ANCC Adult-Gerontology Acute Care Nursing 2 — Questions and Answers
Question 1: A patient with ARDS is on mechanical ventilation. Which ventilator strategy reduces ventilator-induced lung injury?
- High tidal volumes to maximize oxygenation
- Low tidal volume ventilation (6 mL/kg ideal body weight) (Correct answer)
- High PEEP with unrestricted FiO2
- Pressure-controlled ventilation with high inspiratory pressures
Correct answer: Low tidal volume ventilation (6 mL/kg ideal body weight)
Low tidal volume ventilation (6 mL/kg ideal body weight) is the evidence-based lung-protective strategy for ARDS. The ARDSNet trial demonstrated significant mortality reduction compared to 12 mL/kg tidal volumes.
Lung-protective ventilation in ARDS uses tidal volumes of 4-8 mL/kg ideal body weight targeting 6 mL/kg, plateau pressures at or below 30 cmH2O, and moderate to high PEEP. The ARDSNet ARMA trial showed 22% relative mortality reduction. Permissive hypercapnia (pH above 7.20) is acceptable. High tidal volumes cause overdistension in relatively normal lung units, worsening injury.
Question 2: When caring for a patient post-CABG, which finding requires immediate intervention?
- Serosanguinous drainage from chest tube totaling 50 mL in first hour
- Urine output of 35 mL/hr
- Mediastinal chest tube output of 250 mL/hr for two consecutive hours (Correct answer)
- Temperature of 37.8 degrees C on postoperative day 1
Correct answer: Mediastinal chest tube output of 250 mL/hr for two consecutive hours
Chest tube output greater than 200 mL/hr for 2 consecutive hours post-CABG indicates excessive bleeding requiring immediate surgical re-exploration.
Post-CABG chest tube drainage greater than 200 mL/hr for 2 or more consecutive hours is the standard threshold for surgical re-exploration. Acceptable drainage is typically less than 100-150 mL/hr in the first few hours. Urine output of 35 mL/hr is acceptable. Low-grade fever on POD1 is a normal post-surgical inflammatory response.
Question 3: A patient with acute liver failure and hepatic encephalopathy needs management of cerebral edema. Which nursing intervention is the priority?
- Administer lactulose and maintain head of bed flat
- Elevate head of bed to 30 degrees and minimize stimulation (Correct answer)
- Encourage ambulation to reduce portal hypertension
- Administer high-protein enteral nutrition to support liver regeneration
Correct answer: Elevate head of bed to 30 degrees and minimize stimulation
Elevating the head of bed to 30 degrees promotes venous drainage and reduces intracranial pressure. Minimizing stimulation reduces ICP spikes.
In acute liver failure with cerebral edema: HOB at 30 degrees promotes cerebral venous outflow, minimizing stimulation avoids ICP spikes, and avoiding hypotension preserves CPP. High-protein diets are restricted in severe hepatic encephalopathy as ammonia worsens encephalopathy. Head-flat positioning increases ICP.
Question 4: According to the Surviving Sepsis Campaign, what is the recommended fluid resuscitation target within the first 3 hours of septic shock?
- At least 20 mL/kg crystalloid
- At least 30 mL/kg crystalloid (Correct answer)
- 10 mL/kg colloid followed by reassessment
- 2 liters of normal saline regardless of weight
Correct answer: At least 30 mL/kg crystalloid
The Surviving Sepsis Campaign recommends at least 30 mL/kg intravenous crystalloid fluid within the first 3 hours of sepsis-induced hypoperfusion or septic shock.
The 2021 Surviving Sepsis Campaign guidelines recommend at least 30 mL/kg IV crystalloid (normal saline or lactated Ringer's) within the first 3 hours for sepsis-induced hypoperfusion. After initial resuscitation, ongoing fluid administration is guided by dynamic measures of fluid responsiveness. Vasopressors (norepinephrine) are initiated if MAP remains below 65 mmHg despite initial fluids.
Question 5: Which intervention is most supported by evidence to prevent and treat ICU delirium?
- Routine physical restraints to prevent falls during confusion
- Benzodiazepine administration to manage agitation
- Early mobilization, sleep protocol, and reorientation using the ABCDEF bundle (Correct answer)
- Continuous antipsychotic infusion as first-line treatment
Correct answer: Early mobilization, sleep protocol, and reorientation using the ABCDEF bundle
The ABCDEF bundle (Assess, Both SAT/SBT, Choice of analgesia/sedation, Delirium assessment, Early mobility, Family engagement) is the evidence-based framework for preventing and treating ICU delirium.
The ABCDEF bundle is the cornerstone of ICU delirium prevention. Physical restraints worsen delirium. Benzodiazepines are associated with increased delirium incidence — prefer dexmedetomidine or propofol. Delirium is monitored with CAM-ICU or ICDSC. Early mobility and family engagement are critical non-pharmacological components.
Question 6: A patient with TBI has ICP of 28 mmHg and MAP of 85 mmHg. What is the CPP and is it within the recommended range?
- CPP = 57 mmHg; below the recommended minimum of 60-70 mmHg (Correct answer)
- CPP = 57 mmHg; within acceptable range
- CPP = 113 mmHg; dangerously high
- CPP = 28 mmHg; critical ICP elevation only
Correct answer: CPP = 57 mmHg; below the recommended minimum of 60-70 mmHg
CPP = MAP minus ICP = 85 minus 28 = 57 mmHg. The Brain Trauma Foundation recommends CPP of 60-70 mmHg. A CPP of 57 mmHg is below the minimum and requires intervention.
CPP = MAP minus ICP = 85 minus 28 = 57 mmHg. BTF guidelines recommend CPP of 60-70 mmHg for severe TBI. CPP below 60 mmHg is associated with ischemia. Interventions: lower ICP (elevated HOB, osmotherapy, CSF drainage via EVD, avoid hypercarbia) and raise MAP (vasopressors, fluid). ICP above 20 mmHg for more than 5 minutes is the treatment threshold.
ANCC Adult-Gerontology Acute Care Nursing 2
A patient with ARDS is on mechanical ventilation.
Which ventilator strategy reduces ventilator-induced lung injury?