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.