AACN CCRN (Adult) Exam Questions

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1.

Which of the following nonpharmacological techniques do NOT help in reducing pain in the critically ill patient?

  • Non-steroidal anti-inflammatory agents (NSAIDs)

  • Cutaneous stimulation

  • Music therapy

  • Hypnosis

Correct answer: Non-steroidal anti-inflammatory agents 

A variety of nonpharmacologic pain-reducing strategies are useful in patients with trauma, and the nurse may combine these with drug therapy for maximal effect. Cognitive interventions for pain include music and pet therapy, deep breathing and progressive relaxation, cutaneous stimulation (i.e., massage), family presence at the bedside, guided imagery, dim lighting, and hypnosis. These nonpharmacologic cognitive interventions can all be valuable adjuncts to pharmacologic modalities.

NSAIDs are pharmacological techniques used frequently for pain reduction in critically ill patients, often in conjunction with narcotics and the cognitive interventions listed above. 

2.

All of the following are both patient and provider goals for end-of-life care EXCEPT:

  • advanced care measures and treatment

  • control symptoms

  • improve quality of life

  • prevent hospitalization

Correct answer: advanced care measures and treatment 

Goals of end-of-life care and end-stage decisions include controlling symptoms, improving quality of life, and preventing hospitalization if at all possible. Patient options include advanced care measures and treatment, experimental surgery/drugs, and whether or not to engage in palliative care/hospice. Conflicts regarding the withdrawal of life-sustaining treatments often reflect differences in values and beliefs. Patients must choose if/when to forego treatments that have minimal benefit, shifting from dramatic and aggressive life-saving interventions toward a calm and peaceful end-of-life experience.

3.

In the patient with acute gastrointestinal (GI) bleeding, initial estimates of blood loss are MOST reliably guided by:

  • Vital signs and mental status

  • Level of consciousness (LOC)

  • BUN levels and presence or absence of melena 

  • Hematocrit and hemoglobin (H&H) values

Correct answer: Vital signs and mental status

The initial assessment of the patient with GI bleeding begins with a physical examination in which vital signs and mental status are the most reliable indicators of the amount of blood lost. In the presence of hemodynamic instability, resuscitation begins. 

In addition to vital signs and physical assessment, measures of BUN, H&H and melena (among others), help determine the severity of the bleed. It can also be used to predict risk of complications, as well as to guide treatment modalities. 

4.

Systemic inflammatory response syndrome (SIRS) consists of a series of systemic events that occur in response to an insult to the body. There are essentially four different types of cells that are activated as a part of this response.

Which is NOT one of these cells?

  • Cytokines

  • Neutrophils

  • Macrophages

  • Endothelial cells 

Correct answer: Cytokines

When a patient becomes septic from infection, it is important to understand the variety of immune mechanisms, which, when unchecked, can lead to organ damage. The body responds at a cellular level, initiating a number of mediator-induced responses, which are both inflammatory and immune in nature.

The four types of cells that are activated as part of the response to an insult include: 

  • polymorphonuclear cells (neutrophils)
  • macrophages
  • platelets
  • endothelial cells

These cells are activated to become directly involved in the reaction (e.g., platelet aggregation), or are stimulated to produce and release chemical mediators into the circulation (e.g., cytokines or plasma enzymes).

Cytokines are active chemical substances (or mediators) secreted by cells in response to a stimulus; they are not cells themselves.

5.

The Glasgow Coma Scale (GCS) is often used for critically ill patients to monitor their neurologic status. Which of the following is NOT a category that the score is based upon?

  • Pain stimuli

  • Eye opening

  • Motor response

  • Verbal response

Correct answer: Pain stimuli

The GCS is often used to monitor neurologic status in critically ill patients, because it provides a standardized approach to assessing and documenting level of consciousness (LOC).

Response is determined based on eye opening, motor response, and verbal response. The best response in each category is scored, and the results are added to give a total score. Scores range from 3 to 15, with 15 indicating a patient that is alert, fully oriented, and following commands.

If the patient does not follow commands, the next step is to assess the response to pain stimuli in all four extremities. 

6.

The nurse is caring for a 27-year-old female with a diagnosis of Acute Renal Failure (ARF) related to severe hemorrhage and subsequent hypotension following a car accident. The critical care nurse understands the patient's renal failure to be characterized as:

  • prerenal ARF

  • intrarenal ARF

  • acute tubular necrosis

  • postrenal ARF

Correct answer: prerenal ARF

Physiologic conditions that lead to decreased perfusion of the kidneys, without intrinsic damage to the renal tubules, are identified as prerenal failure. The decreased perfusion to the kidneys causes a decrease in the rate of filtration of the blood through the glomerulus. The most significant causes of prerenal ARF are dehydration, heart failure, sepsis, and severe blood loss.

Postrenal ARF occurs when an obstruction in the urinary tract below the kidneys causes waste to build up in the kidneys. Intrarenal failure involves physiologic conditions that damage the renal tubule, nephron, or renal blood vessels. Acute tubular necrosis (ATN) is the most common form of intrarenal failure; this involves damage or injury within both kidneys.

7.

Which of the following is MOST LIKELY to be true about a patient who is experiencing a hypertensive crisis?

  • They will likely be found to have been noncompliant with ordered antihypertensive therapies

  • They are likely to have never been diagnosed with hypertension previously

  • They have likely been diagnosed with diabetes prior to the hypertensive crisis

  • They are likely to be pregnant

Correct answer: They will likely be found to have been noncompliant with ordered antihypertensive therapies

Most patients who are experiencing a hypertensive crisis are found to have been noncompliant with ordered antihypertensive therapies. These patients likely have established hypertension that is not being treated correctly. While a diagnosis of diabetes may increase the risk of chronic hypertension and a subsequent hypertensive crisis, this diagnosis is not the most common feature for patients experiencing a hypertensive crisis. Pregnancy is a risk factor for developing a hypertensive crisis; however, patients who experience a hypertensive crisis are more likely to have it as a complication of chronic, untreated hypertension.

8.

The critical care nurse should expect renal trauma if a patient presents with which of the following findings?

  • Hematoma in the flank region

  • Dysuria

  • Anuria

  • Oliguria

Correct answer: Hematoma in the flank region

A nurse would expect renal trauma if a patient presents with a hematoma in the flank region. Other signs and symptoms of renal trauma include:

  • Abdominal rigidity
  • Flank pain that increases with movement and that radiates to the groin
  • Frank or microscopic hematuria
  • Hypotension or hypovolemic shock (if significant blood loss occurs)
  • Swelling or a mass in the flank

Oliguria may occur following a renal trauma, but is not normally an indicator of renal trauma.

9.

Nursing interventions that decrease the incidence of hospital-acquired pneumonia include:

  • brushing the patient’s teeth with a toothbrush

  • placing gastric tubes through the nose

  • administering systemic antibiotics

  • keeping the patient NPO

Correct answer: brushing the patient's teeth with a toothbrush

In addition to the high morbidity and mortality associated with pneumonia in critically ill patients, high priority must be given to strategies to prevent the development of hospital-acquired pneumonia, otherwise known as Ventilator-Associated Pneumonia (VAP). Evidence-based practice guidelines for the prevention of VAP include oral care involving the implementation of a comprehensive oral hygiene program that includes oral suctioning, teeth-brushing, and use of an oral chlorhexidine gluconate rinse daily.

10.

Of the following, which is NOT a contributing factor to malnutrition in the patient with liver failure?

  • Esophageal and gastric varices 

  • Decreased appetite

  • Impaired thought processes

  • Altered metabolism and storage of nutrients

Correct answer: Esophageal and gastric varices 

The liver performs many nutrition-related functions; it metabolizes carbohydrates, fats, and proteins. It also plays a key role in the storage of essential minerals, vitamins, and glycogen. 

When the liver is not able to synthesize and store glycogen, rapid muscle loss will occur. Impaired thought processes may lead to a decrease in oral intake, which will further compromise the nutritional status of the patient. 

Esophageal and gastric varices result from portal hypertension and develop in most patients with advanced cirrhosis. These are a potential manifestation of liver failure, not a contributing factor to malnutrition. 

11.

A family member insists on staying with an ICU patient during a sterile procedure, even after explanations regarding potential infection risks. What is the BEST next course of action?

  • Assess the patient's wishes

  • Insist that the family member leave

  • Assess if there is a way the patient's family member's wishes can be accommodated

  • Have security escort the family member out

Correct answer: Assess the patient's wishes

The family member may be permitted to stay during a sterile procedure if it is safe and consistent with the patient's wishes. It will only be necessary to assess if there is a way the patient's family member's wishes can be accommodated if the patient is okay with them being there and the patient's wishes should be assessed prior to taking time to assess the ability to accommodate this wish. Insisting the family member leave and involving security will only be necessary if the patient does not wish the family member to stay or if the patient's family member's wishes can not be accommodated.

12.

A patient has a diagnosis of Syndrome of Inappropriate Antidiuretic Hormone (SIADH). As a nurse, you understand that the symptoms of SIADH result from:

  • water intoxication

  • elevated potassium levels

  • increased serum osmolality

  • hypertension

Correct answer: water intoxication

ADH (Antidieuretic Hormone) is produced by the hypothalamus and is stored in the posterior pituitary gland. ADH exerts its primary effects in the distal collecting tubules of the kidneys where it decreases water excretion, conserving body water, thereby increasing urine concentration (osmolality) and hemodilution. SIADH is characterized by excessive release of ADH unrelated to the plasma osmolality. Normal mechanisms that control ADH secretion fail, causing impaired water excretion and profound hyponatremia. 

SIADH is a syndrome of water intoxication. Your responsibility as a nurse of a patient with SIADH includes interventions to prevent or treat symptoms caused by water intoxication. Symptoms include weakness, increased blood pressure, confusion, abdominal cramps, vomiting, and seizures.

13.

All of the following are evidence-based treatment approaches in the acute management of Myocardial Infarction (MI) EXCEPT:

  • Fibrinolytics for NSTEMI

  • Fibrinolytics for STEMI

  • ECG obtained within ten minutes of arrival to emergency department

  • Percutaneous coronary intervention for NSTEMI

Correct answer: Fibrinolytics for NSTEMI

For acute management of MI, the optimal time for initiation of therapy is within one hour of symptom onset (rarely feasible due to delay in seeking treatment). Fibrinolytics are not recommended for reperfusion of a NSTEMI (Non-ST-Elevation Myocardial Infarction). 

Fibrinolytics should be initiated within 30 minutes of the arrival of a STEMI. PCI (Percutaneous Coronary Intervention) should be performed within 24 hours of arrival for NSTEMI reperfusion. An initial ECG (Electrocardiogram) should be obtained within ten minutes of emergency department arrival for all acute coronary symptomatology.

14.

Which of the following signs and symptoms is least likely to be present in a patient experiencing shock due to an aortic rupture?

  • Hypertension

  • Tachycardia

  • Tachypnea

  • Pallor

Correct answer: Hypertension

Hypotension, tachycardia, tachypnea, and pallor are common signs of shock, including in cases of an aortic rupture. Hypertension is less likely to be present during shock from an aortic rupture as the patient typically experiences a significant drop in blood pressure due to blood loss.

15.

When blood bypasses the alveoli, gas exchange cannot occur and blood returns to the left side of the heart without being oxygenated. This is referred to as: 

  • Shunting

  • Diffusion defect

  • Dead space

  • Overall hypoventilation 

Correct answer: Shunting

A shunt is when blood, going through an abnormal pathway, does not travel its normal route. This causes hypoxemia because gas exchange cannot take place and blood returns unoxygenated. Physiologic shunts are caused by multiple conditions that result in closed, nonventilated alveoli, such as seen in ARDS (acute respiratory distress syndrome). Shunts caused anatomically include pulmonary arteriovenous fistulas (AVFs) or congenital cardiac anomalies of the heart and great vessels (such as Tetrology of Fallot). 

Dead space is characterized as the volume of a breath that does not participate in gas exchange; it is ventilation without perfusion. 

Diffusion defect occurs when thickening of the alveolar-capillary membrane decreases oxygen diffusion and leads to hypoxemia.

Overall hypoventilation occurs when decreases in tidal volume (VT), respiratory rate, or both reduce minute ventilation and cause hypoventilation. 

16.

Which of the following factors will NOT increase the risk of developing pneumonia in a critically ill patient?

  • Increased salivary flow rate

  • Limited mobility

  • Poor oral hygiene

  • Inability to eat by mouth (NPO)

Correct answer: Increased salivary flow rate

Pneumonia is the most common respiratory infection, and is the most common cause of acute respiratory failure (ARF) in a critically ill patient. High-risk individuals include infants and children, older adults, those with chronic cardiopulmonary disease, and immunocompromised individuals. Routes of entry include aspiration of oropharyngeal or gastric contents into the lungs, inhalation of bacteria-containing particles, and spread of the causative agent into the lungs from another site in the body.

Several factors present in critically ill patients increase the risk for the development of pneumonia. Systemic antibiotics, limited mobility, poor oral hygiene, inability to eat by mouth, and a decreased (not increased) salivary flow rate all contribute to an increased risk of colonization. 

Symptoms include fever, productive cough, purulent sputum, dyspnea, chest pain, tachypnea, and abnormal breathing sounds.

17.

Following bariatric surgery, close and careful respiratory monitoring is required for how long to reduce the risk of airway obstruction and oxygenation complications?

  • 24 to 48 hours

  • 12 to 24 hours

  • 72 to 96 hours

  • Five to seven days

Correct answer: 24 to 48 hours

The post-surgical bariatric patient should be monitored very carefully and closely for 24 to 48 hours because airway obstruction and oxygenation problems, such as sleep apnea, are common among this patient population, placing them at higher risk for postoperative respiratory problems.

18.

The ONLY universal sign of acute pancreatitis is:

  • acute pain

  • distended, tender abdomen

  • nausea and vomiting

  • fever

Correct answer: acute pain

A sudden onset of pain in the upper abdomen, the only universal sign of acute pancreatitis, is caused by peritoneal irritation from activated pancreatic exocrine enzymes, edema or distention of the pancreas, or interruption of the blood supply to the pancreas. Treating the pain is a priority because it causes increased exocrine enzyme release by the pancreas, which may worsen the pathologic process. 

The other answer choices are other signs/symptoms that may accompany acute pancreatitis.

19.

In which of the following ways is Methicillin-Resistant Staphylococcus Aureus (MRSA) LEAST LIKELY to be spread?

  • Unprotected sexual intercourse

  • Personal contact with contaminated items

  • The hands of infected persons

  • Equipment of healthcare providers

Correct answer: Unprotected sexual intercourse 

MRSA (Methicillin-Resistant Staphylococcus Aureus) is a type of gram-positive pathogenic organism resistant to traditional antibiotic therapy. MRSA can be transmitted via personal contact with contaminated objects such as dressings or other infected materials and can be spread by the hands or equipment of healthcare providers, such as stethoscopes.

MRSA could theoretically spread through sexual intercourse; however, as a pathogen that is spread through contact transmission, this method of transmission is the least likely.

20.

A nurse overhears a fellow nurse providing incorrect medical information to a critically ill patient. What should be the nurse's initial response?

  • Discuss the incorrect information privately with your colleagues

  • Do nothing, as the patient is not theirs

  • Immediately correct the information to the patient with the other nurse present

  • Correct the information to the patient once the other nurse is no longer present

Correct answer: Discuss the incorrect information privately with your colleagues

The nurse should discuss the issue privately with their fellow nurses to prevent the spread of incorrect information, give them an opportunity to correct themselves to the patient, and to maintain a professional atmosphere. Doing nothing could harm the patient, while publicly correcting the information in front of the other nurse could cause embarrassment and conflict. Correcting the other nurse without them being present could embarrass them and undermine their therapeutic rapport and trust with the patient.