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CCRN (Adult) study materials
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CCRN (Adult) practice questions

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Question 1Clinical Judgment

A patient admitted with suspected sepsis has a lactate of 4.2 mmol/L and a blood pressure of 84/50 mmHg. Which action should the nurse take first?

  1. Withhold antibiotics until the culture results finalize
  2. Give furosemide to reduce preload before antibiotics
  3. Insert a central line before any antibiotic is given
  4. Draw cultures, then give antibiotics within the hour Correct answer.

Explanation

In sepsis with hypotension or elevated lactate, cultures should be obtained promptly but antibiotic administration must not be delayed and should occur within one hour. Fluid resuscitation with an isotonic crystalloid is given concurrently, not diuretics or line placement first.

Question 2Clinical Judgment

A patient with ARDS has a predicted body weight of 70 kg, and the provider orders a tidal volume of 6 mL/kg of predicted body weight. Which tidal volume should be set?

  1. 560 mL
  2. 700 mL
  3. 420 mL Correct answer.
  4. 280 mL

Explanation

Lung-protective ventilation uses 6 mL/kg of predicted body weight, so 70 kg x 6 mL/kg equals 420 mL. Predicted body weight, based on height and sex, is used rather than actual weight to avoid overdistention.

Question 3Clinical Judgment

A patient with an anterior STEMI arrives at a rural hospital 90 minutes after symptom onset. Primary PCI cannot be performed within 120 minutes, and there are no contraindications to fibrinolysis. Which action is most appropriate?

  1. Give aspirin and clopidogrel only, then arrange elective catheterization
  2. Start a heparin infusion alone and observe for 24 hours
  3. Give a fibrinolytic now and transfer for planned PCI Correct answer.
  4. Wait for transfer and PCI without giving any reperfusion drug

Explanation

When PCI cannot be achieved within 120 minutes of first medical contact, fibrinolysis should be given within 30 minutes of arrival in eligible patients, followed by transfer for angiography. Reperfusion should never be deferred while awaiting transfer when timely PCI is not possible.

Question 4Clinical Judgment

An adult with an acute ischemic stroke has no contraindications and was last known well at the time of symptom onset thirty minutes ago. Within what interval may intravenous thrombolytic therapy be given?

  1. Within 60 minutes of last known well
  2. Within 12 hours of last known well
  3. Within 6 hours of last known well
  4. Within 4.5 hours of last known well Correct answer.

Explanation

Intravenous alteplase or tenecteplase is approved for eligible patients treated within 4.5 hours of last known well. Beyond that window, treatment decisions depend on advanced imaging and endovascular candidacy rather than routine IV thrombolysis.

Question 5Clinical Judgment

An adult with diabetic ketoacidosis and a glucose of 480 mg/dL has a blood pressure of 96/60 mmHg and no history of heart failure. Which fluid should be infused initially?

  1. Dextrose 5% in water
  2. 3% sodium chloride
  3. 0.9% sodium chloride Correct answer.
  4. 0.45% sodium chloride

Explanation

Isotonic crystalloid such as 0.9% sodium chloride is used first to restore intravascular volume in DKA. Dextrose-containing fluids are added later, once glucose falls to roughly 200 to 250 mg/dL, to allow continued insulin infusion.

Question 6Clinical Judgment

A patient with a potassium of 7.1 mEq/L has a widened QRS complex and a peaked T wave. Which medication should be administered first?

  1. IV calcium gluconate Correct answer.
  2. Regular insulin with dextrose
  3. Oral sodium polystyrene sulfonate
  4. Nebulized albuterol

Explanation

IV calcium stabilizes the myocardial membrane and is given first whenever hyperkalemia produces ECG changes, because it acts within minutes to prevent ventricular dysrhythmias. Insulin with dextrose, albuterol, and binders shift or remove potassium but do not protect the heart immediately.

Question 7Clinical Judgment

A ventilated patient has a peak airway pressure of 45 cm H2O and a plateau pressure of 20 cm H2O. Which problem is most likely?

  1. A pneumothorax
  2. Decreased lung compliance
  3. Worsening pulmonary edema
  4. Increased airway resistance Correct answer.

Explanation

A high peak pressure with a normal plateau pressure means the gradient across the airway is increased, which reflects resistance in the airway or circuit. Compliance problems such as ARDS, edema, or pneumothorax raise both peak and plateau pressures.

Question 8Clinical Judgment

Which hemodynamic profile is most consistent with cardiogenic shock?

  1. CI 4.5, PCWP 8, SVR 620
  2. CI 2.1, PCWP 4, SVR 1750
  3. CI 3.0, PCWP 12, SVR 900
  4. CI 1.6, PCWP 26, SVR 1600 Correct answer.

Explanation

Cardiogenic shock shows a low cardiac index with high filling pressures from pump failure and a compensatory rise in systemic vascular resistance. Low filling pressures point to hypovolemia, while a high output with low resistance suggests a distributive process such as sepsis.

Question 9Clinical Judgment

Thirty minutes into a packed red blood cell transfusion, a patient develops fever, chills, flank pain, and dark urine. Which action should the nurse take first?

  1. Stop the transfusion and infuse saline Correct answer.
  2. Give acetaminophen and reassess in 30 minutes
  3. Slow the rate and give diphenhydramine
  4. Continue and recheck the unit number later

Explanation

Fever, flank pain, and hemoglobinuria suggest an acute hemolytic transfusion reaction, most often from ABO incompatibility. The transfusion must be stopped immediately and the line kept patent with normal saline while the provider and blood bank are notified.

Question 10Clinical Judgment

A patient with a traumatic brain injury has an intracranial pressure of 22 mmHg. Which nursing action is appropriate?

  1. Hyperventilate routinely to a PaCO2 of 25 mmHg
  2. Position the hips flexed at 90 degrees
  3. Keep the head of bed at 30 degrees with the head midline Correct answer.
  4. Place the patient in Trendelenburg position

Explanation

Elevating the head of the bed about 30 degrees with the head in neutral midline promotes venous drainage and lowers intracranial pressure. Hip flexion and Trendelenburg position impede jugular venous return and raise ICP.

Question 11Clinical Judgment

Four hours after open abdominal surgery, a patient has a heart rate of 124 beats/min, blood pressure of 88/52 mmHg, urine output of 15 mL/hr, and 250 mL of sanguineous drain output in the past hour. Which action should the nurse take?

  1. Give a diuretic to improve urine output
  2. Notify the surgeon and start a fluid bolus Correct answer.
  3. Increase the opioid dose for pain control
  4. Document the output and reassess in one hour

Explanation

Tachycardia, hypotension, oliguria, and brisk sanguineous drainage indicate ongoing postoperative hemorrhage and hypovolemia. The surgeon must be notified while volume resuscitation begins so that the patient can return to the operating room if bleeding continues.

Question 12Clinical Judgment

A patient who has had vomiting and diarrhea for three days has a BUN of 42 mg/dL, creatinine of 1.8 mg/dL, urine sodium of 10 mEq/L, and a fractional excretion of sodium of 0.6%. Urine output rises after one liter of saline. Which condition is most likely?

  1. Postrenal obstruction
  2. Prerenal azotemia Correct answer.
  3. Acute interstitial nephritis
  4. Acute tubular necrosis

Explanation

A high BUN-to-creatinine ratio with a low urine sodium and low fractional excretion of sodium indicates intact tubular reabsorption driven by hypovolemia, which is prerenal azotemia. The response to fluid administration confirms a volume-responsive, prerenal process.

Question 13Clinical Judgment

Which intervention best supports prevention of delirium in an older adult admitted to the intensive care unit?

  1. Physical restraints to prevent device removal
  2. Scheduled benzodiazepines at bedtime
  3. Early mobilization with sleep hygiene measures Correct answer.
  4. Restricting family visits to reduce stimulation

Explanation

Nonpharmacologic bundles that preserve orientation, promote sleep, and encourage early mobility reduce the incidence and duration of delirium. Benzodiazepines and restraints are themselves risk factors for delirium in older adults.

Question 14Clinical Judgment

A patient with a T6 spinal cord injury has a blood pressure of 78/50 mmHg, a heart rate of 48 beats/min, and warm, dry skin. Which cause is most likely?

  1. Neurogenic shock Correct answer.
  2. Cardiogenic shock
  3. Septic shock
  4. Hypovolemic shock

Explanation

Cervical and high thoracic injuries interrupt sympathetic outflow, producing hypotension with bradycardia and warm, dry skin from loss of vascular tone. Hemorrhagic shock would typically produce tachycardia and cool, clammy skin.

Question 15Clinical Judgment

A patient becomes acutely dyspneic with a heart rate of 128 beats/min and an SpO2 of 88% two days after total knee arthroplasty. The blood pressure is stable. Which test is most appropriate to confirm the diagnosis?

  1. CT pulmonary angiography Correct answer.
  2. Repeat lower extremity ultrasound
  3. Chest radiograph
  4. D-dimer assay

Explanation

CT pulmonary angiography is the preferred confirmatory study for hemodynamically stable patients with suspected pulmonary embolism. D-dimer is sensitive but nonspecific and is most useful in low-risk patients to rule out embolism.

Question 16Clinical Judgment

A patient with cirrhosis has hematemesis and melena, a heart rate of 122 beats/min, and a blood pressure of 84/56 mmHg. Which action should the nurse take first?

  1. Start a beta blocker infusion
  2. Establish two large-bore IVs and resuscitate Correct answer.
  3. Insert a nasogastric tube for lavage
  4. Send the patient for immediate endoscopy

Explanation

The initial priority in acute variceal hemorrhage is hemodynamic stabilization with large-bore intravenous access and volume resuscitation. Endoscopy is performed after stabilization, and vasoactive drugs and prophylactic antibiotics are given concurrently.

Question 17Clinical Judgment

A patient with type 1 diabetes is found unresponsive with a point-of-care glucose of 42 mg/dL, and no intravenous access can be obtained. Which action is appropriate?

  1. Wait for the vascular access team to arrive
  2. Administer intramuscular glucagon Correct answer.
  3. Give subcutaneous regular insulin
  4. Place oral glucose gel in the mouth

Explanation

When severe hypoglycemia occurs without IV access, intramuscular or subcutaneous glucagon is given to raise glucose through hepatic glycogenolysis. Oral glucose is unsafe in an unresponsive patient because of aspiration risk.

Question 18Clinical Judgment

Which description is characteristic of a stage 3 pressure injury?

  1. Full-thickness loss with exposed bone
  2. Partial-thickness loss of the dermis
  3. Full-thickness loss with visible fat Correct answer.
  4. Intact skin with nonblanchable erythema

Explanation

A stage 3 injury involves full-thickness loss of skin with visible subcutaneous fat, but no exposed bone, tendon, or muscle. Exposure of deeper structures such as bone or fascia defines a stage 4 injury.

Question 19Clinical Judgment

A patient has muffled heart sounds, distended neck veins, hypotension, and a 14 mmHg drop in systolic pressure during inspiration. Which finding would confirm the suspected diagnosis?

  1. Mitral stenosis with an enlarged left atrium
  2. Pericardial effusion with right ventricular collapse Correct answer.
  3. Aortic dissection with a widened mediastinum
  4. Left ventricular dilation with reduced ejection fraction

Explanation

Beck triad with pulsus paradoxus indicates cardiac tamponade, in which pericardial fluid raises intrapericardial pressure and collapses the right ventricle during diastole. Emergent pericardiocentesis is required to restore filling.

Question 20Clinical Judgment

A patient in convulsive status epilepticus has been seizing for four minutes. Which medication is first-line therapy?

  1. IV lorazepam Correct answer.
  2. IV propofol
  3. IV levetiracetam
  4. IV phenytoin

Explanation

A benzodiazepine such as lorazepam, midazolam, or diazepam is the first-line agent for terminating convulsive status epilepticus. Second-line antiseizure medications are given if seizures persist after adequate benzodiazepine dosing.

Question 21Clinical Judgment

A patient with ARDS on FiO2 of 0.80 and PEEP of 12 cm H2O has a PaO2/FiO2 ratio of 90 and remains hypoxemic despite optimal lung-protective ventilation. Which intervention has been shown to reduce mortality?

  1. Increasing tidal volume to improve minute ventilation
  2. Routine hyperventilation to a PaCO2 of 30 mmHg
  3. Prone positioning for 12 to 16 hours daily Correct answer.
  4. A fluid bolus to raise cardiac output

Explanation

In moderate to severe ARDS, prone positioning for at least 12 hours per day improves oxygenation and reduces mortality by recruiting dorsal lung regions and reducing ventral overdistention. Higher tidal volumes and routine hyperventilation worsen ventilator-induced lung injury.

Question 22Clinical Judgment

A patient with chronic obstructive pulmonary disease and chronic hypercapnia is receiving supplemental oxygen. Which oxygen saturation target is recommended?

  1. 88% to 92% Correct answer.
  2. 95% to 100%
  3. 80% to 85%
  4. 85% to 87%

Explanation

In patients with COPD who are at risk for hypercapnia, titrating oxygen to an SpO2 of 88% to 92% reduces the risk of worsened hypercapnia and acidosis. Oxygen is still given when needed, but the target range is lower than for most other acutely ill adults.

Question 23Clinical Judgment

A patient with septic shock has a central venous oxygen saturation of 52% and a cardiac index of 2.0 L/min/m2 after fluid resuscitation. How should this finding be interpreted?

  1. Oxygen delivery is inadequate for demand Correct answer.
  2. Peripheral oxygen extraction is impaired
  3. Oxygen consumption is reduced by sedation
  4. A left-to-right intracardiac shunt is present

Explanation

A low central venous oxygen saturation means the tissues are extracting a greater proportion of delivered oxygen because delivery is insufficient relative to demand. In septic shock this typically reflects low cardiac output, anemia, or hypoxemia rather than impaired extraction.

Question 24Clinical Judgment

A patient admitted for alcohol withdrawal has a CIWA-Ar score of 18 with tremors, diaphoresis, and a heart rate of 118 beats/min. Which medication is indicated?

  1. Clonidine as monotherapy
  2. IV haloperidol
  3. Diazepam titrated to the symptom score Correct answer.
  4. Dexmedetomidine as monotherapy

Explanation

Benzodiazepines are first-line treatment for alcohol withdrawal because they restore GABA-mediated inhibition and prevent seizures and delirium tremens. Dosing is titrated to validated symptom scores such as CIWA-Ar.

Question 25Clinical Judgment

A patient admitted with acute pancreatitis has a heart rate of 118 beats/min and a hematocrit of 51%. Which intervention is indicated in the first 24 hours?

  1. Urgent ERCP for every patient
  2. Prophylactic broad-spectrum antibiotics
  3. Lactated Ringer's solution at 5 to 10 mL/kg/hr Correct answer.
  4. Routine nasogastric suctioning

Explanation

Early aggressive isotonic crystalloid resuscitation, preferably with Lactated Ringer's, is the cornerstone of initial pancreatitis management and helps prevent pancreatic necrosis. Antibiotics are reserved for infected necrosis or concurrent cholangitis, and ERCP is limited to patients with cholangitis or persistent biliary obstruction.

Question 26Clinical Judgment

Which intervention is most effective for preventing ventilator-associated pneumonia in an intubated adult?

  1. Elevate the head of the bed to 30 to 45 degrees Correct answer.
  2. Change the ventilator circuit tubing every 12 hours
  3. Keep the patient supine during and after tube feedings
  4. Instill 5 mL of saline into the airway before each suction pass

Explanation

Semi-recumbency reduces aspiration of oropharyngeal and gastric secretions, which is the main route by which bacteria reach the lower airway in intubated patients. Saline instillation, routine circuit changes, and supine positioning all increase risk rather than reduce it.

Question 27Clinical Judgment

A patient with suspected septic shock has a lactate of 4 mmol/L and no history of heart failure or end-stage renal disease. Which initial fluid order is consistent with current sepsis guidelines?

  1. A 10 mL/kg bolus of 5% albumin over 24 hours
  2. Furosemide 40 mg IV to maintain urine output
  3. Rapid infusion of 5 mL/kg of packed red blood cells
  4. A 30 mL/kg bolus of balanced crystalloid Correct answer.

Explanation

Sepsis with hypoperfusion, indicated by an elevated lactate, warrants at least 30 mL/kg of isotonic crystalloid given rapidly, typically within the first three hours. Reassessment of perfusion follows each bolus rather than a fixed volume over a prolonged period.

Question 28Clinical Judgment

A patient in septic shock remains hypotensive after adequate crystalloid resuscitation. Which vasopressor is recommended as the first-line agent?

  1. Phenylephrine at 100 mcg/min
  2. Norepinephrine titrated to a MAP of 65 mmHg Correct answer.
  3. Dopamine at 10 mcg/kg/min
  4. Vasopressin at 0.04 units/min

Explanation

Norepinephrine has predominant alpha-1 activity with modest beta-1 activity and is the first-line vasopressor for septic shock, titrated to a mean arterial pressure of about 65 mmHg. Vasopressin is added as a second agent to reduce norepinephrine requirements, and dopamine is reserved for selected patients because of arrhythmia risk.

Question 29Clinical Judgment

A patient admitted with an aneurysmal subarachnoid hemorrhage is awake and alert. Which medication should the nurse anticipate administering to reduce the risk of delayed cerebral ischemia?

  1. Intravenous mannitol every 6 hours
  2. Subcutaneous enoxaparin daily
  3. Intravenous dexamethasone daily
  4. Oral nimodipine every 4 hours Correct answer.

Explanation

Nimodipine, a dihydropyridine calcium channel blocker, reduces the incidence and severity of neurologic deficits from vasospasm after aneurysmal subarachnoid hemorrhage and is given enterally for 21 days. It is not titrated to blood pressure and is not interchangeable with other antihypertensives.

Question 30Clinical Judgment

Two hours after a total thyroidectomy, a patient reports perioral numbness and tingling of the fingertips, and a Chvostek sign is positive. Which action should the nurse take?

  1. Encourage slow breathing into a paper bag
  2. Administer the next scheduled dose of levothyroxine
  3. Document the findings as expected after surgery
  4. Notify the surgeon and prepare IV calcium Correct answer.

Explanation

Perioral numbness with a positive Chvostek sign after thyroid surgery suggests hypocalcemia from intraoperative parathyroid injury or devascularization. The provider should be notified and intravenous calcium prepared, because untreated hypocalcemia can progress to tetany, laryngospasm, and seizures.

Question 31Clinical Judgment

A chest tube connected to a water seal drainage system shows continuous bubbling in the water seal chamber throughout the respiratory cycle. How should the nurse interpret this finding?

  1. A normal finding that indicates the lung has fully re-expanded
  2. An air leak from the lung or the drainage system Correct answer.
  3. Expected oscillation of the water level with each breath
  4. A pleural fluid leak requiring a new drainage unit

Explanation

Continuous bubbling in the water seal chamber reflects air moving through the system during both inspiration and expiration, indicating an air leak from the lung or a loose connection. Intermittent bubbling only with coughing or exhalation may occur as a pneumothorax resolves.

Question 32Clinical Judgment

A postoperative patient receiving IV hydromorphone has a respiratory rate of 6 breaths/min and is difficult to arouse. Which action should the nurse take?

  1. Withhold the next opioid dose and document the sedation level
  2. Stimulate the patient, support ventilation, and give naloxone Correct answer.
  3. Increase oxygen flow and recheck the rate in 15 minutes
  4. Administer flumazenil and monitor for seizures

Explanation

Opioid-induced respiratory depression requires immediate airway support with stimulation and ventilation, followed by naloxone to reverse the opioid effect. Naloxone is titrated to restore adequate breathing rather than full alertness, and the patient must be monitored for renarcotization.

Question 33Clinical Judgment

A patient is 24 hours after an open cholecystectomy and has a temperature of 38.2°C, decreased breath sounds at the bases, and a clean, dry incision. Which cause of the fever is most likely?

  1. Anastomotic leak
  2. Atelectasis Correct answer.
  3. Deep vein thrombosis
  4. Superficial surgical site infection

Explanation

Fever within the first 48 hours after surgery is most often caused by atelectasis from splinting, retained secretions, and shallow breathing. Wound infection typically appears around postoperative day five to seven, and thrombotic or anastomotic complications usually present later with additional findings.

Question 34Clinical Judgment

A patient in diabetic ketoacidosis has a glucose of 480 mg/dL, an arterial pH of 7.12, and a potassium level of 3.1 mEq/L. Which action should the nurse take before starting the insulin infusion?

  1. Give 50% dextrose 50 mL IV push
  2. Give sodium bicarbonate 50 mEq IV push
  3. Start the insulin and add potassium to the next fluid bag
  4. Administer intravenous potassium chloride Correct answer.

Explanation

Insulin drives potassium into cells and can precipitate life-threatening hypokalemia, so potassium must be repleted when the level is below about 3.3 mEq/L before insulin is begun. Bicarbonate is reserved for severe acidemia, and dextrose is added only when glucose falls toward the normal range.

Question 35Clinical Judgment

A patient with severe acute pancreatitis has received 4 L of crystalloid, and now has a bladder pressure of 24 mmHg, rising peak airway pressures, and urine output of 10 mL/h. Which action is most appropriate?

  1. Administer furosemide to reduce intra-abdominal volume
  2. Increase the intravenous fluid rate to improve renal perfusion
  3. Place the patient in the Trendelenburg position
  4. Discuss abdominal decompression with the provider Correct answer.

Explanation

A bladder pressure above 20 mmHg with new organ dysfunction defines abdominal compartment syndrome, which requires decompression such as paracentesis or laparotomy. Additional fluid worsens visceral edema and pressure, and positioning does not relieve the underlying cause.

Question 36Clinical Judgment

A patient with severe asthma on volume-control ventilation has a peak inspiratory pressure of 55 cm H2O, a plateau pressure of 15 cm H2O, and the expiratory flow waveform does not return to zero before the next breath. Which problem do these findings indicate?

  1. A tension pneumothorax
  2. Air trapping from auto-PEEP Correct answer.
  3. Mucus plugging of the large airways
  4. Decreased lung compliance

Explanation

A high peak pressure with a normal plateau pressure localizes the problem to the airways, and expiratory flow that does not reach zero confirms incomplete exhalation with air trapping. Auto-PEEP increases work of breathing and can cause hypotension; treatment includes slowing the rate and prolonging expiratory time.

Question 37Clinical Judgment

A patient who has received unfractionated heparin for 6 days has a platelet count that fell from 250,000 to 90,000/mm3 and now has a new deep vein thrombosis. Which action should the nurse anticipate?

  1. Transfuse platelets to keep the count above 50,000/mm3
  2. Stop all heparin and begin a non-heparin anticoagulant Correct answer.
  3. Continue heparin and recheck the platelet count in 24 hours
  4. Start warfarin alone to prevent further clotting

Explanation

A platelet drop of more than 50 percent beginning five to ten days after heparin exposure, accompanied by thrombosis, indicates heparin-induced thrombocytopenia. Heparin must be stopped immediately and a non-heparin anticoagulant such as argatroban started, because warfarin alone can worsen thrombosis until platelets recover.

Question 38Clinical Judgment

A patient with an acute ischemic stroke has a blood pressure of 192/108 mmHg and is otherwise eligible for IV alteplase. Which action is correct?

  1. Give aspirin 325 mg chewed, then proceed with alteplase
  2. Lower the pressure below 185/110, then give alteplase Correct answer.
  3. Cancel alteplase permanently because the pressure exceeds 185/110
  4. Give alteplase now, because pressure falls after reperfusion

Explanation

A pressure above 185/110 mmHg must be reduced with agents such as labetalol or nicardipine before thrombolysis, and maintained below 180/105 for the next 24 hours to limit hemorrhagic transformation. The elevation is treatable and does not by itself permanently exclude the patient.

Question 39Clinical Judgment

A patient remains comatose after return of spontaneous circulation following cardiac arrest. Which temperature management order is appropriate?

  1. Avoid all temperature control measures so that shivering is prevented
  2. Maintain a temperature of 32°C to 37.5°C for at least 24 hours Correct answer.
  3. Cool the patient to 28°C and maintain it for 48 hours
  4. Rewarm the patient as quickly as possible to 37.5°C

Explanation

Targeted temperature management after cardiac arrest maintains a controlled temperature between 32°C and 37.5°C for at least 24 hours, followed by slow rewarming and strict avoidance of fever. Deep cooling below 32°C and rapid rewarming are associated with harm.

Question 40Clinical Judgment

A patient in septic shock remains hypotensive despite norepinephrine and fluids and has hyponatremia, hyperkalemia, and hypoglycemia. Which medication should the nurse anticipate?

  1. Vasopressin 0.04 units/min intravenously
  2. Hydrocortisone 100 mg intravenously Correct answer.
  3. Levothyroxine 100 mcg intravenously daily
  4. Fludrocortisone 0.1 mg by mouth daily

Explanation

Hyponatremia, hyperkalemia, hypoglycemia, and catecholamine-refractory hypotension suggest adrenal insufficiency, including critical illness-related corticosteroid insufficiency. Intravenous hydrocortisone is given after a cortisol level is drawn when the patient remains unstable despite adequate vasopressor support.

Question 41Clinical Judgment

A patient with Guillain-Barré syndrome has a vital capacity that fell from 20 to 12 mL/kg over four hours, and is now using accessory muscles. Which action is the priority?

  1. Encourage hourly incentive spirometry
  2. Apply noninvasive ventilation with a tight-fitting mask
  3. Prepare for intubation and mechanical ventilation Correct answer.
  4. Obtain an arterial blood gas and reassess in two hours

Explanation

A vital capacity below 15 to 20 mL/kg, a rapid downward trend, and accessory muscle use predict impending respiratory failure in Guillain-Barré syndrome and warrant elective intubation before crisis occurs. Noninvasive ventilation often fails in this population because bulbar and bulbar-related weakness impair airway protection.

Question 42Clinical Judgment

Twenty-four hours after two serotonergic medications were started, a patient has agitation, diaphoresis, a temperature of 38.9°C, inducible clonus, and hyperreflexia that is more pronounced in the legs. Which condition is most likely?

  1. Anticholinergic toxicity
  2. Serotonin syndrome Correct answer.
  3. Neuroleptic malignant syndrome
  4. Malignant hyperthermia

Explanation

Serotonin syndrome develops within hours of adding or increasing serotonergic agents and is characterized by clonus, hyperreflexia, agitation, autonomic instability, and hyperthermia. Neuroleptic malignant syndrome evolves over days with lead-pipe rigidity and bradyreflexia, and malignant hyperthermia follows volatile anesthetics or succinylcholine.

Question 43Clinical Judgment

A patient found unresponsive after a prolonged period on the floor has a creatine kinase of 45,000 U/L, dark urine, and a rising creatinine. Which intervention is the priority?

  1. Administer a loop diuretic to flush myoglobin from the tubules
  2. Restrict fluids to prevent pulmonary edema and dilutional anemia
  3. Give sodium bicarbonate to every patient with dark urine
  4. Infuse crystalloid to keep urine output at 200 to 300 mL/h Correct answer.

Explanation

Rhabdomyolysis releases myoglobin that precipitates in tubules and causes acute kidney injury, and vigorous crystalloid resuscitation targeting a high urine output limits that injury. Alkalinization and diuretics are adjuncts used in selected patients, not routine therapy.

Question 44Clinical Judgment

A patient who ingested a tricyclic antidepressant has a QRS duration of 0.14 seconds, hypotension, and a decreasing level of consciousness. Which intravenous therapy is indicated?

  1. Sodium bicarbonate 1 to 2 mEq/kg Correct answer.
  2. Flumazenil 0.2 mg
  3. Naloxone 2 mg
  4. Calcium chloride 1 g

Explanation

Sodium bicarbonate provides a sodium load and alkalinization that reverse the sodium channel blockade responsible for QRS widening, hypotension, and ventricular arrhythmia in tricyclic overdose. Narrow-complex antidotes have no effect on this toxicity.

Question 45Clinical Judgment

A patient with acute decompensated heart failure has a blood pressure of 158/92 mmHg, a respiratory rate of 32 breaths/min, an SpO2 of 88% on 4 L/min, and crackles with accessory muscle use. Which intervention will most rapidly reduce the work of breathing and improve oxygenation?

  1. Noninvasive positive pressure ventilation Correct answer.
  2. Intravenous morphine 4 mg
  3. A high-flow nasal cannula at 50% FiO2
  4. An intravenous bolus of furosemide

Explanation

Positive pressure ventilation recruits flooded alveoli, reduces preload and afterload, and decreases the work of breathing within minutes in cardiogenic pulmonary edema. Diuretics provide benefit over hours and do not correct hypoxemia as quickly.

Question 46Clinical Judgment

A patient with a severe traumatic brain injury has a MAP of 68 mmHg, an ICP of 22 mmHg, and a blood pressure of 96/54 mmHg. Which action is most appropriate?

  1. Place the patient flat with the head of the bed at 0 degrees
  2. Document the cerebral perfusion pressure as acceptable for this patient
  3. Give a bolus of 0.45% sodium chloride to raise the blood pressure
  4. Report the findings and anticipate therapy to raise MAP and lower ICP Correct answer.

Explanation

Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure, which is 46 mmHg here and below the usual target of 60 to 70 mmHg. The provider should be notified so that MAP can be supported, typically with vasopressors, while intracranial pressure is reduced.

Question 47Clinical Judgment

A patient with severe anorexia nervosa and a BMI of 14 kg/m2 has enteral feeding advanced to a full-calorie goal. Forty-eight hours later the patient has confusion and weakness, with a phosphate of 1.2 mg/dL, potassium of 3.0 mEq/L, and magnesium of 1.4 mg/dL. Which action is the priority?

  1. Start an insulin infusion to correct the electrolyte shifts
  2. Slow the feeding and replete phosphate, potassium, and magnesium Correct answer.
  3. Give a 50% dextrose bolus followed by sliding-scale insulin
  4. Increase the feeding rate to meet full caloric goals

Explanation

Refeeding syndrome occurs when rapid carbohydrate delivery drives insulin release and intracellular shifts of phosphate, potassium, and magnesium in a malnourished patient. Treatment is to slow or hold feeding and replace electrolytes, especially phosphate, while monitoring for cardiac and respiratory failure.

Question 48Clinical Judgment

Six hours after coronary artery bypass grafting, a patient has chest tube output of 250 mL/h for two consecutive hours, a rising central venous pressure, a heart rate of 118 beats/min, and a blood pressure of 88/60 mmHg. Which action is the priority?

  1. Give protamine sulfate and reassess in one hour
  2. Increase IV fluids and continue hourly monitoring
  3. Notify the surgeon and prepare for re-exploration Correct answer.
  4. Strip the chest tubes and reposition the patient

Explanation

Chest tube drainage exceeding 200 mL/h for two or more consecutive hours, with hemodynamic deterioration, indicates hemorrhage and possible tamponade that usually requires surgical re-exploration. Prompt notification and preparation limit the risk of arrest from hypovolemia or pericardial accumulation.

Question 49Clinical Judgment

A patient with atrial fibrillation who takes warfarin has an INR of 4.2 and a new intracerebral hemorrhage with a Glasgow Coma Scale score of 12. Which order should the nurse anticipate?

  1. Transfuse platelets to reverse the warfarin effect in the brain
  2. Give fresh frozen plasma at 10 mL/kg as the only reversal therapy
  3. Administer protamine sulfate intravenously to reverse warfarin
  4. Give IV vitamin K and 4-factor prothrombin complex concentrate Correct answer.

Explanation

Intracranial hemorrhage on warfarin requires rapid, complete reversal with intravenous vitamin K plus 4-factor prothrombin complex concentrate, which corrects the INR within minutes. Fresh frozen plasma is slower, requires larger volumes, and may not fully correct the INR.

Question 50Clinical Judgment

Ninety minutes into a transfusion of packed red blood cells, a patient develops a temperature of 39°C, hypotension, bilateral pulmonary infiltrates, and an SpO2 of 84%, with no jugular venous distension and a normal BNP. Which action is the priority?

  1. Give intravenous furosemide for fluid overload
  2. Stop the transfusion and support oxygenation Correct answer.
  3. Slow the transfusion and reassess in 30 minutes
  4. Give acetaminophen and continue the transfusion as ordered

Explanation

Fever, hypotension, and bilateral infiltrates without volume overload during transfusion indicate transfusion-related acute lung injury, an antibody-mediated noncardiogenic pulmonary edema. The transfusion must be stopped immediately and respiratory and hemodynamic support provided, often including mechanical ventilation.