CCRN (Adult) Critical Care Nursing Exam — All Questions

Six hours after casting of a tibial fracture, a patient reports pain that keeps worsening despite IV morphine and elevation, with numbness of the foot and inability to move the toes. What should the nurse do?

• a.Increase the opioid dose and reassess in an hour
• b.Raise the leg higher and apply a heating pad
• c.Report possible compartment syndrome to the surgeon now✓
• d.Encourage active range of motion of the toes

Pain much greater than expected that does not respond to pain medicine or elevation, with numbness and weakness, suggests acute compartment syndrome, which MedlinePlus says needs fasciotomy right away; permanent nerve injury can follow within hours. More opioid masks the key symptom, heat and further elevation do not relieve compartment pressure, and exercising the limb does not treat it.

Which ICU patient is at greatest risk of a delayed diagnosis of acute compartment syndrome?

• a.An alert patient with a forearm cast who reports pain
• b.A deeply sedated, ventilated patient with a crush injury✓
• c.An alert patient with a sprained ankle and ice
• d.An awake runner with calf pain during exercise

MedlinePlus notes that permanent nerve and muscle injury from delayed diagnosis is more common when the injured person is unconscious or heavily sedated and cannot complain of pain. An alert patient can report escalating pain. Exertional compartment syndrome eases when activity stops and rarely causes permanent injury.

To counter muscular deconditioning in a mechanically ventilated patient, which practice is an essential practice in the 2022 SHEA/IDSA/APIC update?

• a.Passive positioning only, with no mobilization
• b.Strict bed rest until the patient is extubated
• c.Continuous neuromuscular blockade
• d.Maintaining and improving physical conditioning✓

The 2022 SHEA/IDSA/APIC compendium lists maintaining and improving physical conditioning among the essential practices for ventilated adults. Bed rest and passive positioning alone allow further deconditioning, and neuromuscular blockade is listed as a potential risk factor for ventilator-associated events.

A trauma patient with a pelvic fracture and ongoing hemorrhage arrives 90 minutes after injury. When is tranexamic acid associated with a survival benefit in the CRASH-2 data?

• a.At any time within the first 24 hours
• b.Only when started within 30 minutes of injury
• c.Only after bleeding has been surgically controlled
• d.When started within 3 hours of injury✓

In CRASH-2, the reduction in death from bleeding and all causes on the day of injury was seen only in patients treated within 3 hours of injury; there was no reduction when treatment began later. The benefit is not limited to 30 minutes, it is an early adjunct rather than a post-surgical drug, and it did not extend across 24 hours.

A patient with severe traumatic brain injury has a mean arterial pressure of 72 mm Hg and an intracranial pressure of 26 mm Hg. What is the cerebral perfusion pressure, and how does it compare with the SIBICC threshold?

• a.72 mm Hg, above the 60 mm Hg minimum
• b.46 mm Hg, below the 60 mm Hg minimum✓
• c.98 mm Hg, above the 90 mm Hg maximum
• d.46 mm Hg, within the 40–70 mm Hg goal

Cerebral perfusion pressure is MAP minus ICP: 72 − 26 = 46 mm Hg. SIBICC adopted the Brain Trauma Foundation thresholds of ICP 22 mm Hg and a minimum CPP of 60 mm Hg, so this patient's ICP is high and CPP is too low. Adding the values gives 98, which is wrong, and 72 is simply the MAP. SIBICC does not endorse a 40–70 goal.

For a patient with severe traumatic brain injury and an ICP monitor, which order should the nurse question as not recommended by the SIBICC consensus?

• a.Hyperventilate to keep PaCO2 at 26–28 mm Hg routinely✓
• b.Treat fever to keep core temperature at or below 38 °C
• c.Drain CSF through the ventriculostomy for high ICP
• d.Give a bolus of hyperosmolar therapy for an ICP spike

SIBICC lists routinely decreasing PaCO2 below 30 mm Hg among treatments not recommended, allowing only mild hyperventilation (32–35 mm Hg) as a Tier-two option. CSF drainage via ventriculostomy is Tier-one, avoiding fever above 38 °C is a Tier-zero goal, and bolus hyperosmolar therapy is used (it is scheduled or continuous-infusion hyperosmolar therapy that is not recommended).

A patient with a large intracerebral hemorrhage develops a heart rate of 44/min, a blood pressure rising to 196/88 mm Hg and an irregular breathing pattern. How should the nurse interpret this?

• a.Neurogenic shock from brainstem injury
• b.A Cushing response to rising ICP✓
• c.Autonomic dysreflexia from bladder distention
• d.Beta-blocker toxicity from home medications

Bradycardia with rising blood pressure and respiratory changes is the classic Cushing response to acutely elevated intracranial pressure and signals possible herniation. Autonomic dysreflexia occurs in spinal cord injury at or above the mid-thoracic level. Neurogenic shock causes hypotension, not hypertension. Beta-blocker toxicity lowers blood pressure and does not explain the breathing pattern.

A teenager struck in the head with a baseball was briefly unconscious, then alert and talking. Two hours later he becomes drowsy, his left pupil is dilated and his right arm is weak. Which condition should the nurse suspect?

• a.Postictal state after a seizure
• b.Chronic subdural hematoma
• c.Epidural hematoma✓
• d.Concussion without bleeding

MedlinePlus describes the typical epidural hematoma pattern as loss of consciousness, then alertness, then rapid deterioration, with an enlarged pupil on one side and weakness usually on the opposite side; it is an emergency needing surgery. A concussion does not produce a blown pupil with hemiparesis. A chronic subdural develops over weeks, and a postictal state would not explain a unilateral dilated pupil.

A patient arrives with sudden right-sided weakness and slurred speech that began 2 hours ago. Before any clot-dissolving medicine is given, which test is required?

• a.An electroencephalogram
• b.A lumbar puncture for cerebrospinal fluid
• c.A carotid duplex ultrasound
• d.A head CT or MRI to exclude bleeding✓

MedlinePlus explains that a CT or MRI of the brain shows whether there is bleeding, and thrombolytic therapy is only for strokes caused by a clot, started within 4½ hours of symptom onset. A lumbar puncture, carotid ultrasound and EEG may be part of the later workup, but none of them excludes hemorrhage before thrombolysis.

A patient's generalized tonic-clonic seizure has lasted 6 minutes, and there is no IV access. Which initial therapy is supported at Level A by the American Epilepsy Society guideline?

• a.IV phenytoin after an IV is placed
• b.Observation for another 10 minutes
• c.Intramuscular midazolam✓
• d.Oral levetiracetam

The American Epilepsy Society guideline treats seizures lasting more than 5 minutes as status epilepticus and finds IM midazolam superior to IV lorazepam in adults without established IV access (Level A). Oral medicine cannot be given safely during a convulsion, phenytoin is a second-line therapy that would also wait for access, and waiting longer lets the seizure become harder to stop.

A patient on seizure precautions begins a generalized convulsion in bed. Which action is appropriate?

• a.Turn the patient onto the side and protect the head✓
• b.Place a padded tongue blade between the patient's teeth
• c.Leave the room to notify the provider first
• d.Give oral lorazepam as soon as the jaw muscles relax

MedlinePlus advises protecting the person from injury, cushioning the head and turning the person on their side so vomit is not inhaled. It also says not to place anything between the teeth and not to give anything by mouth until the person is fully awake, and to stay with the person; help is summoned without leaving the seizing patient alone.

A patient with a T4 spinal cord injury suddenly reports a pounding headache. Blood pressure is 208/112 mm Hg, heart rate 50/min, and the skin above the injury is flushed and sweaty. What should the nurse do first?

• a.Apply warm blankets and recheck in 15 minutes
• b.Give a PRN oral analgesic for the headache
• c.Sit the patient up and loosen tight clothing✓
• d.Lay the patient flat and raise the legs

These findings are autonomic dysreflexia. MedlinePlus states that a person with symptoms should sit up with the head raised and remove tight clothing, then the cause, most often a blocked urinary catheter or constipation, is found and removed. Lying flat raises pressure further, an analgesic treats only the symptom, and waiting risks stroke or intracranial bleeding.

Shortly after a C6 spinal cord injury, a patient has a blood pressure of 78/40 mm Hg, a heart rate of 48/min and warm, dry extremities. Which type of shock is most likely?

• a.Obstructive shock
• b.Neurogenic shock✓
• c.Cardiogenic shock
• d.Hypovolemic shock

Injury to the cervical or upper thoracic cord (T6 and above) disrupts sympathetic tone, causing vasodilation, hypotension and bradycardia. Hypovolemic and cardiogenic shock usually bring tachycardia with cool, clammy skin, and obstructive shock (tamponade, tension pneumothorax) typically causes tachycardia and distended neck veins.

A patient is admitted with a complete C4 spinal cord injury. Which assessment is the priority in the first hours?

• a.Bowel sounds
• b.Level of sensation in both legs
• c.Breathing effort and ventilation✓
• d.Pressure points over the sacrum

MedlinePlus notes that high cervical injuries can cause severe breathing problems from paralysis of the breathing muscles, and death is possible from paralysis of the breathing muscles. Bowel function, skin integrity and sensory level all matter, but airway and breathing come first.

A patient with long-standing heavy alcohol use is admitted malnourished and develops confusion, an unsteady gait and nystagmus. Which treatment should be given as soon as possible?

• a.IV haloperidol
• b.Glucose infusion alone
• c.IV or IM thiamine✓
• d.Oral folic acid alone

Confusion, ataxia and abnormal eye movements in a person with alcohol use disorder suggest Wernicke encephalopathy, caused by vitamin B1 (thiamine) deficiency; MedlinePlus says thiamine is usually given by vein or muscle as soon as possible and that treatment should start immediately. Haloperidol treats agitation, folic acid does not correct thiamine deficiency, and glucose alone does nothing for the deficiency.

A 79-year-old in the ICU after surgery is oriented in the morning but agitated and picking at lines each evening. Which intervention should the nurse try first?

• a.Keep room lights on all night for closer observation
• b.Reorient with clock, calendar, glasses and day–night lighting✓
• c.Apply bilateral soft wrist restraints every evening
• d.Add a scheduled benzodiazepine dose at bedtime each night

MedlinePlus lists reality orientation, clocks, calendars, lighting that marks day and night, and hearing aids or glasses as helpful treatments for delirium, and notes that avoiding or minimizing sedatives lowers risk. A scheduled benzodiazepine can worsen delirium, restraints are not a first-line treatment, and constant light disrupts the day–night cycle.

Which feature best distinguishes delirium from dementia in a newly confused ICU patient?

• a.Disorientation to time, place and situation
• b.Problems with short-term memory
• c.Advanced age
• d.Sudden onset with a fluctuating course✓

MedlinePlus describes delirium as sudden severe confusion with quick shifts between mental states, such as lethargy to agitation and back, and alertness that varies across the day. Memory problems and disorientation occur in both conditions, and older age is a risk factor for both, so they do not distinguish them.

A patient admitted three days ago after a fall now has fever, tachycardia, drenching sweats, tremor and is seeing insects on the wall. The family says he drinks heavily every day. What is the most likely cause?

• a.Delirium tremens✓
• b.Wernicke encephalopathy
• c.Hepatic encephalopathy
• d.Opioid withdrawal

MedlinePlus states that delirium tremens usually occurs 48–96 hours after the last drink and causes fever, severe confusion, hallucinations, tremor and a rapid heart rate. Wernicke encephalopathy causes confusion, ataxia and eye movement problems without this hyperadrenergic picture. Hepatic encephalopathy lacks fever and hallucinations, and nothing in the history suggests opioid use.

A patient with an opioid overdose wakes up after IV naloxone. Why does the nurse keep monitoring closely for several hours?

• a.The opioid may cause seizures later in the day
• b.Naloxone lowers the seizure threshold
• c.Naloxone often causes delayed rebound hypertension
• d.Naloxone can wear off before the opioid does✓

MedlinePlus explains that because the effect of naloxone is often short, patients may be monitored for 4 to 6 hours and moderate to severe cases admitted, since respiratory depression can return as naloxone wears off. The other options are not the reason for extended observation after opioid reversal.

After an intentional overdose, a patient who is now medically stable tells the nurse, "I wish I hadn't woken up." What is the priority action?

• a.Reassure the patient that these feelings usually pass after discharge
• b.Ask the family to take the patient's belongings home, then continue routine checks
• c.Document the statement and address it at the next routine assessment
• d.Keep continuous observation and arrange a suicide risk assessment✓

A statement like this after a deliberate overdose indicates active suicide risk. Joint Commission National Patient Safety Goal 15.01.01 requires screening and assessment of suicide risk and protective actions for at-risk patients, and MedlinePlus notes a mental health evaluation is needed when a person with overdose is suicidal. Reassurance, delayed follow-up or routine checks leave the risk unaddressed.

A patient who survived septic shock is preparing for discharge and describes nightmares, poor sleep and low mood. Which plan reflects the 2026 Surviving Sepsis Campaign recommendations for survivors?

• a.Start a long-term benzodiazepine for sleep
• b.Tell the patient these symptoms resolve once infection clears
• c.Defer any referral until the first primary care visit
• d.Offer mental health and recovery support after discharge✓

The 2026 guideline recommends strategies to support sepsis survivors and families during post-hospital recovery and offering services that support mental health after discharge, reflecting post-intensive care syndrome. Dismissing the symptoms or deferring referral leaves them untreated, and a long-term benzodiazepine does not address the underlying problem.

A patient is found with arms and legs held rigidly extended, toes pointed down and head arched back after a brain injury. How should the nurse describe and interpret this posture?

• a.Decerebrate posture, usually indicating severe brain damage✓
• b.A seizure aura that will resolve on its own
• c.Opisthotonos from tetanus, needing no neurological workup
• d.Decorticate posture, indicating an isolated spinal injury

MedlinePlus describes decerebrate posture as the arms and legs held straight out, toes pointed down and head and neck arched back, usually meaning severe brain damage and needing emergency care including airway support. Decorticate posture involves flexion, not extension. Opisthotonos can look similar but still requires urgent evaluation, and an aura precedes a seizure rather than presenting as rigid extension.