AACN CCRN (Adult) Exam Questions

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81.

Which of the following types of cardiomyopathy is MOST LIKELY to cause a left bundle branch block (LBBB) on a 12-lead lectrocardiogram?

  • Dilated cardiomyopathy

  • Hypertrophic cardiomyopathy

  • Restrictive cardiomyopathy

  • A bundle branch block is not indicative of any type of cardiomyopathy

Correct answer: Dilated cardiomyopathy

Dilated cardiomyopathy, the most common type of cardiomyopathy, is often caused by coronary artery disease, and is associated with impaired myocardial contractility and increased ventricular filling pressures. 

Dilated cardiomyopathy can be diagnosed with a 12-lead electrocardiogram (ECG or EKG) showing:

  • bundle branch block (LBBB most common)
  • ST-segment and T-wave changes
  • left axis deviation
  • left ventricular hypertrophy

ECG changes associated with hypertrophic cardiomyopathy include ST-segment and T-wave changes, septal Q waves due to septal hypertrophy, and left ventricular hypertrophy.

ECG changes associated with restrictive cardiomyopathy include ST-segment and T-wave changes, and low QRS amplitude. 

82.

The nurse is caring for a newly-admitted patient in the ICU who was found unconscious on the street and was discovered to be in Diabetic Ketoacidosis (DKA) with a blood sugar of 695. The patient is homeless, has had multiple admissions for DKA, and could benefit from the use of an insulin pump, but states that they have repeatedly been told, "Those are for insured patients who can afford them."

What ethical principle supports this patient's right to have an insulin pump?

  • Justice

  • Beneficence

  • Autonomy

  • Nonmaleficence

Correct answer: Justice

The ethical principle of justice is defined as fairness, and in health care it is often applied to the manner in which goods, burdens, and services are distributed among a population. The principle of justice supports this patient's right to access an insulin pump since her socioeconomic status should not impact their ability to receive care. Nurses must advocate for equal treatment for all patients, regardless of circumstances.

83.

Which of the following is LEAST LIKELY to contribute to the development of hyperglycemia in the critical care environment?

  • Malnutrition

  • Physiological stress

  • Inadequate insulin in patients with type 2 diabetes

  • New onset of HHS

Correct answer: Malnutrition

Malnutrition will lead to hypoglycemia, not hyperglycemia. Physiological stress can increase blood glucose levels, leading to hyperglycemia. Inadequate insulin in patients with any type of diabetes in the critical care environment can lead to hyperglycemia. Even patients with type 2 diabetes will be managed by insulin while hospitalized. A new onset of Hyperosmolar Hyperglycemic Syndrome (HHS) will cause hyperglycemia.

84.

The nurse is caring for a patient with Disseminated Intravascular Coagulation (DIC). The doctor has ordered heparin for this patient. The nurse understands that heparin is used in DIC because it:

  • neutralizes thrombin

  • prevents the conversion of vitamin K back to its active form

  • contains clotting factors

  • increases circulating platelets

Correct answer: neutralizes thrombin

Heparin is used in Disseminated Intravascular Coagulation (DIC) because it neutralizes thrombin, which prevents further clot formation. It is often used as therapy (or prophylaxis) in patients with slowly evolving DIC who have (or are at risk of) venous thromboembolism.

In DIC, the clotting mechanism is activated and bleeding results when a deficit in clotting factors occurs. Heparin stops clotting by neutralizing thrombin; this activates fibrinogen to form a fibrin clot. Warfarin (not heparin) works by preventing the conversion of vitamin K back to its active form from the vitamin K epoxide, impairing the formation of vitamin K-dependent clotting factors. Warfarin is indicated in the treatment of venous thrombosis or pulmonary embolism following heparin therapy.

85.

Pulmonary embolism develops due to all of the following complications EXCEPT:

  • atrial fibrillation

  • Deep Venous Thrombosis (DVT)

  • long bone fracture

  • air entering the circulatory system

Correct answer: atrial fibrillation

A pulmonary embolism, or a blood clot in the lungs, is a complication of Deep Venous Thrombosis (DVT), long bone fracture, or air entering the circulatory system. A large percentage of pulmonary emboli arise from thrombosis of the veins in the lower leg. Atrial fibrillation may increase the risk of brain attacks, but it does not increase the risk of pulmonary embolisms.

86.

Which of the following will NOT precipitate Acute Respiratory Failure (ARF) in patients with Chronic Obstructive Pulmonary Disorder (COPD)?

  • Decreased metabolic oxygen demand

  • Decreased muscle strength

  • Decreased chest wall elasticity

  • Increased airway resistance

Correct answer: Decreased metabolic oxygen demand

Chronic Obstructive Pulmonary Disorder (COPD) exacerbations causing Acute Respiratory Failure (ARF) are due to conditions that decrease the ability to ventilate the lungs or due to conditions that increase the demand for oxygen. An increased, not decreased metabolic oxygen demand, will precipitate ARF in COPD patients. Decreased muscle strength, decreased chest wall elasticity, and increased airway resistance all decrease the ability to ventilate the lungs, potentially precipitating ARF.

87.

Meperidine, a short-acting opioid, is avoided in patients taking monoamine oxidase inhibitors (MAOIs) because of the potential for development of:

  • Hypertensive crisis

  • Distributive shock

  • Seizures 

  • Opioid toxicity

Correct answer: Hypertensive crisis

Meperidine is a short-acting opioid that has one-seventh the potency of morphine. Patients who are taking MAOIs, a strong class of antidepressants, should not concurrently take meperidine because of the risk of developing a hypertensive crisis that may be fatal. A hypertensive crisis may develop in these patients up to 2 weeks after initiation of meperidine.

While meperidine is an opioid, opioid toxicity is not the primary concern when combining it with MAOIs. The role of this agent as an analgesic has been reduced drastically due to seizure potential, which is an adverse effect of meperidine alone, not in combination with other drugs. Distributive shock is not a concern here.

88.

Analyze and interpret the arterial blood gas (ABG) results: 

  • pH: 7.33
  • PaCO2: 55 mmHg
  • HCO3: 22 mEq/L

  • Uncompensated respiratory acidosis

  • Compensated respiratory acidosis 

  • Uncompensated metabolic acidosis

  • Compensated metabolic acidosis 

Correct answer: Uncompensated respiratory acidosis

Normal pH ranges from 7.35–7.45. Normal CO2 (carbon dioxide) levels range from 35–45 mm Hg, 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.

In this scenario, the pH is acidotic at 7.33 (below 7.35) and CO2 is also acidotic at 55 mm Hg (above 45 mm Hg), so the primary mechanism is respiratory acidosis. HCO3 is normal at 22. Thus, there is no indication of an attempt to compensate by the body.

89.

The critical care nurse is caring for a patient with a diagnosis of cardiogenic shock. Which of the following hemodynamic parameters are aligned with this diagnosis?

  • Left Atrial Pressure (LAP) 15 mmHg

  • Pulmonary Artery Wedge Pressure (PAWP) 5 mmHg

  • Heart rate 82 beats per minute

  • Cardiac Output (CO) 8.9 L/min

Correct answer: Left Atrial Pressure (LAP) 15 mmHg

Normal values of LAP are 6–12 mmHg; thus an elevated LAP of 15 mmHg best aligns with the diagnosis of cardiogenic shock. 

In cardiogenic shock, the heart ceases to function effectively as a pump, resulting in decreases in stroke volume and cardiac output; this leads to a decrease in blood pressure and tissue perfusion. The inadequate emptying of the ventricle increases left atrial pressure, which then increases pulmonary venous pressure. As a result, pulmonary capillary pressure increases, resulting in pulmonary edema. 

Normal values of CO are 4–8 L/m and are decreased in cardiogenic shock; thus a CO of 8.9 L/min does not align with cardiogenic shock. Cardiogenic shock generally causes PAWP to increase; thus a PAWP of 5 mmHg does not align with the diagnosis (normal is 6–12 mmHg). Patients in shock generally present as tachycardic, so a normal heart rate of 82 does not align with cardiogenic shock.

90.

If a patient has a history of emphysema, which of the following values would MOST LIKELY be seen on Arterial Blood Gases (ABGs)?

  • PaCO2 50, HCO3 28

  • PaCO2 44, HCO3 25

  • PaCO2 35, HCO3 32

  • PaCO2 40, HCO3 22

Correct answer: PaCO2 50, HCO3 28

In the patient with emphysema, a form of Chronic Obstructive Pulmonary Disease (COPD), there is a progressive destruction of the inner walls of the alveolar sacs, resulting in large blebs with a reduced surface area for gas exchange. Since there is a chronically restrictive state, the patient is generally in a state of hypercapnia (PaCO2 > 45 mmHg, HCO3 > 26 mEq/L). The kidneys attempt to compensate by increasing the amount of HCO3 in the body until normal or near-normal pH levels occur. This mechanism creates a compensated respiratory acidosis.

91.

An ICU patient's family member approaches the nurse and expresses frustration that the different doctors are providing inconsistent information. What is the MOST appropriate action for the nurse to take?

  • Schedule a care conference with all involved healthcare providers

  • Ask the family member to address their concerns with the physicians directly

  • Apologize for the confusion and attempt to clarify the conflicting information

  • Tell the family member that information from the intensivist supersedes all other providers

Correct answer: Schedule a care conference with all involved healthcare providers

While apologizing for the confusion and attempting to clarify information is a good immediate step, scheduling a care conference is the most effective long-term solution. It will ensure all providers are on the same page and can provide consistent information. Simply asking the family member to address their concerns with the doctors does not support collaboration and may make the situation worse. Telling the family member that information from the intensivist supersedes all other providers may not be correct.

92.

Which of the following interventions is KEY for a patient who is experiencing a transfusion related acute lung injury (TRALI)?

  • Aggressive respiratory support 

  • Begin dialysis

  • Administer antipyretics

  • Administer antihistamines and steroids 

Correct answer: Aggressive respiratory support 

TRALI is a serious and potentially fatal complication of blood product transfusion in which a patient develops rapid onset lung injury and noncardiogenic pulmonary edema, generally within 6 hours of the transfusion, due to activation of immune cells in the lungs.

Once the blood transfusion has been discontinued, the patient should undergo aggressive respiratory support, including mechanical intubation and ventilation if necessary. 

Dialysis may be indicated, but the priority is respiratory support, which is critical for this patient. Antipyretics are indicated in the diagnosis of an acute febrile reaction from a blood transfusion, not TRALI. Antihistamines and steroids are indicated if the patient experiences an acute allergic reaction. 

93.

During a unit staff meeting, a suggestion is made to use a new technique for improving ventilation in patients with septic shock. What response by the critical care nurse is BEST?

  • Research the technique and its impact on septic shock outcomes

  • Ask the respiratory therapists their impressions of the efficacy of the new technique

  • Begin implementing the new technique into her practice

  • Use established techniques that the nurse is familiar with

Correct answer: Research the technique and its impact on septic shock outcomes

As part of the nurse's ongoing process of questioning and evaluating their practice, they should research the technique and its impact on septic shock outcomes to evaluate whether they should implement the new technique into their clinical practice. Asking the respiratory therapists their impressions of the efficacy of the new technique is not as ideal as researching the technique using evidence-based studies. Beginning to implement the new technique into practice or avoiding using the technique in favor of previously used techniques is not correct until the nurse has researched it.

94.

Which of the following electrolyte imbalances is common in the patient with acute kidney injury (AKI), indicating the need for initiation of dialysis?

  • Hyperkalemia

  • Hypercalcemia

  • Hypocalcemia

  • Hypokalemia

Correct answer: Hyperkalemia 

Hyperkalemia is one of the common electrolyte abnormalities in the patient with AKI, and is the most common reason for initiation of dialysis. 

Hyperkalemia is considered the most life-threatening of all the electrolyte disorders because of potassium's profound impact on the electrophysiology of the heart. These conduction abnormalities can lead to serious cardiac arrhythmias and death. 

95.

How much does the hematocrit increase with each unit of Packed Red Blood Cells (PRBC) transfused?

  • 2% to 3%

  • 3% to 4%

  • 4% to 5%

  • 5% to 6%

Correct answer: 2% to 3%

Packed Red Blood Cells (PRBC) are used to rapidly increase the hematocrit while providing less volume compared to when whole blood is used. Each unit of PRBC increases the hematocrit by 2% to 3% while improving gas exchange. However, it may take as long as 24 hours after the administration of blood for changes to be reflected in hematocrit values.

96.

Which of the following patients would be the BEST candidate for a coronary artery bypass graft (CABG)?

  • A 51-year-old with significant left main coronary artery disease 

  • A 59-year-old female with an EF of 10%

  • A 61-year-old female with severe COPD and a troponin of 1.24 ng/mL

  • An 87-year-old male with a STEMI

Correct answer: A 51-year-old with significant left main coronary artery disease 

Coronary artery bypass grafting is one method of (surgical) revascularization generally used in patients with atherosclerosis of three or more coronary vessels, or in the case of significant left main coronary artery disease. In these patients, CABG has been shown to improve outcomes over other treatment methods (medical therapy, angioplasty, stent). It is performed both emergently and electively. It may also be done either prior to or following an MI.  

While a lower ejection fraction (EF) is an indication for CABG, an EF less than 15% will make it difficult to ween off of cardiopulmonary bypass following the procedure. Severe COPD and very elderly patients are both generally contraindications of CABG.

97.

Which of the following psychiatric conditions is MOST LIKELY due to the long-term effect of critical care hospitalization?

  • Post-Traumatic Stress Disorder (PTSD)

  • Depression

  • Schizophrenia

  • Long-term psychiatric conditions do not develop as a result of critical care hospitalization

Correct answer: Post-Traumatic Stress Disorder (PTSD)

Post-Intensive Care Syndrome (PICS) is a form of Post-Traumatic Stress Disorder (PTSD) occurring after hospitalization in a critical care unit. PICS can be a long-term effect of critical care hospitalization, occurring in patients or their family members several months or even years following the patient's hospitalization.

98.

A nurse notices that the rate of Catheter-Associated Urinary Tract Infections (CAUTIs) has increased in her ICU over the last quarter. The nurse feels that introducing a CAUTI prevention bundle could be beneficial. What should the nurse do FIRST?

  • Research the evidence supporting the use of a CAUTI prevention bundle

  • Informally suggest the bundle to her peers to see their response

  • Educate other nurses on how to implement components of a CAUTI prevention bundle

  • Write down the elements she believes should be part of a CAUTI prevention bundle, then present her suggestions to the team

Correct answer: Research the evidence supporting the use of a CAUTI prevention bundle

Researching the evidence supporting the use of a CAUTI prevention bundle can provide information that the nurse can then use to make evidence-based suggestions. Informally suggest the bundle to her peers to see their response may provide feedback on how to implement the bundle; however, the bundle must first be designed before feedback can be sought or before any staff education can be provided. The nurse should not begin development of the elements she believes should be part of a CAUTI prevention bundle until she has researched the evidence supporting the use of the bundle.

99.

Your patient’s diagnosis is respiratory failure. Which arterial blood gas (ABG) value would you expect?

  • pH 7.33, PaCO2 50 mmHg, PaO2 70 mmHg, HCO3- 26 mEq/L

  • pH 7.50, PaCO2 30 mmHg, PaO2 60 mmHg, HCO3- 24 mEq/L

  • pH 7.30, PaCO2 20 mmHg, PaO2 80 mmHg, HCO3- 16 mEq/L

  • pH 7.40, PaCO2 50 mmHg, PaO2 70 mmHg, HCO3- 26 mEq/L

Correct answer: pH 7.33, PaCO2 50 mmHg, PaO2 70 mmHg, HCO3- 26 mEq/L

Respiratory acidosis frequently accompanies respiratory failure (eg, ARDS, severe asthma, pneumonia, COPD, sleep apnea). It occurs when the pH is below 7.35 and the PaCO2 is above 45 mm Hg. In respiratory acidosis, there is an inadequate amount of ventilation and removal of CO2 from the body. If these ABG changes persist for more than 24 hours, the kidneys attempt to compensate for the decreased pH by increasing the amount of HCO3- in the body.

Normal ABG values are:

  • pH between 7.35 and 7.45
  • PaO2 between 80 and 100 mm Hg
  • PaCO2 between 35 and 45 mm Hg
  • HCO3- between 22 and 26 mEq/L

pH 7.50, PaCO2 30 mmHg, PaO2 60 mmHg, HCO3- 24 mEq/L indicates respiratory alkalosis.

pH 7.30, PaCO2 20 mmHg, PaO2 80 mmHg, HCO3- 16 mEq/L indicates metabolic acidosis.

pH 7.40, PaCO2 50 mmHg, PaO2 70 mmHg, HCO3- 26 mEq/L indicates compensated respiratory acidosis (pH is normal, but PaCO2 remains above 45 mmHg).

100.

Which of the following is a serious complication for a patient in Diabetic Ketoacidosis (DKA)?

  • Hypovolemic shock

  • Oliguria

  • Hyperkalemia

  • Hypercalcemia

Correct answer: Hypovolemic shock

A common and serious complication for a patient with Diabetic Ketoacidosis (DKA) is hypovolemic shock resulting from severe fluid loss. Volume depletion decreases glomerular filtration of glucose and creates a cycle of progressive hyperglycemia. Sustained hyperglycemia leads to intracellular dehydration and intravascular fluid loss due to excessive polyuria from osmotic diuresis.

Electrolyte depletion is present with losses of potassium (hypokalemia), magnesium, phosphate, and calcium (hypocalcemia).