AACN PCCN NOV 2023 Exam Hanbook version 1.1.1 Exam Questions

Page 1 of 33

1.

The PCU is short-staffed, and there is only one dialysis machine available for two patients who both need urgent treatment. One is a 25-year-old female patient with acute kidney injury due to a recent infection, while the other is the 62-year-old male patient with end-stage renal disease. You must decide which patient will receive dialysis first, knowing both have a critical need.

In making this decision, which ethical principle is being instituted?

  • Justice

  • Autonomy

  • Beneficence

  • Nonmaleficence

Correct answer: Justice

The ethical principle of justice is about fairness in the distribution of resources and care. In this scenario, you must consider how to fairly allocate the limited resource (the dialysis machine) between two patients, ensuring that both patients receive equitable consideration based on their medical needs and circumstances.

Autonomy focuses on respecting a patient's right to make their own decisions about their care. Beneficence is acting in the best interest of the patient by providing the most beneficial care. Nonmaleficence is the principle of "do no harm," ensuring that actions do not cause unnecessary harm to patients. While these principles are important, justice specifically addresses the concept of fairness, which is central in this context.

2.

Which of the following is the MOST common indication for initiating renal replacement therapy in acute kidney injury?

 

  • Severe hyperkalemia

  • Severe hypertension

  • Severe hypercalcemia

  • Severe hypoglycemia

Correct answer: Severe hyperkalemia

Severe hyperkalemia is one of the most common and urgent indications for initiating renal replacement therapy in patients with acute kidney injury. Elevated potassium levels can lead to life-threatening cardiac arrhythmias, making it crucial to reduce potassium levels through dialysis rapidly.

Hypertension is typically managed with antihypertensive medications and does not usually require renal replacement therapy unless it is associated with fluid overload or other complications.

Hypercalcemia is managed through hydration, medications like bisphosphonates, and sometimes dialysis, but it is a less common reason for renal replacement therapy than hyperkalemia.

Hypoglycemia is treated with glucose administration, not dialysis, and is unrelated to the initiation of renal replacement therapy.

3.

A 50-year-old male patient with a recent hip replacement develops sudden shortness of breath and tachypnea. His vital signs are BP 140/90 mmHg, HR 100 bpm, RR 30 breaths/min, and O2 saturation 88% on room air. Which clinical finding is MOST likely to confirm the diagnosis of a pulmonary embolism?

  • Elevated D-dimer levels

  • ST elevation on ECG

  • Bibasilar crackles on lung auscultation

  • Widened pulse pressure

Correct answer: Elevated D-dimer levels

Elevated D-dimer levels suggest the presence of a thrombus, which, in the context of sudden shortness of breath and hypoxia, is highly suggestive of a pulmonary embolism. D-dimer is a fibrin degradation product, and its elevation indicates active clot formation and breakdown.

ST elevation on ECG is indicative of myocardial infarction rather than pulmonary embolism. Bibasilar crackles on lung auscultation are more associated with congestive heart failure or pneumonia. A widened pulse pressure is nonspecific and is not a primary diagnostic indicator for pulmonary embolism.

4.

A 72-year-old female patient with a history of chronic hypothyroidism is admitted to the PCU with suspected myxedema coma. Despite appropriate treatment with intravenous levothyroxine and supportive care, the patient remains comatose and hemodynamically unstable. 

What factor is MOST likely contributing to her poor prognosis?

  • Delayed initiation of thyroid hormone replacement

  • Severe underlying cardiac disease

  • Concurrent sepsis

  • Advanced age

Correct answer: Delayed initiation of thyroid hormone replacement

In myxedema coma, the prognosis heavily depends on the timing of the intervention. A delay in initiating thyroid hormone replacement can lead to irreversible damage and a poor outcome. The longer the condition remains untreated, the higher the risk of death or severe complications.

Severe underlying cardiac disease may contribute to the patient’s instability but is not the primary factor in the poor response to treatment. Concurrent sepsis could exacerbate the situation, but the delay in treatment is the most critical factor. Advanced age is a risk factor for poor outcomes in general, but timely and appropriate treatment can significantly improve the prognosis in elderly patients with myxedema coma.

5.

Which of the following statements about the postsurgical care of the cardiac transplantation patient is TRUE?

  • If dysrhythmias such as Supraventricular Tachycardia (SVT) occur, calcium channel blockers or beta-blockers are used

  • Patients usually have a lower resting heart rate than normal

  • In cases of chronic rejection with diffuse coronary artery disease, patients may experience severe angina

  • With the loss of vagal tone, and if the sinus rate increases, there is a greater potential for junctional rhythms to develop

Correct answer: If dysrhythmias such as Supraventricular Tachycardia (SVT) occur, calcium channel blockers or beta blockers are used

For dysrhythmias such as SVT in post-cardiac transplantation patients, calcium channel blockers or beta-blockers are used to decrease the heart rate.

Following cardiac transplantation, the patient usually has a higher resting heart rate than normal due to the loss of vagal influence. 

Cardiac denervation creates a concern in cardiac transplantation patients as pain impulses are not transmitted to the brain. This occurs in cases of chronic rejection, in which even diffuse coronary artery disease does not cause the patient to experience angina. Following cardiac transplantation, patients require more stabilization before position changes or exercise to avoid orthostasis. 

Due to the loss of vagal tone, and if the sinus rate decreases, the risk of developing junctional rhythms increases.

6.

Which of the following is an intrinsic cause of hemolysis? 

  • Sickle cell anemia

  • A transfusion reaction

  • Splenic disorders

  • Damage from cardiopulmonary bypass

Correct answer: Sickle cell anemia

Sickle cell anemia is an example of an abnormality intrinsic to the red blood cell.

Extrinsic sources of hemolysis include immune destruction from a transfusion reaction, cardiopulmonary bypass, splenic dysfunction, damage by artificial heart valves, and use of an intra-aortic balloon pump.

7.

A 52-year-old female patient with a history of mitral regurgitation undergoes a mitral clip procedure. Postoperatively, she develops increasing shortness of breath and bilateral lung crackles. 

Which of the following findings is LEAST likely to be related to the mitral clip procedure?

  • Acute myocardial infarction

  • Left ventricular failure

  • Pulmonary edema

  • Severe mitral regurgitation recurrence

Correct answer: Acute myocardial infarction

While acute myocardial infarction is possible in any patient, it is least likely to be directly related to the mitral clip procedure itself. The mitral clip primarily affects mitral valve function, not the coronary arteries.

Left ventricular failure is a possible complication after mitral valve repair, particularly if the left ventricle has been overloaded. Pulmonary edema can occur if mitral valve function is still compromised, leading to backflow into the lungs. Severe mitral regurgitation recurrence could cause worsening symptoms post-procedure, such as shortness of breath.

8.

A 40-year-old male patient has been diagnosed with both anxiety and depression. His vitals are as follows: BP 115/78 mmHg, HR 89 bpm, RR 20 breaths/min, SpO2 97%. The patient reports feeling overwhelmed and unable to complete daily tasks. 

What is the BEST initial nursing intervention?

  • Encourage deep breathing and grounding exercises

  • Administer a Selective Serotonin Reuptake Inhibitor (SSRI)

  • Refer the patient to a psychiatrist

  • Begin cognitive behavioral therapy

Correct answer: Encourage deep breathing and grounding exercises

In a clinical setting, immediate relief techniques such as deep breathing and grounding exercises can help manage acute anxiety symptoms while awaiting further evaluation and treatment.

Administering an SSRI requires physician authorization and wouldn’t provide immediate relief.
Referral to a psychiatrist is appropriate but not an immediate intervention for the current anxiety symptoms. Cognitive Behavioral Therapy (CBT) may be effective in the long term but is not an immediate nursing intervention during an acute anxiety episode.

9.

A 60-year-old female patient is admitted to the Progressive Care Unit (PCU) with pulmonary disease. She and her family speak very little English. Which of the following actions is MOST appropriate for you to take to help the patient and family understand what evaluation for hypoxemia will involve?

  • Show the patient and her family the unit's simple, printed brochure describing the evaluation, which includes a picture of a treadmill, and write out simple instructions

  • Explain the procedure in English using short sentences

  • Request a respiratory therapist come to the unit to demonstrate the procedure

  • Assume the pulmonary technician will explain the evaluation procedure

Correct answer: Show the patient and her family the unit's simple, printed brochure describing the evaluation, which includes a picture of a treadmill, and write out simple instructions

This teaching incorporates individualized education into patient care, involves the family, and is based on their needs and level of understanding.

Explaining the procedure in English will not best facilitate understanding, even if you use short sentences.

While requesting a Respiratory Therapist (RT) to demonstrate the procedure could be useful, the most appropriate intervention is to start with a brochure with pictures and simple instructions. 

Do not assume someone else will explain the procedure.

10.

A 58-year-old patient with a history of asthma and hypertension is admitted to the Progressive Care Unit (PCU) for hypertensive crisis. The patient is prescribed IV labetalol for blood pressure management. 

Which of the following statements is TRUE about labetalol administration and its effects?

  • Labetalol can cause bronchospasm and should be used cautiously in patients with asthma

  • Labetalol selectively blocks beta-1 receptors, leading to decreased heart rate and cardiac output

  • Labetalol is administered as a continuous infusion only, not in bolus doses

  • Labetalol primarily causes peripheral vasoconstriction, increasing systemic vascular resistance

Correct answer: Labetalol can cause bronchospasm and should be used cautiously in patients with asthma

Labetalol can cause bronchospasm due to its nonselective beta-blocking effects. This is especially important in patients with asthma or other reactive airway diseases, as blocking beta-2 receptors in the lungs can lead to bronchoconstriction.

Labetalol is a nonselective beta-blocker and also has alpha-1 blocking activity. It decreases heart rate and cardiac output and causes vasodilation by blocking both beta and alpha receptors.

It can be administered both as an intermittent IV bolus and as a continuous infusion, depending on the clinical situation and the physician’s order.

Labetalol primarily causes peripheral vasodilation due to its alpha-1 blocking effects, which lowers systemic vascular resistance. It does not cause peripheral vasoconstriction.

11.

A 39-year-old female patient, six months post-cardiac transplantation, presents with fever, shortness of breath, and fatigue. The healthcare team is concerned about acute rejection. 

Which diagnostic test is MOST likely to confirm the diagnosis of acute cardiac allograft rejection?

  • Endomyocardial biopsy

  • Echocardiogram

  • Cardiac catheterization

  • Chest x-ray

Correct answer: Endomyocardial biopsy

Endomyocardial biopsy is the gold standard for diagnosing acute cardiac allograft rejection. It involves taking a small sample of the heart muscle tissue to look for signs of rejection under a microscope. This test is crucial for confirming the diagnosis and guiding treatment.

An echocardiogram can show signs of heart dysfunction, such as reduced ejection fraction or ventricular dysfunction, but it cannot definitively diagnose rejection without biopsy confirmation.

Cardiac catheterization may be used to assess coronary arteries or measure pressures within the heart but is not the primary tool for diagnosing rejection.

A chest x-ray can show heart size and fluid accumulation in the lungs but does not provide specific information to diagnose cardiac allograft rejection.

12.

Which of the following are evidence-based practice guidelines related to family interventions that should occur during the evaluation stage of the nursing process?

  • Use multiple methods to evaluate achievement of meeting family needs

  • Make referrals as appropriate for support services

  • Establish optimal methods to contact the family

  • Provide information according to family needs

Correct answer: Use multiple methods to evaluate achievement of meeting family needs

Methods that may be used to evaluate whether a family's needs are or have been met include satisfaction surveys, feedback, care conferences, and follow-up after discharge.

In the intervention stage of the nursing process in family interventions, the following interventions are appropriate:

  • Determine spokesperson and contact person
  • Establish optimal methods to contact and communicate with family
  • Make referrals for support services as appropriate
  • Provide information according to family needs
  • Provide a comfortable environment
  • Include family in direct care as appropriate
  • Encourage family participation and presence during team rounds

13.

You are caring for a 76-year-old male patient with a history of chronic heart failure, admitted with shortness of breath and swelling in his legs. His vital signs are blood pressure 132/86 mmHg, heart rate 85 beats per minute, respiratory rate 20 breaths per minute, and SpO2 94% on room air. He has a history of chronic heart failure. 

Which of the following is the MOST common cause of heart failure exacerbation?

  • Noncompliance with medications

  • Myocardial infarction

  • Atrial fibrillation

  • Hypertension

Correct answer: Noncompliance with medications

Noncompliance with prescribed heart failure medications, particularly diuretics, is the most common cause of heart failure exacerbations. Patients may skip their medications for various reasons, leading to fluid overload and decompensation of heart failure.

Myocardial infarction can exacerbate heart failure but is less common than noncompliance. Atrial fibrillation can also lead to exacerbations but usually in combination with other factors. Hypertension is a common contributing factor in chronic heart failure, but poorly controlled blood pressure is not the most frequent cause of exacerbation in stable heart failure patients.

14.

You are evaluating the effectiveness of a lung-protective ventilation strategy in a 45-year-old male patient with ARDS and a history of Chronic Obstructive Pulmonary Disease (COPD). The patient’s current ventilator settings include low tidal volume and high PEEP, with oxygen saturation maintained at 92% and a respiratory rate of 24 breaths per minute. Which outcome is MOST critical in evaluating the success of this ventilation strategy?

  • Improvement in arterial oxygenation without signs of ventilator-induced lung injury

  • Reduction in the patient's work of breathing as evidenced by decreased respiratory rate

  • Patient’s comfort and tolerance of the ventilator settings

  • Decrease in the need for sedation to maintain patient-ventilator synchrony

Correct answer: Improvement in arterial oxygenation without signs of ventilator-induced lung injury

The most critical outcome to evaluate the success of a lung-protective ventilation strategy in ARDS is the improvement in arterial oxygenation without signs of ventilator-induced lung injury. This strategy aims to optimize oxygenation while minimizing the risk of further lung damage from high pressures or volumes.

Reduction in the patient's work of breathing is important but secondary to ensuring that the lungs are not being further injured by the ventilator settings.

Patient comfort and tolerance are essential for care but are not the primary measure of success in managing ARDS with lung-protective strategies.

A decrease in the need for sedation might indicate improved patient-ventilator synchrony, but it does not directly reflect the success of the lung-protective strategy in preventing further lung injury and improving oxygenation.

15.

A 42-year-old female patient with a history of Pulmonary Arterial Hypertension (PAH) presents to the progressive care unit for a scheduled right-heart cardiac catheterization. During the procedure, the healthcare team administers a vasodilator to assess her response. The response is positive, with a significant decrease in pulmonary artery pressures.

Which of the following medications is MOST appropriate in this context? 

  • Calcium channel blockers

  • Endothelin receptor antagonists

  • Phosphodiesterase-5 inhibitors

  • Prostacyclin analogs

Correct answer: Calcium channel blockers

For patients with PAH who demonstrate a positive vasodilator response, calcium channel blockers are the most appropriate treatment. These medications can help to lower pulmonary artery pressures and improve symptoms in this specific subset of PAH patients.

Endothelin receptor antagonists are effective in treating PAH but are not the first choice for patients who show a positive response to vasodilators during right-heart catheterization.

Phosphodiesterase-5 inhibitors are used in the management of PAH but are typically considered for patients who do not respond to vasodilator testing.

While effective for PAH, prostacyclin analogs are usually reserved for more advanced disease or for those who do not respond to initial vasodilator testing.

16.

You are caring for a patient who has just been admitted with complications of congestive heart failure. As you are preparing to administer their medications, their family arrives and starts asking detailed questions about their condition, treatment plan, and prognosis.

During this time, another nurse, who is not assigned to your patient, overhears the conversation and casually asks you for more information about the patient's history and current health status. You feel the pressure to respond quickly to both the family and your colleague while managing your other duties.

In this situation, which ethical obligation do you have a legal mandate to honor under the Health Information Portability and Accountability Act (HIPAA)?

  • Maintaining patient confidentiality and protecting their private health information

  • Transparency in sharing all patient details with family members and colleagues 

  • Ensuring all medical staff have access to the patient's full medical history 

  • Disclosing patient information only in emergency situations

Correct answer: Maintaining patient confidentiality and protecting their private health information

HIPAA is designed to ensure the privacy and security of patients' health information. Nurses and other healthcare providers are legally and ethically obligated to protect this information from unauthorized access or disclosure. In the scenario, you must ensure that the patient's health information is shared only with individuals who have a legitimate need to know and are authorized to receive it.

While transparency in healthcare is important, HIPAA specifically restricts the sharing of patient information to only those who are directly involved in the patient's care and who have the patient's consent. This applies to both family members and other medical staff.

While there are provisions under HIPAA for disclosing patient information in emergency situations to provide necessary care, HIPAA's main focus is broader. It requires protecting patient privacy at all times, not just in emergencies.

17.

Which of the following statements is TRUE about insulin administration?

  • Humalog peaks within 30 to 90 minutes, while Humulin R peaks in two to three hours

  • Humalog peaks within two to three hours, while Humulin R peaks within 30 to 90 minutes

  • Novolin R has a duration of less than five hours, while Humulin R has a duration of eight hours

  • Humulin R has a duration of three to five hours, while Novolin R has a duration of less than three hours

Correct answer: Humalog peaks within 30 to 90 minutes, while Humulin R peaks in two to three hours

Humalog (insulin lispro) is a rapid-acting insulin that peaks within 30 to 90 minutes, making it effective for controlling blood sugar spikes after meals. Humulin R (regular insulin) is a short-acting insulin that peaks in two to three hours, making it suitable for mealtime blood sugar control as well but with a slightly longer action profile.

Novolin R and Humulin R are both brands of regular insulin with similar pharmacokinetic profiles. Both typically have a duration of action of five to eight hours.

18.

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.

19.

A 49-year-old female patient presents with confusion and hypotension following an overdose of narcotics. Her ABG results show pH 7.22, PaCO2 65 mmHg, and HCO3 24 mEq/L. 

What would be the BEST initial management to improve her condition?

  • Administer naloxone

  • Begin intravenous fluid resuscitation

  • Provide Non-Invasive Positive Pressure Ventilation (NIPPV)

  • Start sodium bicarbonate infusion

Correct answer: Administer naloxone

The patient’s ABG results show a low pH (7.22), high PaCO2 (65 mmHg), and normal bicarbonate (HCO3) (24 mEq/L), which indicates acute respiratory acidosis due to hypoventilation. Narcotic overdose is a common cause of hypoventilation and respiratory depression. Naloxone, an opioid antagonist, can reverse the effects of narcotics, improving respiratory drive and helping to correct the underlying cause of respiratory acidosis.

Intravenous fluid resuscitation might be necessary if there is concurrent hypovolemia or shock, but it does not address the primary issue of opioid-induced respiratory depression.

NIPPV could be considered to support ventilation if the patient’s condition does not improve quickly after naloxone administration or if there is significant respiratory compromise. However, addressing the narcotic overdose is the priority.

Starting a sodium bicarbonate infusion is not indicated in isolated respiratory acidosis unless there is concurrent metabolic acidosis or significant acidemia. The primary issue here is ventilatory failure, not metabolic derangement.

20.

A 58-year-old male patient presents with a blood pressure of 220/120 mmHg, severe headache, and visual disturbances. What is the MOST likely underlying condition causing these symptoms?

  • Hypertensive encephalopathy

  • Acute myocardial infarction

  • Acute kidney injury

  • Pulmonary embolism

Correct answer: Hypertensive encephalopathy

Hypertensive encephalopathy is the most likely underlying condition, given the patient’s presentation. These symptoms indicate increased intracranial pressure and potential cerebral edema, which are hallmarks of hypertensive encephalopathy.

Acute myocardial infarction can cause severe symptoms but is typically associated with chest pain and other signs of cardiac ischemia. Acute kidney injury may occur due to high blood pressure but does not present with neurological symptoms. Pulmonary embolism typically presents with respiratory symptoms like shortness of breath and chest pain rather than neurological symptoms.