CCRN (Adult) Critical Care Nursing Exam — All Questions

Four hours after coronary artery bypass surgery, a patient's heart rate rises to 128/min and blood pressure falls to 80/58 mm Hg, dropping further with each inspiration. Central venous pressure has climbed from 8 to 17 mm Hg, the neck veins are distended, heart sounds are faint, and the lungs are clear. Which complication do these findings most suggest?

• a.Vasodilation during rewarming
• b.Cardiac tamponade✓
• c.Left ventricular failure
• d.Hypovolemia from third spacing

Hypotension with distended neck veins, a rising CVP, faint heart sounds and a blood pressure that falls on inspiration is the picture of fluid compressing the heart; MedlinePlus lists heart surgery as a cause of cardiac tamponade and these as its exam findings. Hypovolemia and rewarming vasodilation both lower the CVP rather than raise it. Left ventricular failure would be expected to bring pulmonary congestion, but the lungs are clear.

A patient with echocardiogram-confirmed cardiac tamponade is hypotensive while the team prepares for pericardiocentesis. Which temporizing order should the nurse anticipate?

• a.IV furosemide to relieve venous distention
• b.Positive-pressure ventilation with high PEEP
• c.An IV fluid bolus to support ventricular filling✓
• d.A nitroglycerin infusion to reduce preload

In tamponade the compressed ventricles depend on filling pressure, so fluids are given to hold blood pressure until the fluid around the heart can be drained (MedlinePlus). Furosemide and nitroglycerin both lower preload and would deepen the hypotension even though the neck veins look full. High PEEP raises intrathoracic pressure and further impairs venous return to an already compressed heart.

A 63-year-old with long-standing hypertension reports sudden, tearing chest pain moving to the area between the shoulder blades. Blood pressure is 178/96 mm Hg in the right arm and 136/80 mm Hg in the left. While imaging is arranged, which therapy should the nurse expect to be started first?

• a.A therapeutic heparin infusion
• b.Fibrinolytic therapy
• c.A 1-liter crystalloid bolus
• d.An IV beta-blocker✓

Tearing pain radiating to the back with a blood pressure difference between the arms suggests aortic dissection, and beta-blockers are the medicines of first choice to lower heart rate and blood pressure (MedlinePlus). Fibrinolytics and heparin would promote bleeding into the torn aortic wall. A fluid bolus would raise the pressure driving the dissection in a hypertensive patient.

CT angiography confirms an aortic dissection that involves the ascending aorta. Which plan of care should the nurse prepare the patient and family for?

• a.Emergency surgical repair✓
• b.Catheter-directed thrombolysis of the false lumen
• c.Coronary angiography with stent placement
• d.Oral antihypertensives with repeat CT in three months

Dissections of the ascending aorta are treated with surgery, whereas descending dissections may be managed with surgery or medicines (MedlinePlus). Oral therapy with delayed imaging is follow-up care after repair, not the plan for an acute ascending dissection. A coronary stent does not address the torn aorta, and thrombolysis would worsen bleeding.

A patient being treated medically for a descending aortic dissection develops new abdominal pain, and urine output falls from 60 mL/h to 15 mL/h over two hours. Which explanation should the nurse consider first?

• a.Expected renal effect of IV beta-blocker therapy
• b.Dissection extending into renal and gut arteries✓
• c.Constipation caused by the opioid analgesia
• d.Delayed allergic reaction to the CT contrast dye

A dissection can narrow or occlude aortic branches, and MedlinePlus lists damage to the intestines and kidneys among its complications, so new abdominal pain with falling urine output signals malperfusion until proven otherwise. Beta-blockade does not normally cause oliguria of this degree. Constipation does not explain oliguria, and a contrast reaction would not typically produce new abdominal pain.

A 34-year-old admitted after a viral illness has sharp chest pain that worsens when lying flat and eases when leaning forward. A scratchy sound is heard over the precordium. Which treatment should the nurse anticipate?

• a.Fibrinolytic therapy for coronary occlusion
• b.A continuous heparin infusion
• c.An NSAID given with colchicine✓
• d.Emergency coronary angiography

Positional pleuritic pain relieved by sitting forward with a pericardial rub is typical of acute pericarditis, which MedlinePlus says is treated with NSAIDs such as ibuprofen given with colchicine. Fibrinolytics and emergency angiography are reperfusion strategies for coronary occlusion, not pericardial inflammation. A heparin infusion treats thrombosis and adds bleeding risk into an inflamed pericardium.

Three weeks after a myocardial infarction, a patient returns with fever, pleuritic chest pain and a pericardial friction rub, and the team diagnoses late post-infarction pericarditis (Dressler syndrome). Which complication should the nurse monitor for most closely?

• a.Hypertensive emergency
• b.Acute aortic dissection
• c.Cardiac tamponade✓
• d.Rupture of the papillary muscle

MedlinePlus notes that pericardial effusion often occurs in Dressler syndrome and lists cardiac tamponade among the complications of post-MI pericarditis. Aortic dissection and hypertensive emergency are not complications of pericardial inflammation. Papillary muscle rupture is a mechanical complication of the infarct itself, typically in the first days, and presents with a new murmur and pulmonary edema rather than a rub and fever.

A patient has been on a sodium nitroprusside infusion near the top of the dose range for many hours. The patient becomes confused, and serial blood gases show a worsening metabolic acidosis. What is the nurse's priority?

• a.Increase the infusion rate to improve tissue perfusion
• b.Cover the bag with foil and continue the current rate
• c.Give sodium bicarbonate and continue the infusion unchanged
• d.Stop the infusion and report possible cyanide toxicity✓

The FDA label warns that, except at low rates or brief use, nitroprusside releases cyanide that can reach lethal levels, that acid-base balance may indicate toxicity, and that the infusion should be stopped when the maximum rate fails. Raising the rate adds more cyanide. Bicarbonate treats a number, not the cause, and light protection prevents degradation of the drug but does nothing about cyanide already formed.

A patient with known Wolff-Parkinson-White syndrome develops atrial fibrillation with a very rapid, irregular, wide-complex rhythm but remains awake. An order is written for IV verapamil. Which response by the nurse is correct?

• a.Give the dose slowly over 2 minutes as the drug label directs
• b.Question it; verapamil is contraindicated with an accessory pathway✓
• c.Give the dose after a vagal maneuver fails to slow the rate
• d.Give the dose after pretreating the patient with IV calcium chloride

The verapamil injection label lists atrial flutter or fibrillation with an accessory bypass tract such as Wolff-Parkinson-White as a contraindication, because the drug can precipitate ventricular tachyarrhythmia including ventricular fibrillation. Giving it slowly, after a vagal maneuver, or after calcium pretreatment does not remove that risk; those steps apply to supraventricular tachycardia, not pre-excited atrial fibrillation.

A patient with an anterior myocardial infarction has cool, clammy skin, a systolic pressure of 84 mm Hg and falling urine output. Which pulmonary artery catheter profile is consistent with cardiogenic shock?

• a.Cardiac index 1.9 L/min/m²; wedge pressure 3 mm Hg
• b.Cardiac index 1.7 L/min/m²; wedge pressure 25 mm Hg✓
• c.Cardiac index 3.3 L/min/m²; wedge pressure 10 mm Hg
• d.Cardiac index 4.9 L/min/m²; wedge pressure 7 mm Hg

Normal values given by MedlinePlus are a cardiac index of 2.8–4.2 L/min/m² and a wedge pressure of 4–12 mm Hg. Cardiogenic shock shows a pump that is not moving blood forward (low index) with blood backing up into the lungs (high wedge). A high index with a low wedge fits a distributive state, a low index with a low wedge fits hypovolemia, and the last profile is within normal limits.

A patient arrives in the emergency department with an ST-elevation myocardial infarction, and the center performs primary angioplasty. Within what time from hospital arrival should the procedure ideally be done?

• a.120 minutes
• b.30 minutes
• c.180 minutes
• d.90 minutes✓

MedlinePlus states that angioplasty should be done within 90 minutes after arrival at the hospital. Thirty minutes is the ideal arrival-to-drug time for thrombolytic therapy, not angioplasty. Twelve hours is the usual outer limit after symptom onset for reperfusion, and 3 hours is not the arrival-to-angioplasty goal.

A 76-year-old woman with diabetes, admitted for pneumonia, reports new fatigue and shortness of breath but denies chest pain. What should the nurse do first?

• a.Obtain a 12-lead ECG✓
• b.Give the ordered PRN anxiolytic
• c.Request an outpatient stress test
• d.Walk her in the hall to assess tolerance

MedlinePlus notes that older adults, people with diabetes and women may have little or no chest pain during a heart attack and may instead have shortness of breath, fatigue and weakness, so an ECG is the first step to look for ischemia. Walking her adds myocardial demand before ischemia is excluded. An anxiolytic masks the symptom, and an outpatient test delays evaluation of a possible acute event.

A patient who has been in atrial fibrillation for several days is scheduled for elective electrical cardioversion. Which risk is the main reason blood thinners may be started before the procedure?

• a.Hypoglycemia from preprocedure fasting
• b.Burns under the electrode patches
• c.Ventricular irritability from the sedation
• d.An atrial clot dislodging and causing a stroke✓

MedlinePlus explains that some people need blood thinners before cardioversion to prevent small clots, because the irregular rhythm of atrial fibrillation promotes clots that can travel to the brain. Skin burns are a recognized but minor local complication that anticoagulation does not prevent. Fasting hypoglycemia and sedation effects are unrelated to anticoagulation.

Before discharge after mechanical aortic valve replacement, which statement by the patient shows correct understanding?

• a."I'll need a blood thinner and INR checks for life."✓
• b."I can stop warfarin once my incision has healed."
• c."This valve will need to be replaced in 12 to 15 years."
• d."The clicking I hear means the valve is starting to fail."

MedlinePlus states that mechanical valves last the longest but require blood-thinning medicine such as warfarin for the rest of the patient's life, and warfarin is monitored with the PT/INR. Clicking of a mechanical valve is normal. The 12-to-15-year lifespan describes tissue valves, and stopping warfarin after the incision heals would expose the valve to clot and stroke.

A patient's blood pressure is 232/138 mm Hg. Which additional finding most clearly indicates that this is malignant hypertension requiring IV therapy in the ICU?

• a.A mild headache relieved by acetaminophen
• b.Swelling of the optic nerve✓
• c.A history of missed antihypertensive doses
• d.A repeat reading of 226/134 mm Hg

MedlinePlus describes malignant hypertension as a medical emergency with organ damage such as swelling of the optic nerve, retinal bleeding, mental status change and reduced urine output, treated with IV medicines in hospital. Missed doses explain the cause but not the severity. A mild, relieved headache is not evidence of organ injury, and a second similar reading confirms the number without showing damage.

Minutes after a pulmonary artery catheter is placed through the right subclavian vein, the patient becomes acutely short of breath with diminished breath sounds on the right. Which complication should the nurse suspect?

• a.Catheter-tip infection
• b.Air embolism through an open stopcock
• c.Pneumothorax✓
• d.Pulmonary artery rupture from balloon wedging

MedlinePlus lists puncture of the lung causing collapse (pneumothorax) as a risk when neck or chest veins are used for right heart catheterization, and unilateral loss of breath sounds right after a subclavian stick fits it. Infection develops over days. Pulmonary artery rupture typically presents with hemoptysis during balloon inflation. Air embolism causes sudden cardiopulmonary collapse without one-sided loss of breath sounds.

Under the 2024 global definition of ARDS, which nonintubated patient meets the oxygenation and imaging criteria?

• a.SpO2/FiO2 of 250 on a 6 L/min nasal cannula, with right lower lobe consolidation
• b.PaO2/FiO2 of 350 on high-flow nasal oxygen at 40 L/min, with bilateral opacities
• c.SpO2/FiO2 of 250 on high-flow nasal oxygen at 40 L/min, with bilateral opacities✓
• d.SpO2/FiO2 of 250 on high-flow oxygen at 15 L/min, with opacities fully explained by effusions

The 2024 global definition accepts high-flow nasal oxygen at ≥30 L/min, uses PaO2/FiO2 ≤300 or SpO2/FiO2 ≤315 (when SpO2 ≤97%), and requires bilateral opacities not fully explained by effusions, collapse or nodules. A low-flow cannula and a unilateral consolidation do not qualify. A PaO2/FiO2 of 350 is above the threshold. Flow of 15 L/min is below 30 L/min, and opacities explained by effusions are excluded.

A patient with sepsis-induced ARDS is ventilated with a tidal volume of 8 mL/kg of actual body weight, and the plateau pressure is 34 cm H2O. Which change reflects lung-protective ventilation?

• a.Lower the tidal volume toward 6 mL/kg of predicted body weight to keep plateau pressure ≤30✓
• b.Keep the tidal volume and base all future settings on actual rather than predicted body weight
• c.Raise the tidal volume to 10 mL/kg of predicted body weight so that carbon dioxide clears faster
• d.Keep the tidal volume and accept the plateau pressure while oxygen saturation stays above 92%

The Surviving Sepsis Campaign 2021 recommends low tidal volume ventilation (about 6 mL/kg of predicted body weight) and an upper plateau pressure goal of 30 cm H2O in sepsis-induced ARDS. Raising the volume increases overdistension. Actual body weight overestimates lung size in heavier patients. A normal saturation does not make a plateau pressure above 30 safe.

A patient with moderate to severe ARDS has refractory hypoxemia despite optimized ventilator settings. The team plans prone positioning. How long should each daily prone session last according to the Surviving Sepsis Campaign?

• a.About 2 hours
• b.About 4 hours
• c.More than 12 hours✓
• d.Only overnight, about 8 hours

The Surviving Sepsis Campaign 2021 recommends prone ventilation for more than 12 hours daily in adults with sepsis-induced moderate to severe ARDS. Sessions of 2, 4 or 8 hours are shorter than the duration the recommendation is based on and would forfeit much of the benefit.

A unit is revising its oral care protocol for mechanically ventilated adults. Which practice is listed among the essential practices in the 2022 SHEA/IDSA/APIC update?

• a.Toothbrushing without chlorhexidine✓
• b.Antiseptic swabs in place of brushing
• c.Routine probiotic administration
• d.Chlorhexidine oral rinse every 12 hours

The 2022 SHEA/IDSA/APIC compendium lists oral care with toothbrushing but without chlorhexidine as an essential practice, and places oral care with chlorhexidine and probiotics in the 'generally not recommended' category. Replacing brushing with antiseptic swabs removes the part of oral care the guideline endorses.

According to the 2022 SHEA/IDSA/APIC update, when should the ventilator circuit of an intubated adult be changed?

• a.Every 48 hours, whether or not it is soiled
• b.Only when visibly soiled or malfunctioning✓
• c.Every 7 days, whether or not it looks soiled
• d.After each spontaneous breathing trial

The 2022 update lists changing the ventilator circuit only if visibly soiled or malfunctioning (or per the manufacturer's instructions) as an essential practice. Scheduled changes every 48 hours or weekly, or after each breathing trial, add circuit breaks and handling without reducing pneumonia.

A patient has a chest drain for a pneumothorax. Overnight the water column stops swinging and bubbling, and the patient becomes more short of breath. What should the nurse do?

• a.Lift the drainage unit above chest level to restart the flow
• b.Clamp the drain and reassess the patient's breathing in 30 minutes
• c.Strip the tubing firmly from the chest toward the drainage bottle
• d.Keep it unclamped, check for kinks or clots, get an urgent X-ray✓

A drain that neither swings nor bubbles is blocked or displaced. For a drain placed for pneumothorax, the published troubleshooting advice is not to clamp it and to obtain a chest X-ray at once, to avoid tension pneumothorax. Clamping traps air in the chest. Stripping is not recommended after lung resection and is 'ineffective and potentially harmful' after cardiac surgery. Raising the unit above the chest lets fluid flow back into the pleural space.

On the third day after hip surgery, a patient suddenly develops dyspnea, pleuritic chest pain, a heart rate of 124/min and SpO2 of 86%. CT angiography shows a large pulmonary embolism. Which additional finding would most strongly support systemic thrombolytic therapy?

• a.A heart rate above 110/min
• b.An elevated D-dimer
• c.Pleuritic chest pain
• d.Sustained hypotension✓

Thrombolysis is reserved for severe, life-threatening pulmonary embolism, and the ESC 2019 guideline defines that high-risk group by hemodynamic instability such as sustained hypotension. Tachycardia and pleuritic pain are common in embolism of any size, and an elevated D-dimer supports the diagnosis without measuring severity.

A patient with heart failure wakes up acutely short of breath, coughing pink frothy sputum, with crackles to the apices. What should the nurse do first?

• a.Sit the patient upright and give oxygen✓
• b.Start a 500 mL normal saline bolus
• c.Lay the patient flat and elevate the legs
• d.Walk the patient to help clear secretions

Acute pulmonary edema fills the alveoli with fluid; MedlinePlus lists oxygen and diuretics as treatment, and sitting upright relieves the orthopnea described. Lying flat with the legs raised increases venous return to a congested heart. A saline bolus adds volume, and exertion raises oxygen demand in a patient who cannot oxygenate.

A patient with an exacerbation of COPD is receiving 6 L/min oxygen by nasal cannula. SpO2 is 99%, the patient has become drowsy, and PaCO2 has risen since admission. Which action is most appropriate?

• a.Give a sedative to relieve the patient's anxiety
• b.Change to a non-rebreather mask at 15 L/min
• c.Titrate oxygen down to an SpO2 of 88–92%✓
• d.Keep oxygen as is to hold SpO2 above 98%

Guidelines recommend titrating oxygen to an SpO2 of 88–92% in COPD exacerbations because high inspired oxygen can cause hypercapnia and acidosis and increase mortality. A non-rebreather and a target above 98% add more oxygen to a patient already retaining carbon dioxide. A sedative further depresses the drive to breathe.

An adult with sepsis develops acute hypoxemic respiratory failure and is not in immediate need of intubation. Which initial respiratory support does the Surviving Sepsis Campaign 2026 guideline favor?

• a.High-flow nasal cannula✓
• b.Noninvasive ventilation
• c.A simple face mask
• d.Early elective intubation

The 2026 guideline favors high-flow nasal cannula over conventional oxygen and noninvasive ventilation as the initial device for sepsis with acute hypoxemic respiratory failure. A simple mask is conventional oxygen. Noninvasive ventilation was not preferred, and elective intubation is not an initial support strategy for a patient who does not yet need it.

A patient's arterial blood gas is pH 7.27, PaCO2 60 mm Hg and HCO3 25 mEq/L after opioid sedation. How should the nurse interpret it?

• a.Compensated respiratory alkalosis
• b.Metabolic acidosis with respiratory compensation
• c.Mixed metabolic and respiratory alkalosis
• d.Acute respiratory acidosis✓

The pH is low and the PaCO2 is high, so the primary disorder is respiratory acidosis, and a bicarbonate still in the normal range shows the kidneys have not yet compensated, which fits an acute process such as opioid-induced hypoventilation. Metabolic acidosis would show a low bicarbonate. Alkalosis requires a pH above normal.

A patient with severe COPD has increasing dyspnea on exertion, distended neck veins, ankle swelling and an enlarged liver. Which condition do these findings suggest?

• a.Cor pulmonale✓
• b.Tension pneumothorax
• c.Left ventricular failure
• d.Acute pulmonary embolism

Right-sided heart failure caused by lung disease produces swelling of the neck veins, ankle swelling, liver enlargement and abdominal fluid, which MedlinePlus lists as exam findings of cor pulmonale. Tension pneumothorax is abrupt and would cause unilateral loss of breath sounds with shock. Left ventricular failure primarily congests the lungs. Pulmonary embolism is sudden rather than a gradual progression of exertional symptoms.

During treatment for a severe asthma attack, which change in the patient should the nurse treat as the most urgent warning sign?

• a.Audible expiratory wheezing in all lung fields
• b.Increasing drowsiness and confusion✓
• c.A productive cough with white sputum
• d.A respiratory rate of 24/min

MedlinePlus lists decreased alertness such as severe drowsiness or confusion during an asthma attack, along with difficulty speaking and bluish lips, as emergency symptoms; in a tiring patient they signal failing ventilation. A productive cough and audible wheeze show that air is still moving. A rate of 24/min is elevated but less ominous than a falling level of consciousness.

Which sedation approach for a mechanically ventilated adult is listed among the essential practices for preventing ventilator-associated events in the 2022 SHEA/IDSA/APIC update?

• a.Neuromuscular blockade to improve synchrony
• b.Deep sedation until the FiO2 falls below 0.40
• c.A continuous benzodiazepine infusion for comfort
• d.Minimize sedation and avoid benzodiazepines✓

The 2022 update lists minimizing sedation (avoiding benzodiazepines in favor of other agents, using a sedation-minimization protocol and a ventilator liberation protocol) as an essential practice. Deep sedation and a continuous benzodiazepine infusion are the opposite, and the compendium lists sedatives and neuromuscular blockade among potential risk factors for ventilator-associated events.

A patient with diabetic ketoacidosis has an admission potassium of 3.2 mmol/L. The insulin infusion is ready to hang. According to the 2024 ADA/EASD hyperglycemic crises consensus, what should the nurse do?

• a.Start insulin now at half the usual infusion rate
• b.Replace potassium; hold insulin until K is above 3.5 mmol/L✓
• c.Start insulin now and recheck the potassium in 4 hours
• d.Give sodium bicarbonate before starting the insulin

The 2024 consensus report states that when potassium is below 3.5 mmol/L, replacement should begin (about 10 mmol/h) and insulin should be delayed until potassium rises above 3.5 mmol/L, because insulin drives potassium into cells and can cause life-threatening arrhythmias and respiratory muscle weakness. A reduced insulin rate still lowers potassium. Routine bicarbonate is not recommended and also shifts potassium into cells.

Six hours into treatment for DKA, the patient's glucose has fallen to 236 mg/dL, but the ketones and acidosis have not resolved. What change should the nurse anticipate?

• a.Continue current orders until glucose is below 150 mg/dL
• b.Stop the insulin infusion and begin subcutaneous insulin
• c.Add 5–10% dextrose to the fluids; continue the insulin✓
• d.Halve the insulin infusion and keep the same IV fluid

Per the 2024 consensus, glucose usually falls below 250 mg/dL before ketoacidosis resolves, so dextrose 5–10% is added to allow insulin to continue until ketonemia is corrected while preventing hypoglycemia. Stopping or cutting insulin leaves ketogenesis unchecked, and waiting for 150 mg/dL on the same fluids risks hypoglycemia.

A patient taking an SGLT2 inhibitor presents with vomiting, deep rapid breathing, a pH of 7.18, a β-hydroxybutyrate of 5.2 mmol/L and a glucose of 168 mg/dL. How should the nurse interpret these findings?

• a.Starvation ketosis without acidosis
• b.Lactic acidosis from dehydration
• c.Hyperosmolar hyperglycemic state
• d.Euglycemic diabetic ketoacidosis✓

The 2024 consensus defines euglycemic DKA as glucose below 200 mg/dL with the ketosis and metabolic acidosis criteria of DKA, and notes that SGLT2 inhibitor-associated DKA may present this way. HHS requires marked hyperglycemia and hyperosmolality. Starvation ketosis does not produce a pH of 7.18, and a high β-hydroxybutyrate points to ketoacidosis rather than lactate.

A patient with small cell lung cancer has a serum sodium of 124 mEq/L, concentrated urine and mild confusion, and is diagnosed with SIADH. Which intervention should the nurse anticipate first?

• a.Rapid IV 0.9% saline
• b.Free-water flushes
• c.Desmopressin
• d.Fluid restriction✓

MedlinePlus states that in all cases of SIADH the first step is to limit fluid intake, reserving 3% saline for severe symptoms. Isotonic saline can worsen hyponatremia when urine is highly concentrated. Desmopressin is an ADH analog and adds to the problem, and free-water flushes add the water the patient cannot excrete.

The day after transsphenoidal pituitary surgery, a patient's urine output is 450 mL/h of very pale urine, and serum sodium has risen from 141 to 150 mEq/L. Which medication should the nurse expect to be ordered?

• a.Desmopressin✓
• b.Hydrochlorothiazide
• c.Furosemide
• d.Conivaptan

Surgery near the pituitary is the most common cause of central diabetes insipidus, which produces large volumes of dilute urine and rising sodium; MedlinePlus states that central DI is treated with desmopressin. Furosemide would increase water loss. Conivaptan blocks ADH and would worsen the diuresis. Thiazides are used for nephrogenic DI, not acute central DI after surgery.

A patient who took prednisone for years stopped it abruptly a week ago. The patient is now confused, hypotensive, hypoglycemic and vomiting. Which treatment is the priority?

• a.IV hydrocortisone✓
• b.IV levothyroxine
• c.IV regular insulin
• d.IV fludrocortisone

Stopping long-term glucocorticoids suddenly is a listed cause of acute adrenal crisis, which presents with low blood pressure, low blood sugar, vomiting and confusion; MedlinePlus says hydrocortisone must be given right away IV or IM, with fluids for hypotension. Levothyroxine treats hypothyroidism. Insulin would worsen the hypoglycemia. Fludrocortisone is an oral mineralocorticoid, not an IV emergency treatment.

A patient with untreated hyperthyroidism is admitted with pneumonia and develops a temperature of 40.1 °C, a heart rate of 158/min, agitation and a wide pulse pressure. Which medication class is given IV to slow the heart rate and block the effects of excess thyroid hormone?

• a.Loop diuretics
• b.Beta-blockers✓
• c.Calcium supplements
• d.Cardiac glycosides

This is a thyroid storm triggered by infection, and MedlinePlus states that beta-blockers are often given IV to slow the heart rate, lower blood pressure and block the effects of thyroid hormone excess, alongside thionamides, iodine and cooling. Calcium, loop diuretics and cardiac glycosides do not block thyroid hormone effects.

On day 7 of a heparin infusion, a patient's platelet count has fallen from 260,000 to 95,000/mm³ and a new deep vein thrombosis is found. The 4Ts score is high. Which plan reflects the ASH guideline?

• a.Stop all heparin, including flushes; start a non-heparin anticoagulant✓
• b.Stop heparin and transfuse platelets before giving any anticoagulant
• c.Switch to enoxaparin and recheck the platelet count tomorrow morning
• d.Continue heparin and add warfarin to treat the new thrombosis

For suspected HIT with a high-probability 4Ts score, ASH recommends discontinuing heparin and starting a non-heparin anticoagulant at therapeutic intensity (argatroban, bivalirudin, fondaparinux or a DOAC). ASH suggests against routine platelet transfusion in HIT without bleeding. Enoxaparin is also a heparin. Starting warfarin before platelet recovery is recommended against.

A patient with confirmed acute heparin-induced thrombocytopenia is on an argatroban infusion, and the platelet count is 48,000/mm³. Which new order should the nurse question?

• a.Warfarin 5 mg by mouth tonight✓
• b.Daily platelet counts
• c.Sequential compression devices
• d.Titration of argatroban to aPTT

ASH recommends against starting a vitamin K antagonist in acute HIT until the platelet count has recovered, usually to at least 150 × 10⁹/L, because early warfarin can precipitate limb gangrene. Daily platelet counts track recovery, mechanical compression adds no heparin exposure, and monitoring argatroban with the aPTT is standard.

Fifteen minutes into a unit of packed red blood cells, a patient develops chills, fever, flank pain and dark urine. What is the nurse's first action?

• a.Give acetaminophen and continue
• b.Recheck vital signs in 15 minutes
• c.Stop the transfusion✓
• d.Call the provider and keep the transfusion running

Fever, chills, flank pain and blood in the urine during a transfusion suggest a hemolytic transfusion reaction; MedlinePlus states the transfusion must be stopped right away and recipient and donor samples tested. Calling the provider while the unit keeps running, or treating the fever and continuing, gives more incompatible cells; the provider is informed after the transfusion is stopped. Waiting 15 minutes delays the key action.