit from a supportive family member, such as the patient's daughter, can provide comfort, reduce anxiety, and promote emotional well-being.

While telephone communication can be helpful, in-person visits from supportive family members provide more direct and tangible emotional support.

Education about the condition is important but may not be the immediate priority in the acute phase of recovery. Emotional support takes precedence to help the patient feel secure and cared for.

While distraction can be useful for relaxation, it does not provide the same level of emotional support and connection as a visit from a loved one.

44.

A 23-year-old male patient with septic shock develops DIC. His labs reveal a platelet count of 40,000/mm³, elevated D-dimer, prolonged PT, and low fibrinogen. 

Based on these findings, what is the MOST likely explanation for his clinical condition?

  • He is experiencing an excessive clotting response, leading to consumption of clotting factors

  • His platelet count is increased due to immune-mediated destruction

  • His liver function is impaired, causing decreased production of clotting factors

  • He has a bleeding disorder unrelated to his septic shock

Correct answer: He is experiencing an excessive clotting response, leading to consumption of clotting factors

In DIC, widespread clot formation consumes clotting factors, platelets, and fibrinogen, leading to low platelet counts, prolonged PT, and elevated D-dimer.

The patient's platelet count is decreased, not increased, due to consumption in the clotting process, not immune-mediated destruction. Impaired liver function would decrease production of clotting factors, but in DIC, the issue is consumption, not production. A bleeding disorder unrelated to septic shock would not explain these clotting abnormalities.

45.

In ethics, paternalism occurs when the principle of beneficence overrides which of the following?

  • Autonomy

  • Advocacy

  • Justice

  • Veracity

Correct answer: Autonomy

In ethics, paternalism describes situations in which a decision is made on behalf of a person, typically with the intention of benefiting them or preventing harm, but it overrides that person's autonomy—their right to make their own decisions. The principle of beneficence, which focuses on doing good for the patient, is prioritized over the patient's autonomy in paternalistic actions. This occurs when, for example, a healthcare provider makes a decision for a patient because they believe it is in the patient's best interest, even if it goes against the patient's own wishes or choices.

Nursing advocacy protects the rights, health, and safety of patients. It seeks to empower the patient and uphold their autonomy, so it is not the principle being overridden in cases of paternalism.

Paternalism does not directly relate to justice, as it deals more with the balance between beneficence (doing good) and autonomy (respecting patient choice) rather than fairness or equality in care.

Veracity relates to the obligation to tell the truth and provide accurate information to patients. It is associated with honesty and transparency in the patient-provider relationship.

46.

A 68-year-old male patient with a recent insertion of a temporary pacemaker is being assessed for stimulation threshold testing. His vital signs are stable. During testing, it is determined that the stimulus threshold is 1 mA. You set the pacemaker output to 2 mA. Shortly after, the patient’s intrinsic heart rate increases from 70 to 80 beats per minute, and the pacemaker is no longer capturing. 

What is the MOST appropriate action to take to ensure safe and effective pacing?

  • Lower the pacing rate to allow the pacemaker to override the intrinsic rhythm

  • Increase the pacemaker output to 3 mA to achieve capture

  • Check the lead position and adjust if necessary to ensure consistent capture

  • Stop the pacemaker and monitor the patient’s intrinsic rhythm

Correct answer: Lower the pacing rate to allow the pacemaker to override the intrinsic rhythm

Lowering the pacing rate is the most appropriate action when the patient’s intrinsic rhythm is faster than the set pacing rate, causing the pacemaker to no longer capture. Lowering the pacing rate makes the pacemaker more likely to override the intrinsic rhythm, allowing for proper pacing and assessment of the stimulation threshold. This intervention helps confirm the adequacy of the pacing settings and ensures that the pacemaker captures when the patient's intrinsic rate falls below the pacing rate.

Increasing the pacemaker output to 3 mA is unnecessary in this scenario because the loss of capture is due to the patient’s intrinsic heart rate being higher than the pacemaker’s rate, not due to inadequate output. The pacing threshold was already determined to be 1.0 mA, and the output was appropriately set at 2.0 mA, which provides a safe margin above the threshold.

Checking the lead position and adjusting if necessary could be appropriate in other situations when lead displacement might cause loss of capture. However, in this case, the issue is with the intrinsic rhythm overriding the pacemaker, not with lead displacement.

Stopping the pacemaker and monitoring the patient’s intrinsic rhythm would not address the need to ensure the pacemaker captures when the intrinsic rate falls. The pacemaker should remain active with proper settings to provide pacing support when needed, especially for patients requiring pacing.

47.

A 78-year-old male patient with a history of advanced Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) is admitted to the PCU with worsening dyspnea and fatigue. His condition has been gradually deteriorating, and he is now receiving oxygen therapy. During his previous visit, he discussed his preferences regarding future medical care with his primary care physician. As his condition continues to decline, his family is concerned about his ability to make decisions regarding his treatment.

You are reviewing his medical record and come across a document that outlines his specific wishes for care if he becomes unable to make decisions. Which of the following BEST describes this type of document?

  • Advance directive

  • Durable power of attorney for healthcare

  • Do-Not-Resuscitate (DNR) order

  • Living will

Correct answer: Advance directive

Advance directive is a broad term that encompasses documents such as living wills and durable powers of attorney for healthcare. In these documents, an individual outlines their wishes for medical care if they become unable to make decisions themselves. The advance directive ensures that the patient’s preferences are known and respected even when they are no longer competent to express them.

A durable power of attorney for healthcare designates another individual to make healthcare decisions on the patient’s behalf if they cannot do so. This is also typically included within an advance directive.

A DNR order is a specific medical order that instructs healthcare providers not to perform Cardiopulmonary Resuscitation (CPR) if the patient’s heart stops. It is often a part of an advance directive but does not encompass all aspects of end-of-life care preferences.

A living will specifically details the types of medical treatment a person wishes to receive or avoid if they become unable to communicate their decisions. However, it is just one part of an advance directive.

48.

A 68-year-old male patient with a history of COPD is admitted for acute exacerbation of his condition. He is experiencing significant respiratory distress and agitation, which is making it difficult to initiate noninvasive ventilation. The physician decides to administer a sedative to help manage his agitation.

Which of the following sedative medications is MOST appropriate for this patient, considering his respiratory status?

  • Dexmedetomidine

  • Midazolam

  • Lorazepam

  • Propofol

Correct answer: Dexmedetomidine

Dexmedetomidine is a sedative that provides sedation without significant respiratory depression, making it a suitable choice for patients with compromised respiratory function, such as those with COPD. 

While midazolam and lorazepam are effective sedatives, they can cause respiratory depression, which could exacerbate the patient's respiratory distress. Propofol is also associated with respiratory depression and is generally used in controlled settings, such as ICU with continuous monitoring.

49.

When reviewing discharge instructions with a patient who is going home with new orders for dabigatran, what information do you include in the teaching?

  • Monitoring parameters will include hemoglobin, hematocrit, aPTT, Ecarin Clotting Time (ECT), and signs of active bleeding

  • If the patient has difficulty swallowing the capsule, it can be opened and the contents taken with a small bite of soft food, such as applesauce

  • The medication is usually taken once daily

  • It is indicated for the treatment of venous thrombosis or pulmonary embolism following full-dose parenteral anticoagulant therapy

Correct answer: Monitoring parameters will include hemoglobin, hematocrit, aPTT, Ecarin Clotting Time (ECT), and signs of active bleeding

Dabigatran prevents stroke and blood clots in patients who have nonvalvular atrial fibrillation. This medicine is an anticoagulant (blood thinner). In clinical trials, it was superior to warfarin for reducing the risk of systemic embolism and stroke with comparatively lower minor bleed risk.

Dabigatran also has the potential for use as VTE prophylaxis after total hip or knee replacement surgery, as well as for the treatment of pulmonary embolism and DVT. Warfarin (not dabigatran) is used to treat venous thrombosis or pulmonary embolism following full-dose parenteral anticoagulant therapy.

The usual dose of dabigatran is 150 mg PO twice daily. It is important to note that dabigatran capsules cannot be opened for oral or feeding tube administration.

50.

A 32-year-old female patient undergoing a blood transfusion reports back pain and chills 20 minutes after the transfusion starts. Her blood pressure drops to 90/60 mmHg, her heart rate is 110 bpm, and her respiratory rate is 20.

Which type of transfusion reaction is MOST likely occurring?

  • Acute hemolytic reaction

  • Febrile non-hemolytic transfusion reaction

  • Allergic reaction

  • Transfusion-associated circulatory overload

Correct answer: Acute hemolytic reaction

Acute hemolytic reactions typically occur within the first 15–30 minutes of the transfusion and are the result of ABO incompatibility, leading to hemolysis. Symptoms include chest and back pain, chills, fever, hypotension, tachypnea, and tachycardia, as seen in this patient. Immediate discontinuation of the transfusion and supportive care are critical.

Febrile non-hemolytic reactions can cause chills and fever but usually occur later in the transfusion and do not present with hypotension or back pain. Allergic reactions are typically mild, causing itching, hives, or anaphylaxis. Back pain and hypotension are less likely in mild allergic reactions. Transfusion-associated circulatory overload involves dyspnea, pulmonary edema, and hypertension, not hypotension or back pain.

51.

Which of the following principles argues for a thoughtful and comprehensive approach when making decisions involving the allocation of nursing resources?

  • Justice

  • Paternalism

  • Resource availability

  • Veracity

Correct answer: Justice

The principle of justice in healthcare argues for fairness in the distribution of resources, including nursing resources. It emphasizes that decisions regarding the allocation of nursing resources should be made thoughtfully and comprehensively to ensure that all patients receive fair and equitable care.

Paternalism refers to making decisions for others, typically for their own good, but does not directly relate to the fair distribution of resources.

Resource availability refers to the actual presence of resources but does not specifically address the ethical principle of how those resources should be allocated.

Veracity is the principle of truth-telling or honesty in interactions with patients, which is important but not directly related to resource allocation.

52.

Which of the following statements about an Oropharyngeal Airway (OPA) is FALSE?

  • It is used to maintain a patent airway in alert or semiconscious patients

  • It is inserted with the concave curve of the airway facing up into the roof of the mouth

  • It is situated so the tip rests near the posterior pharyngeal wall

  • It must be removed at least every 24 hours to provide oral care and check for pressure injuries

Correct answer: It is used to maintain a patent airway in alert or semiconscious patients

The OPA, or oral bite block, is an airway made of rigid plastic or rubber material. It should be used only in unconscious patients, as it can stimulate the gag reflex in alert or semiconscious patients, potentially causing vomiting and aspiration.

The concave curve of the airway should face up toward the roof of the mouth during insertion and then rotate 180 degrees once it is past the tongue to ensure proper placement without causing trauma.

The tip of the OPA rests near the posterior pharyngeal wall, allowing it to keep the tongue from obstructing the airway.

Removing the OPA at least every 24 hours is necessary to provide oral care and check for pressure injuries, as prolonged use can lead to tissue breakdown and other complications. 

53.

A 28-year-old male patient presents with sudden onset of chest pain and shortness of breath. His vital signs are BP 125/80 mmHg, HR 105 bpm, RR 30 breaths/min, and SpO2 90%. 

Which assessment finding is MOST likely to confirm a diagnosis of pneumothorax?

  • Absent breath sounds on one side

  • Wheezing throughout lung fields

  • Bilateral crackles

  • Pericardial friction rub

Correct answer: Absent breath sounds on one side

Absent breath sounds on one side are most likely to confirm a diagnosis of pneumothorax. This finding indicates that air is present in the pleural space, preventing lung expansion and airflow.

Wheezing throughout lung fields suggests airway constriction, which is more commonly associated with conditions like asthma or chronic obstructive pulmonary disease.

Bilateral crackles are typically heard in cases of fluid accumulation in the lungs, such as in pulmonary edema or pneumonia.

A pericardial friction rub is heard in pericarditis and involves a scratchy sound not associated with pneumothorax.

54.

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.

55.

Which of the following statements is TRUE about ketorolac (Toradol)?

  • Administration of higher doses of ketorolac provides no additional benefit and significantly increases the risk of toxicity

  • The preferred route of administration is Intramuscular (IM)

  • The recommended loading dose is 30 mg followed by 15 mg every four hours; it may increase to 45 mg every six hours for severe pain

  • Ketorolac should not be used for more than ten days

Correct answer: Administration of higher doses of ketorolac provides no additional benefit and significantly increases the risk of toxicity

One of the Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) commonly used in the acute care setting is ketorolac (Toradol). It is the only parenteral NSAID preparation currently available in the United States. The recommended dosing is a loading dose of 30 mg followed by 15 mg every six hours. Like other NSAIDs, ketorolac does have a ceiling effect in that higher doses provide no therapeutic benefit and increase the risk of toxicity.

Ketorolac can be administered safely Intravenously (IV); IM administration is not recommended due to the potential for unpredictable and irregular absorption. The severity of NSAID-related side effects increases with prolonged use; ketorolac should not be used for more than five days.

56.

Which of the following is the preferred route of medication administration in the acutely ill patient?

  • Intravenous

  • Subcutaneous

  • Oral

  • Intramuscular

Correct answer: Intravenous

In acutely ill patients, the Intravenous (IV) route is the preferred method of medication administration because it permits reliable, complete delivery.

The Subcutaneous (SC) or Intramuscular (IM) routes of medication administration are rarely used in the acutely ill for several reasons:

  • Delayed onset of action
  • Unpredictable, incomplete, erratic, or unreliable absorption, possibly due to decreased tissue perfusion
  • Decreased subcutaneous fat or inadequate muscle tissue
  • Bleeding complications or hematomas in compromised patients

Medication administration via the SC or IM routes may also be painful for these patients. 

The oral (PO) route of medication administration in the acutely ill may also result in incomplete, unpredictable, or erratic drug absorption.

57.

Hyperkalemia is suspected in a patient with which of the following clinical presentations?

  • Tall, tented T waves; diarrhea; decreased deep tendon reflexes

  • Confusion, irritability, inverted T waves

  • Muscle weakness, serum K+ <3.5 mEq/L, nystagmus

  • Polyuria, constipation, renal calculi

Correct answer: Tall, tented T waves; diarrhea; decreased deep tendon reflexes

One of the classic Electrocardiogram (ECG) findings in hyperkalemia is the presence of tall, peaked T waves. Hyperkalemia can cause gastrointestinal symptoms including diarrhea; it can also lead to muscle weakness and decreased deep tendon reflexes. Because potassium impacts normal cardiac and neuromuscular function, it is important to closely monitor these systems when hyperkalemia is suspected. However, a patient may be experiencing hyperkalemia and have no ECG changes or other symptoms. 

Confusion and irritability can be symptoms of various conditions, including electrolyte imbalances, but are not specific to hyperkalemia. Inverted T waves are more commonly associated with ischemia or other conditions than with hyperkalemia.

While muscle weakness can occur in hyperkalemia, the associated serum potassium level of <3.5 mEq/L indicates hypokalemia, not hyperkalemia. Nystagmus is not a typical sign of hyperkalemia or hypokalemia.

Polyuria can be associated with conditions like diabetes insipidus or hypercalcemia. Constipation is more common in hypokalemia. Renal calculi are associated with hypercalcemia, not hyperkalemia.

58.

A 69-year-old female patient is being monitored in the PCU post-cardiac surgery for aortic valve replacement. She is now 48 hours post-op, has a blood pressure of 160/90 mmHg, and reports headache and dizziness. 

Which medication is MOST likely to be initiated to manage her hypertension?

  • Labetalol

  • Furosemide

  • Nitroglycerin

  • Atropine

Correct answer: Labetalol

Labetalol, a beta-blocker, is commonly used in post-op cardiac surgery patients to manage hypertension. It helps control blood pressure and reduces myocardial oxygen demand, which is essential after valve replacement.

Furosemide is a diuretic that may be used for fluid management, but it is not the first-line treatment for hypertension in this scenario.

Nitroglycerin is typically used to treat angina or acute coronary syndromes and is not the first choice for postoperative hypertension.

Atropine is used to treat bradycardia, not hypertension, making it an inappropriate choice for this patient.

59.

Cardiac Output (CO) measurements can be used to rapidly evaluate a patient's hemodynamic status. Which of the following conditions is MOST likely to contribute to an increase in CO?

  • Sepsis

  • Restrictive cardiomyopathy

  • Cardiac tamponade

  • Hypoglycemia

Correct answer: Sepsis

Sepsis often leads to a hyperdynamic state in which the body increases cardiac output as a compensatory mechanism to meet the metabolic demands of tissues due to infection and inflammation.

Restrictive cardiomyopathy restricts the heart's ability to fill properly, leading to decreased cardiac output. In cardiac tamponade, fluid accumulates in the pericardium, leading to compression of the heart and a subsequent decrease in cardiac output. Low blood sugar can impair the body's metabolic functions but is not directly associated with an increase in cardiac output.

60.

A 68-year-old female patient with a history of diabetes and hypertension has been admitted to the Progressive Care Unit (PCU) following a stroke. She has limited mobility and requires assistance with repositioning. On her third day in the unit, you notice a purple, localized area of discolored intact skin on her sacral area, along with a blood-filled blister. The skin surrounding the area is intact.

According to the National Pressure Ulcer Advisory Panel (NPUAP), how should you classify this finding?

  • Deep tissue injury

  • Stage 1 pressure injury

  • Stage 2 pressure injury

  • Unstageable-unknown depth pressure injury

Correct answer: Deep tissue injury

A deep tissue injury is characterized by a purple or maroon localized area of discolored intact skin or a blood-filled blister. This type of injury indicates damage to the underlying soft tissue from pressure and/or shear. The skin remains intact, but the damage has occurred in the deeper layers of the tissue, which can progress rapidly to more severe pressure ulcers if not managed appropriately.

A Stage 1 pressure injury involves intact skin with discoloration (non-blanchable erythema). 

A Stage 2 pressure injury is characterized by partial-thickness tissue loss and a pink or red wound bed.

An unstageable-unknown depth pressure injury involves full-thickness tissue loss, and the wound base is covered with slough or eschar, so it is not visible. 

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