CCRN (Adult) Critical Care Nursing Exam — All Questions

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.

A patient with gram-negative septic shock is oozing from IV sites and the endotracheal tube and has new petechiae. Which laboratory pattern is most consistent with disseminated intravascular coagulation?

• a.Normal platelets, prolonged PTT only, normal D-dimer
• b.High platelets and fibrinogen, short PT and PTT, low D-dimer
• c.Low platelets, normal PT and PTT, normal fibrinogen and D-dimer
• d.Low platelets and fibrinogen, prolonged PT and PTT, high D-dimer✓

In DIC, clotting proteins and platelets are consumed while clot breakdown products rise, so platelets and fibrinogen fall, the PT and PTT lengthen and D-dimer increases; MedlinePlus lists these tests and infection in the blood as a risk factor. Isolated thrombocytopenia with normal clotting studies suggests another cause such as immune thrombocytopenia. An isolated prolonged PTT suggests heparin effect or a factor problem. Raised platelets and fibrinogen describe an inflammatory, not consumptive, state.

Protamine is ordered to reverse heparin in a bleeding patient. Which administration practice does the heparin label require?

• a.As a rapid IV push so the heparin is neutralized as fast as possible
• b.Slowly, no more than 50 mg per 10 minutes, with resuscitation ready✓
• c.1 mg for every 1,000 units of heparin given over the past 24 hours
• d.By intramuscular injection only, so that absorption is slow and even

The heparin label states that protamine is given by slow infusion, no more than 50 mg in any 10-minute period, that each milligram neutralizes about 100 units of heparin, and that because fatal anaphylaxis-like reactions occur it should be given only when resuscitation is available. A rapid push risks hypotension and anaphylactoid reactions. The ratio is 1 mg per 100 units, not per 1,000, and the drug is given IV.

A patient with cirrhosis is vomiting large amounts of bright red blood and is becoming less responsive. Which action is the priority while the team prepares for endoscopy?

• a.Give lactulose to prevent encephalopathy
• b.Obtain a stool sample for occult blood
• c.Insert a nasogastric tube for gastric lavage
• d.Protect the airway; anticipate intubation✓

MedlinePlus notes that with massive variceal bleeding a person may need a ventilator to protect the airway and prevent blood entering the lungs; a falling level of consciousness with ongoing hematemesis makes aspiration the immediate threat. Nasogastric lavage and lactulose may have roles later, and an occult blood test adds nothing when bleeding is obvious.

A patient with acute pancreatitis and no cardiac or renal disease is admitted to the ICU. Which fluid plan matches the 2024 ACG guideline?

• a.Maintenance-rate 0.45% saline until the pain has improved
• b.Albumin 25% as the primary resuscitation fluid for all patients
• c.Aggressive 0.9% saline boluses regardless of volume status
• d.Moderately aggressive lactated Ringer's; more if hypovolemic✓

The 2024 ACG guideline suggests moderately aggressive fluid resuscitation with additional boluses if there is evidence of hypovolemia, and suggests lactated Ringer's over normal saline, with caution for volume overload in cardiac or renal disease. A hypotonic maintenance rate under-resuscitates. Aggressive saline boluses regardless of volume status risk overload. Albumin is not the recommended primary fluid.

A patient with mild acute gallstone pancreatitis says the pain is improving and asks to eat on hospital day 1. What approach does the 2024 ACG guideline suggest?

• a.Keep NPO and begin parenteral nutrition in the ICU today
• b.Keep NPO until the serum lipase level is back to normal
• c.Early oral feeding within 24–48 hours as tolerated✓
• d.Allow clear liquids only after 7 days

For mild acute pancreatitis, the 2024 ACG guideline suggests early oral feeding within 24–48 hours as tolerated rather than the traditional NPO approach. Waiting for a normal lipase or a week prolongs fasting without benefit, and parenteral nutrition is not indicated for a patient able to eat.

A patient with hepatic encephalopathy is receiving lactulose. Which finding best shows the therapy is working?

• a.A rise in the serum sodium level
• b.Ten or more watery stools a day
• c.Two to three soft stools a day, clearer thinking✓
• d.One formed stool every other day, no change in thinking

The ACG hepatic encephalopathy guideline describes titrating lactulose to about 2–3 soft bowel movements daily (2–4 in acute overt HE) and expects mental status to improve within 24–48 hours. Infrequent formed stools mean under-dosing. Sodium is not the target. Profuse watery diarrhea is overtreatment and risks dehydration and electrolyte loss, which can themselves precipitate encephalopathy.

A patient with cirrhosis and grade 2 hepatic encephalopathy asks for something to help her sleep. Which order should the nurse question?

• a.Lorazepam at bedtime✓
• b.Ceftriaxone for a urinary infection
• c.Lactulose three times daily
• d.Rifaximin twice daily

MedlinePlus lists sedatives and tranquilizers among medicines to avoid in hepatic encephalopathy and among its triggers. Lactulose and rifaximin are the recommended ammonia-lowering therapies, and treating infection removes a common precipitant.

A patient presents with severe epigastric pain radiating to the back. Which laboratory result is the more specific indicator of acute pancreatitis?

• a.Serum lipase✓
• b.Serum bilirubin
• c.Serum amylase
• d.Alkaline phosphatase

MedlinePlus states that an increased serum lipase is a more specific indicator of pancreatitis than amylase. Bilirubin and alkaline phosphatase can rise with biliary obstruction, which may accompany gallstone pancreatitis, but they do not measure pancreatic injury.

A patient with acute kidney injury has a potassium of 7.1 mmol/L and peaked T waves on the monitor. Which medication should the nurse expect to give first?

• a.IV sodium bicarbonate
• b.IV calcium✓
• c.IV loop diuretic
• d.Oral potassium binder

With ECG changes, IV calcium is given first to counter the effects of high potassium on the heart; MedlinePlus lists it for the muscle and heart effects, with insulin and glucose, binders, diuretics and dialysis used to lower the level. Bicarbonate is used when acidosis is the cause, an oral binder acts over hours, and a diuretic depends on kidney function this patient may not have.

A patient admitted with acute kidney injury is reviewing home medications with the nurse. Which drug is a common contributor to kidney injury that the nurse should flag?

• a.Ibuprofen✓
• b.Omeprazole
• c.Acetaminophen
• d.Levothyroxine

MedlinePlus lists nonsteroidal anti-inflammatory drugs among the medicines that can cause acute kidney failure, along with IV contrast and certain antibiotics and blood pressure medicines. Acetaminophen at usual doses, omeprazole and levothyroxine are not listed there as causes.

A patient with worsening acute kidney injury is being evaluated for dialysis. Which new finding is an indication to start it?

• a.Mild ankle edema
• b.A creatinine up by 0.3 mg/dL
• c.A pericardial friction rub✓
• d.A urine output of 0.8 mL/kg/h

MedlinePlus lists pericarditis, mental status changes, dangerous potassium levels, too much retained fluid and inability to remove nitrogen wastes as reasons for dialysis in acute kidney failure; a new rub signals uremic pericarditis. Urine output of 0.8 mL/kg/h is adequate, a creatinine rise of 0.3 mg/dL defines injury but not a need for dialysis, and mild edema is not dangerous fluid retention.

A patient with oliguric acute kidney injury is not yet on dialysis. Which fluid and diet plan should the nurse expect?

• a.Fluid limited to about urine output; low protein, salt and potassium✓
• b.Unrestricted fluids; potassium-rich foods to prevent weakness
• c.Fluid limited to 500 mL/day regardless of urine output; high-salt diet
• d.Liberal fluids to flush the kidneys; high-protein diet

MedlinePlus explains that in acute kidney failure fluid intake is limited to the amount of urine the patient can produce and the diet may be high in carbohydrate and low in protein, salt and potassium. Liberal fluids and potassium-rich foods cause overload and hyperkalemia, and a fixed limit with a high-salt diet ignores output and promotes fluid retention.

Which bed-positioning plan helps prevent pressure injuries in an immobile patient who has no medical reason to keep the head of the bed high?

• a.Turn every 2 hours, donut cushion under sacrum, head of bed at 60°
• b.Turn every 4 hours, pillow under knees, head of bed at 45°
• c.Turn once per shift, drag up in bed by the arms, head of bed flat
• d.Turn every 1–2 hours, float heels, head of bed at 30° or less✓

MedlinePlus advises changing position every 1–2 hours, lifting the heels with a pillow under the calves, not putting pillows under the knees, and not raising the head of the bed above 30° so the patient does not slide. A 45° or 60° head elevation causes sliding and shear, donut cushions are discouraged, and dragging damages skin.

A nurse is checking the sacrum of a patient with darkly pigmented skin for an early pressure injury. Which approach is most reliable?

• a.Feel for warmth and for spongy or firm tissue✓
• b.Check only the heels and elbows for changes
• c.Wait until the skin surface has broken down
• d.Look only for blanchable redness of the skin

MedlinePlus lists skin redness, warm areas, spongy or hard skin and breakdown of the top layers as early signs, and notes that redness is harder to detect in darker skin tones, so temperature and tissue consistency add information. Relying on redness alone can miss the injury, waiting for broken skin misses the early stage, and the sacrum and tailbone are among the most common sites.

A patient with fecal incontinence is at risk for moisture-related skin breakdown. Which care measure is recommended?

• a.Scrub the area firmly with a strong soap after every episode
• b.Leave the brief in place until the next scheduled check
• c.Clean and dry the skin right away, then apply a protectant✓
• d.Dust the area with talc powder after each episode

MedlinePlus advises cleaning the area right away after urination or a bowel movement, drying well, using gentle washing without hard scrubbing or strong soaps, avoiding talc powder, and using skin protectants as directed. Scrubbing, talc and leaving soiled briefs in place all increase breakdown.