AACN CCRN (Adult) Exam Questions

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21.

The critical care nurse is caring for an 80 kg patient exhibiting the following signs and symptoms:

T = 102.6, HR = 136 bpm, BP 90/50, UO for last hour = 40 ml/hr, WBC = 10, 000, lactate = 1.8 mmol/L and pan cultures are negative to date.

The patient MOST LIKELY has which of the following?

  • Systemic Inflammatory Response Syndrome (SIRS)

  • Cardiogenic shock

  • Septic shock

  • Multiple Organ Dysfunction Syndrome (MODS)

Correct answer: Systemic Inflammatory Response Syndrome (SIRS) 

The data does not support septic or cardiogenic shock or MODS. This data does meet the definition of SIRS because there are at least two SIRS signs and symptoms being reported: fever and tachycardia. 

Technically, the patient is not septic (WBC is high normal and cultures are negative), but it is suspected given the clinical manifestations. Shock is not present (yet) because there is a normal lactate in the presence of a low normal BP with adequate UO = 0.5/ml/kg/hr. MODS is not the answer because that would be the sequelae to shock and there is only one possible organ involvement reported (cardiovascular). By process of elimination, SIRS is the correct answer in this scenario.

22.

Which cardiac enzyme elevates FIRST in acute cardiac ischemia?

  • Myoglobin

  • Troponin T

  • Troponin I

  • Creatine Kinase-MB (CK-MB)

Correct answer: Myoglobin

Myoglobin is released more rapidly from infarcted myocardium than troponin and CK-MB. It may be detected as early as 2 hours after an acute myocardial infarction (AMI). Levels peak in 6-7 hours, and then return to normal within 24 hours. 

Elevated myoglobin increases suspicion of acute myocardial infarction (AMI) in patients presenting with anginal-type chest pain, and is a better marker for early detection of MI. If myoglobin is not elevated and levels are normal, it is a better negative indicator of MI. 

Troponin I begins to increase 3 hours after onset of MI, peaks at 14 to 18 hours, and remains elevated for 5-7 days. 

Troponin T begins to increase 3-5 hours after symptom onset and remains elevated for 14-21 days. 

CK-MB has good sensitivity and specificity for detecting MI within the first 6 hours. 

23.

A patient has been diagnosed with Immune Thrombocytopenia Purpura (ITP). The nurse knows that treatment for this patient may include all of the following EXCEPT:

  • heparin infusion

  • steroid therapy

  • intravenous immunoglobulin

  • splenectomy

Correct answer: heparin infusion

ITP (Immune Thrombocytopenia Purpura) is an autoimmune disorder that results in the destruction of platelets in the spleen and a platelet count of less than 20,000/mm3. ITP was formerly called idiopathic thrombocytopenia but was renamed when it was identified as an immune process.

Treatment options include steroids, intravenous immunoglobulin, and intravenous administration of monoclonal antibody (mAbs) treatment. In some cases, a splenectomy is a necessary treatment option.

24.

Which of the following does NOT predispose COPD patients to acute exacerbations?

  • Decreased secretion viscosity

  • Altered host defenses

  • Increased secretion volume

  • Impaired secretion clearance

Correct answer: Decreased secretion viscosity

Chronic Obstructive Pulmonary Disease (COPD) creates several pathological changes that predispose patients to exacerbations of their illness. Among these are altered host defenses, increased secretion volume and increased secretion viscosity. Secretion changes lead to impaired secretion clearance. Secretion viscosity increases, not decreases, due to COPD.

25.

Analyze and interpret the ABG results: 

  • pH 7.47
  • PaCO2 55 mmHg
  • Bicarbonate 32 mEq/L
  • PaO2 92

  • Partially compensated metabolic alkalosis, without hypoxemia

  • Normal ABG

  • Uncompensated metabolic acidosis, with hypoxemia

  • Partially compensated respiratory alkalosis, without hypoxemia

Correct answer: Partially compensated metabolic alkalosis, without hypoxemia

Four-step guide to ABG analysis:

  1. Is the pH normal, acidotic, or alkalotic?
  2. Are the pCO2 or HCO3 abnormal? Which one appears to influence the pH?
  3. If both the pCO2 and HCO3 are abnormal, the one which deviates most from the norm is most likely causing an abnormal pH.
  4. Check the pO2. Is the patient hypoxic?

Normal pH ranges from 7.35–7.45. Since this patient's pH is above 7.45, the patient is experiencing alkalosis. Normal CO2 (carbon dioxide) levels range from 35–45 mmHg, and normal HCO3 (bicarbonate) levels range from 22–26 mEq/L. CO2 is the respiratory component and HCO3 is the metabolic component. The component that matches the pH is the system controlling the ABG (Arterial Blood Gas). Normal PaO2 is 80–100 mmHg.

Thus, in this scenario, the patient is experiencing metabolic alkalosis, without hypoxemia (pO2 > 80 mmHg) and compensation is partial; partial compensation occurs when the CO2 and HCO3 rise or fall together (rise in this scenario) but the pH remains abnormal.

26.

Diagnosis of acute myocardial infarction (AMI) is based on two of three findings. 

Of the following, which is NOT one of these findings diagnostic for acute myocardial infarction (AMI)? 

  • ST-segment elevation on ECGs

  • History of ischemic-like symptoms

  • Changes on serial ECGs

  • Elevation and fall of serum cardiac enzymes

Correct answer: ST-segment elevation on ECGs

Diagnosis of AMI is based on two of three findings:

  1. History of ischemic-like symptoms
  2. Changes on serial ECGs (T-wave inversion or ST-segment depression)
  3. Elevation and fall in level of serum cardiac biomarkers (Troponin I or T, myoglobin, and creatine kinase)

Of AMI patients, 50% do not present with ST-segment elevation. 

Other indicators include: ST-segment depression (may indicate NSTEMI), new left bundle branch block (LBBB) and ST-segment depression that resolves with relief of chest pain. T-wave inversion in all chest leads may indicate NSTEMI with a critical stenosis in the proximal left anterior descending coronary artery (LAD). 

27.

An ICU nurse is educating a patient about their newly-diagnosed type 2 diabetes. The patient is struggling with understanding the importance of regular glucose monitoring. Which of the following methods is MOST effective for promoting patient learning in this situation?

  • Explaining how the body regulates glucose levels and the mechanism through which high blood glucose negatively impacts health

  • Presenting the patient with statistics and charts about the negative effects of uncontrolled diabetes

  • Demonstrating how to use a glucometer, then having the patient demonstrate it back

  • Telling the patient that not monitoring glucose could lead to amputation

Correct answer: Explaining how the body regulates glucose levels and the mechanism through which high blood glucose negatively impacts health

If the patient is struggling to understand the importance of regular glucose monitoring, the nurse should explain the rationale for this intervention by explaining how the body regulates glucose levels and the mechanism through which high blood glucose negatively impacts health. Presenting the patient with statistics and charts about the negative effects of uncontrolled diabetes is not likely to be effective unless it is tied in with how regular glucose monitoring mitigates these risks. Demonstrating how to use a glucometer, then having the patient demonstrate it back does not address the underlying lack of understanding about the importance of regular glucose monitoring. Telling the patient that not monitoring glucose could lead to amputation may cause compliance based on fear, not based on an understanding of the rationale for glucose monitoring. 

28.

An acute neurological injury associated with severe, sudden onset headache can be due to:

  • subarachnoid hemorrhage

  • migraine

  • hypoxia

  • subdural hematoma

Correct answer: subarachnoid hemorrhage

Subarachnoid Hemorrhage (SAH) can result from trauma, aneurysm, or other vascular malformations. Patients with SAH experience sudden, severe headaches described as "explosive" or "the worst headache of my life."

Other common signs and symptoms include nausea and vomiting, stiff neck, blurred vision, mental status changes, and photophobia. Focal deficits such as hemiparesis, hemiplegia, or aphasia may also occur. Subdural hematomas are less likely to result in a headache that is sudden. Migraines are not a form of neurological injury.

29.

The critical care nurse knows that all of the following will be priority assessment data to gather from a patient suspected of having an acute respiratory infection such as pneumonia EXCEPT:

  • presence of peripheral edema

  • auscultation of breath sounds

  • presence of chest pain

  • color of nailbeds

Correct answer: presence of peripheral edema

A respiratory assessment, which includes auscultating breath sounds and assessing the nail bed color, is a priority for patients with pneumonia. Assessing for the presence of chest pain (or pressure with movement or coughing) is also an important respiratory assessment, as this symptom can interfere with the patient's ability to breathe deeply.

Assessment of peripheral edema may be appropriate to rule out other causes of the patient's shortness of breath (such as myocardial infarction), but this is not a priority assessment for the patient with pneumonia.

30.

Which of the following statements is ACCURATE regarding the diagnosis of acute myocardial infarction (AMI) and cardiac biomarkers? 

  • Diagnosis is based on two of three findings: history of ischemic-like symptoms, changes in serial ECGs, and elevation/fall in level of serum cardiac biomarkers 

  • Troponin T is released from the myocardium within 2 hours of coronary occlusion

  • Troponins I and T are better markers for an early ruling out of MI than the other cardiac enzymes

  • Of AMI patients, approximately 75% have ST-segment elevation on their initial ECG, and the label "STEMI" is used in this situation 

Correct answer: Diagnosis is based on two of three findings: history of ischemic-like symptoms, changes in serial ECGs, and elevation/fall in level of serum cardiac biomarkers 

Diagnosis of AMI is based on two of three findings:

  • History of ischemic-like symptoms
  • Changes in serial ECGs
  • Elevation and fall in level of serum cardiac biomarkers

Thirty-five percent (not 75%) of patients with AMI have ST-segment elevation on their initial ECG, and in these situations, the label "STEMI" is used. Approximately 65% of those with AMI have no ECG or other diagnostic changes. 

Cardiac enzymes include troponin I and T, myoglobin, and creatine kinase (CK and CK-MB). Myoglobin (not troponin T) is released from the myocardium within 2 hours of coronary occlusion, and is a better marker for early detection of MI. It is also a better negative indicator if negative. 

31.

Of the following White Blood Cell (WBC) counts, which result is abnormal?

  • 4,000/mm3

  • 7,000/mm3

  • 5,000/mm3

  • 10,000/mm3

Correct answer: 4,000/mm3

Leukocytes, or WBCs circulating in the blood, are measured as an indicator of the total amount of WBCs in the body. Normal values of WBCs range from 4,500–10,500 per microliter of blood. Leukopenia is a decrease in the number of WBCs, which places individuals at risk for immune compromise, resulting in infection. This occurs when bone marrow production is inhibited or during certain infections when rapid consumption of WBCs occurs.

32.

In which of the following pressure injuries is osteomyelitis MOST LIKELY to occur?

  • Stage 4 pressure injuries

  • Stage 3 pressure injuries

  • Deep tissue injury

  • Pressure injuries do not increase the risk of osteomyelitis

Correct answer: Stage 4 pressure injuries

Osteomyelitis is an infection of the bones, and is most likely to occur when bone is exposed. Stage 4 pressure injuries are the only type of pressure injuries in which bone may be exposed. Stage 3 pressure injuries cause full thickness tissue loss and may increase the risk of osteomyelitis, but not as much as stage 4 pressure injuries where the bone is actually exposed. Deep tissue injuries may extend down to the bone, but do not expose the bone to the external environment.

33.

Which of the following would indicate late signs of increased Intracranial Pressure (ICP)?

  • Pupillary changes

  • Change in Level of Consciousness (LOC)

  • Lethargy

  • Visual abnormalities

Correct answer: Pupillary changes

Early signs of increased Intracranial Pressure (ICP) include restlessness, confusion, lethargy, headache, nausea or vomiting, and visual abnormalities (i.e., diplopia). Change in Level of Consciousness (LOC) is the most important indicator of elevated ICP, but not a late sign. Changes in vital signs may occur. Systolic blood pressure increases as the body attempts to maintain cerebral perfusion, and heart rate and respiratory pattern alterations may emerge as ICP worsens. Pupillary changes are usually late signs of increased ICP.

34.

A patient with a blood glucose of less than 60 mg/dl who is diaphoretic, conscious and oriented should receive:

  • 15 g carbohydrate by mouth

  • 30 g carbohydrate by mouth

  • 1 ampule D50 intravenously (IV)

  • 1 mg glucagon subcutaneously (SC)

Correct answer: 15 g carbohydrate by mouth

Hypoglycemia occurs when serum blood glucose levels for fingerstick glucose < 60 mg/dL. The management of the patient with acute hypoglycemia depends on the severity of the reaction. For mild reactions, in which the patient is completely alert, and exhibiting symptoms such as diaphoresis, shakiness, tachycardia, excessive hunger, and/or anxiety, treatment includes administering 10g to 15g carbohydrate snack, obtaining a blood glucose measure ten to 15 minutes later, and administering another 10 to 15 g carbohydrate snack only if the condition does not improve. If the patient is not alert enough to swallow or unable to do so (in the case of moderate to severe reactions), injecting 1 to 2 mg glucagon IV/IM/SC, or administering IV glucose (initial bolus is 50% dextrose), followed by a continuous infusion until oral replacement is possible, is indicated. 

35.

Conditions that cause cerebral vasodilation, and thus further the increase of Intracranial Pressure (ICP) include which of the following?

  • Hypoxia, hypercapnia, increased systemic blood pressure

  • Hypoxia, hypocapnia, increased systemic blood pressure

  • Hypoxia, hypocapnia, decreased systemic blood pressure

  • Hypoxia, hypercapnia, decreased systemic blood pressure

Correct answer: Hypoxia, hypercapnia, increased systemic blood pressure

Conditions that cause cerebral vasodilation, and thus further the increase of Intracranial Pressure (ICP) include:

  • Hypoxia (insufficient blood in the arteries)
  • Hypercapnia (elevated CO2 levels in the blood)
  • Increased metabolic demands
  • Drug effects
  • Increased systemic blood pressure

36.

The doctrine of informed consent encompasses four elements. Which of the following is NOT one of these elements of informed consent?

  • Autonomy

  • Disclosure

  • Comprehension

  • Competence

Correct answer: Autonomy 

The doctrine of informed consent encompasses the following four elements:

  • Disclosure
  • Comprehension
  • Voluntariness
  • Competence

The patient's comprehension often depends on how the information is disclosed. Information must be provided in a way that promotes the patient's understanding of their current medical status, the proposed interventions, all possible risks and benefits, and the reasonable alternatives to the proposed treatment. Decisions must be reached voluntarily. Competence reflects the patient's capability to make decisions about their own medical care.

The intent of the informed consent process is based on the principle of autonomy, as it provides an individual with the necessary information to compare options and make a reasoned choice. 

Autonomy, therefore, is not an element of, but rather, a principle upon which informed consent is based.

37.

The nurse is caring for a critically ill patient with a history of treatment for depression. The patient tells the nurse, "I want to die. My life is not worth living anymore." The nurse should implement all of the following into the patient's plan of care EXCEPT:

  • avoid asking the patient directly if they are presently feeling suicidal

  • request a psychiatric consult

  • consult with the doctor about the patient's previous psychiatric medication and the need to maintain the regimen while the patient is hospitalized

  • allow the patient to lead the conversation

Correct answer: avoid asking the patient directly if they are presently feeling suicidal

The nurse should not avoid asking the patient directly about current suicidal thoughts. It is important to note that you do not promote suicidal thoughts by asking the question. Often, the communication of feeling suicidal is a cover for wanting to discuss fear, pain, or loneliness. Similarly, if depression is suspected, ask directly, and allow the patient to initiate conversation. A psychiatric referral is recommended, and it is also important that healthcare providers do not forget to maintain the patient's psychiatric medication regimen while hospitalized to avoid worsening of the patient's psychological status.

38.

Which of the following systems is LEAST important when assessing and evaluating a patient for multiple organ dysfunction syndrome (MODS)?

  • Endocrine 

  • Renal

  • Neurologic 

  • Hematologic

Correct answer: Endocrine

MODS refers to progressive damage to two or more organ systems that may result in permanent change in organ function. In the trauma patient, MODS may be due to infection and sepsis, but may also occur as a result of excessive blood loss. Unless hypoperfusion and shock are rapidly reversed, the organs sustain ischemia, inflammation, injury, and possibly infarction. 

Signs of acute organ system dysfunction include:

  • Cardiovascular (hypotension, tachycardia)
  • Respiratory (tachypnea, hypoxemia)
  • Renal (oliguria, elevated creatinine)
  • Hematologic (thrombocytopenia)
  • Gastrointestinal (ileus or change in bowel sounds)
  • Hepatic (elevated liver enzymes, jaundice)
  • Neurologic (altered LOC, agitation)

The endocrine system is not used as part of the criteria in determining if a patient has MODS.

39.

Which of the following is LEAST LIKELY to be an expected benefit of developing an interprofessional plan of care?

  • Improved patient compliance

  • Improved patient outcomes

  • Reduced duplication of interventions

  • Better prioritization of activities

Correct answer: Improved patient compliance

Developing an interprofessional plan of care leads to several expected benefits for the patient, including improved outcomes. An interprofessional plan of care also results in more efficient care, benefiting the patient medically and financially. These benefits include reduced duplication of interventions and better prioritization of activities. Improved patient compliance is not a major expected benefit of developing an interprofessional plan, although there may be an effect in this area due to improved teaching and reinforcement.

40.

A patient asks the critical care nurse what the difference is between meningitis and encephalitis. Which of the following responses is BEST?

  • They are both inflammation, but affect different parts of the brain. 

  • Both terms describe the same thing.

  • Meningitis is a specific term referring the lining of the brain, while encephalitis is a more general term that includes meningitis.

  • Meningitis is caused by infection, while encephalitis is an inflammatory condition.

Correct answer: They are both inflammation, but affect different parts of the brain. 

Meningitis is inflammation affecting the meninges, the lining of the brain. Encephalitis is inflammation of the brain parenchyma, the brain tissue itself. Both are typically caused by infection. These terms do not describe the same thing. Both have a specific meaning, and encephalitis is not just a more general term that includes meningitis.