CCRN (Adult) Critical Care Nursing Exam — All Questions

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.