PCCN® Exam (Progressive Care Certified Nurse) — Questions and Answers

Question 1: Which ECG change is commonly associated with hypokalemia?

U waves (Correct answer)
Prolonged QT interval
ST elevation
Peaked T waves

Correct answer: U waves

Hypokalemia, a low potassium level, commonly manifests on an ECG as the presence of U waves, which are small, positive deflections following the T wave. It can also cause flattened or inverted T waves and a prolonged QT interval. Peaked T waves, in contrast, are characteristic of hyperkalemia.

Question 2: Which intervention is MOST effective in preventing delirium in a progressive care patient?

Promoting sleep hygiene, early mobility, and reorientation strategies (Correct answer)
Keeping the room darkened and quiet at all times
Administering prophylactic haloperidol nightly
Providing continuous physical restraints to prevent falls

Correct answer: Promoting sleep hygiene, early mobility, and reorientation strategies

Non-pharmacologic bundles including sleep promotion, early mobilization, cognitive stimulation, and reorientation (e.g., ABCDEF bundle) are the most evidence-based approach to delirium prevention.

Question 3: Which of the following medications requires a peak and trough level for safe administration?

Acetaminophen
Azithromycin
Ciprofloxacin
Vancomycin (Correct answer)

Correct answer: Vancomycin

Vancomycin is an antibiotic with a narrow therapeutic index, meaning the difference between an effective and a toxic dose is small. Therefore, peak and trough levels are routinely monitored to ensure therapeutic concentrations are achieved while minimizing the risk of serious adverse effects such as nephrotoxicity (kidney damage) and ototoxicity (hearing damage).

Question 4: Which nursing intervention helps prevent complications of portal hypertension in a patient with cirrhosis?

Encouraging high-protein intake
Limiting fluid intake
Administering lactulose (Correct answer)
Restricting physical activity

Correct answer: Administering lactulose

Portal hypertension in cirrhosis can lead to hepatic encephalopathy due to the accumulation of ammonia and other toxins. Lactulose works by trapping ammonia in the gut and promoting its excretion through the stool, thereby reducing systemic ammonia levels. This intervention directly addresses a major complication of portal hypertension by preventing or treating hepatic encephalopathy.

Question 5: Which medication is commonly used to reduce afterload in heart failure?

Lisinopril (Correct answer)
Digoxin
Metoprolol
Furosemide

Correct answer: Lisinopril

Lisinopril, an ACE inhibitor, reduces afterload by causing vasodilation, which decreases systemic vascular resistance. By lowering the resistance against which the heart must pump, it improves cardiac output and reduces the workload on the failing heart in patients with heart failure. This makes it a cornerstone medication for managing heart failure symptoms.

Question 6: A patient presents with slurred speech, facial droop, and right-sided weakness. Which diagnostic test should be prioritized first?

Carotid Doppler ultrasound
Computed Tomography (CT) scan of the head (Correct answer)
Magnetic Resonance Imaging (MRI)
Electroencephalogram (EEG)

Correct answer: Computed Tomography (CT) scan of the head

A patient presenting with acute neurological deficits like slurred speech, facial droop, and weakness suggests a possible stroke. A CT scan of the head is prioritized to rapidly differentiate between ischemic and hemorrhagic stroke, as this distinction dictates immediate treatment. This quick assessment is critical for timely intervention, such as administering thrombolytics for ischemic stroke, and improving patient outcomes.

Question 7: Which adverse effect should the nurse monitor for when a patient is receiving furosemide?

Hypernatremia
Bradycardia
Hypokalemia (Correct answer)
Hypertension

Correct answer: Hypokalemia

Furosemide is a loop diuretic that works by inhibiting sodium and chloride reabsorption in the loop of Henle, leading to increased excretion of water, sodium, potassium, and chloride. Therefore, hypokalemia (low potassium) is a common and significant adverse effect that nurses must monitor for. Potassium supplementation may be required to prevent cardiac arrhythmias.

Question 8: Which drug is commonly used for sedation in mechanically ventilated patients and has both anxiolytic and amnestic effects?

Dexmedetomidine
Propofol
Midazolam (Correct answer)
Lorazepam

Correct answer: Midazolam

Midazolam is a short-acting benzodiazepine commonly used for sedation in mechanically ventilated patients due to its rapid onset and relatively short duration of action. It provides both anxiolytic (anxiety-reducing) and amnestic (memory-impairing) effects, which are beneficial for patient comfort and tolerance of mechanical ventilation. Other options have different primary uses or side effect profiles.

Question 9: A patient in the progressive care unit develops sudden hypotension, tachycardia, and jugular venous distension after a central line insertion. The nurse suspects:

Tension pneumothorax (Correct answer)
Cardiac tamponade
Pulmonary embolism
Air embolism

Correct answer: Tension pneumothorax

Tension pneumothorax is a known complication of central line insertion presenting with hemodynamic instability and JVD from mediastinal shift.

Question 10: Which laboratory result is most indicative of acute pancreatitis?

Elevated alkaline phosphatase
Elevated amylase and lipase (Correct answer)
Decreased ALT and AST
Low bilirubin

Correct answer: Elevated amylase and lipase

Acute pancreatitis involves inflammation of the pancreas, leading to the release of digestive enzymes into the bloodstream. Amylase and lipase are pancreatic enzymes, and their levels become significantly elevated in acute pancreatitis, often several times the normal range. Lipase is generally considered more specific for pancreatitis than amylase.

Question 11: A family member who has been keeping constant vigil at a critically ill patient's bedside appears exhausted and tearful. The nurse's BEST response is to:

Contact social work and ask them to speak with the family member without involving the nurse
Acknowledge the family member's distress, offer support resources, and gently encourage self-care while validating their presence (Correct answer)
Restrict visiting hours to force the family member to go home and rest
Reassure the family member that worrying is unnecessary as the care team has everything under control

Correct answer: Acknowledge the family member's distress, offer support resources, and gently encourage self-care while validating their presence

Supporting family members is within the progressive care nurse's scope; acknowledging distress, validating their support role, offering chaplaincy or social work, and encouraging self-care are all evidence-based family-centered care strategies.

Question 12: Which medication is typically administered to reverse the effects of opioid overdose?

Naloxone (Correct answer)
Atropine
Protamine sulfate
Flumazenil

Correct answer: Naloxone

Naloxone is an opioid antagonist specifically used to rapidly reverse the effects of opioid overdose by blocking opioid receptors. It is a life-saving medication that can quickly restore respiratory function in patients experiencing opioid-induced respiratory depression. Its rapid action makes it the drug of choice for opioid overdose emergencies.

Question 13: Which parameter is most reliable in evaluating the effectiveness of oxygen therapy?

Respiratory rate
Capillary refill
Lung sounds
SpO₂ level (Correct answer)

Correct answer: SpO₂ level

The SpO₂ (pulse oximetry) level directly measures the percentage of hemoglobin saturated with oxygen in the arterial blood. It provides an immediate and objective assessment of oxygenation status and the effectiveness of oxygen therapy. While other parameters like respiratory rate and lung sounds are important, SpO₂ offers a direct physiological measure of how well the body is being oxygenated.

Question 14: Which of the following is a common side effect of ACE inhibitors such as lisinopril?

Urinary retention
Bradycardia
Dry cough (Correct answer)
Constipation

Correct answer: Dry cough

A persistent, dry cough is a common and well-known side effect of ACE inhibitors like lisinopril. This cough is thought to be related to the accumulation of bradykinin, a substance that ACE inhibitors prevent from breaking down. While generally benign, it can be bothersome enough to warrant a change in medication.

Question 15: A patient admitted for cardiac monitoring discloses feelings of hopelessness and that life is not worth living. What is the nurse's priority action?

Administer an as-needed anxiolytic medication
Document the statement and notify the physician at the next scheduled rounding
Reassure the patient that these feelings are normal after a cardiac event
Perform a structured suicidal ideation assessment and notify the care team immediately (Correct answer)

Correct answer: Perform a structured suicidal ideation assessment and notify the care team immediately

Statements indicating hopelessness and passive suicidal ideation require immediate structured risk assessment and prompt notification of the multidisciplinary team to ensure patient safety.

Question 16: When a nurse admits a terminally ill patient who requests no life-prolonging treatment, the nurse should:

Provide life-sustaining treatments until the DNR is written
Inform the patient they must be resuscitated in all situations
Call the physician to clarify advance directives (Correct answer)
Respect the verbal request as legal and stop all interventions

Correct answer: Call the physician to clarify advance directives

A verbal request for no life-prolonging treatment is important, but it must be legally documented as an advance directive (e.g., DNR/DNI) to be actionable. The nurse's role is to ensure the patient's wishes are formally recognized and ordered by the physician, protecting both the patient's autonomy and the healthcare team legally. Calling the physician clarifies the patient's wishes and initiates the proper documentation process.

Question 17: What is the most serious complication associated with esophageal varices?

Massive upper GI bleeding (Correct answer)
Acid reflux
Strangulated hernia
Aspiration pneumonia

Correct answer: Massive upper GI bleeding

Esophageal varices are dilated blood vessels in the esophagus that develop due to portal hypertension in liver disease. These vessels are fragile and prone to rupture, leading to life-threatening, massive upper gastrointestinal bleeding. This complication is a medical emergency with a high mortality rate, making it the most serious concern.

Question 18: Which of the following hemodynamic parameters is most indicative of left ventricular preload?

Systemic vascular resistance (SVR)
Central venous pressure (CVP)
Cardiac output (CO)
Pulmonary artery wedge pressure (PAWP) (Correct answer)

Correct answer: Pulmonary artery wedge pressure (PAWP)

Pulmonary artery wedge pressure (PAWP), also known as pulmonary capillary wedge pressure (PCWP), is the most accurate hemodynamic parameter for estimating left ventricular preload. It reflects the pressure in the left atrium and, indirectly, the left ventricular end-diastolic pressure, which determines the stretch of the left ventricular muscle fibers before contraction. This measurement is crucial for assessing fluid status and cardiac function.

Question 19: A patient is admitted with an acute inferior wall myocardial infarction. The nurse should be most vigilant for the development of which of the following dysrhythmias?

Ventricular tachycardia
Sinus tachycardia
Atrial fibrillation
Atrioventricular (AV) block (Correct answer)

Correct answer: Atrioventricular (AV) block

An inferior wall myocardial infarction often involves the right coronary artery (RCA), which supplies blood to the atrioventricular (AV) node in the majority of the population. Ischemia or damage to the AV node can lead to conduction disturbances, such as first-degree, second-degree, or third-degree AV block. Therefore, the nurse must closely monitor the patient's ECG for signs of heart block.

Question 20: A patient receiving a blood transfusion develops fever, chills, and flank pain 15 minutes after initiation. What is the nurse's first action?

Stop the transfusion immediately (Correct answer)
Obtain a repeat type and crossmatch
Administer acetaminophen
Slow the transfusion rate

Correct answer: Stop the transfusion immediately

Signs of a hemolytic transfusion reaction require immediate cessation of the transfusion to prevent life-threatening complications.

Question 21: A patient in the progressive care unit is being treated for a severe exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following assessment findings would indicate the most urgent need for intervention?

Use of accessory muscles and a respiratory rate of 28 breaths/min
Reports of increased sputum production and cough
Oxygen saturation of 91% on 2L nasal cannula
Decreased level of consciousness and confusion (Correct answer)

Correct answer: Decreased level of consciousness and confusion

A decreased level of consciousness and confusion are signs of hypercapnia and severe respiratory distress, indicating impending respiratory failure. This is a life-threatening situation that requires immediate intervention, possibly including non-invasive or invasive mechanical ventilation. While the other options are concerning, they do not represent the same level of immediate threat as a change in mental status.

Question 22: The nurse notices that a patient who was previously cooperative has become withdrawn, stopped eating, and states 'nothing matters anymore.' These findings are MOST consistent with:

Delirium with hypoactive features
Physiologic response to pain medication
Normal adjustment to hospitalization
Clinical depression requiring further assessment and intervention (Correct answer)

Correct answer: Clinical depression requiring further assessment and intervention

Withdrawal, anhedonia (loss of interest), anorexia, and hopelessness are hallmark symptoms of clinical depression that require formal assessment using validated tools (e.g., PHQ-2/PHQ-9) and prompt intervention.

Question 23: A patient with acute coronary syndrome is found to have comorbid major depression. The nurse understands that depression in cardiac patients is significant because it:

Is associated with increased mortality, poor medication adherence, and worse cardiac outcomes (Correct answer)
Primarily affects quality of life but has no impact on physiologic cardiac function
Is a normal adjustment reaction that typically resolves without intervention within 6 months
Decreases pain perception and therefore reduces analgesic requirements

Correct answer: Is associated with increased mortality, poor medication adherence, and worse cardiac outcomes

Depression is an independent risk factor for adverse cardiac outcomes; it is associated with increased mortality, poor adherence to cardiac medications and lifestyle changes, and higher rates of recurrent cardiac events.

Question 24: Which finding best differentiates cardiogenic shock from hypovolemic shock?

Cool, clammy skin
Hypotension
Elevated PCWP and reduced cardiac output (Correct answer)
Tachycardia

Correct answer: Elevated PCWP and reduced cardiac output

Cardiogenic shock is characterized by elevated PCWP (fluid backing up) and reduced cardiac output, unlike hypovolemic shock which has low PCWP.

Question 25: A patient with chronic kidney disease reports nausea, fatigue, and a metallic taste. Which lab result supports uremia?

Sodium 140 mEq/L
BUN 80 mg/dL (Correct answer)
Hematocrit 42%
Creatinine 0.9 mg/dL

Correct answer: BUN 80 mg/dL

Uremia is a syndrome of symptoms and signs associated with severe kidney failure, resulting from the accumulation of nitrogenous waste products in the blood. A significantly elevated Blood Urea Nitrogen (BUN) level, such as 80 mg/dL (normal range typically 7-20 mg/dL), is a key indicator of impaired kidney function and the presence of uremia, correlating with symptoms like nausea, fatigue, and a metallic taste.

Question 26: Which finding in a patient with pneumonia requires immediate intervention?

Temperature of 101.2°F (38.4°C)
Productive cough with yellow sputum
Respiratory rate of 24 breaths per minute
New-onset confusion and restlessness (Correct answer)

Correct answer: New-onset confusion and restlessness

New-onset confusion and restlessness in a patient with pneumonia can indicate hypoxemia (low oxygen levels) or developing sepsis, especially in older adults. These are signs of worsening respiratory status or systemic compromise that require immediate assessment and intervention to prevent further deterioration. Other findings like cough and fever are expected with pneumonia but are less immediately concerning than acute neurological changes.

Question 27: A nurse assigned to care for a former romantic partner should:

Continue with care as assigned
Inform the patient not to disclose their past relationship
Request reassignment to avoid potential conflict (Correct answer)
Ask a co-worker to do all treatments

Correct answer: Request reassignment to avoid potential conflict

To maintain professional boundaries, avoid potential conflicts of interest, and ensure objective care, a nurse should request reassignment if a patient is a former romantic partner. This protects both the patient's privacy and the nurse's professional integrity, preventing any emotional or personal biases from affecting care. Continuing care could compromise the therapeutic relationship.

Question 28: Which of the following signs is most concerning for impending brain herniation in a patient with traumatic brain injury?

Dilated, non-reactive pupils (Correct answer)
Vomiting
Restlessness and agitation
Headache

Correct answer: Dilated, non-reactive pupils

Dilated, non-reactive pupils, especially if unilateral, are a critical sign of impending brain herniation. This indicates compression of the oculomotor nerve (CN III) due to severe increased intracranial pressure, which is a neurological emergency. While restlessness, headache, and vomiting are also symptoms of increased ICP, dilated non-reactive pupils signify a more advanced and life-threatening stage of brain compression.

Question 29: Which parameter best reflects the adequacy of oxygen delivery during resuscitation from shock?

Heart rate below 100 bpm
Blood pressure normalization
Central venous oxygen saturation (ScvO2) > 70% (Correct answer)
Urine output > 30 mL/hr alone

Correct answer: Central venous oxygen saturation (ScvO2) > 70%

ScvO2 > 70% indicates that tissues are receiving adequate oxygen relative to demand, reflecting successful resuscitation at the cellular level.

Question 30: A patient on telemetry suddenly reports chest pain and shortness of breath. What should the nurse do first?

Increase oxygen flow rate
Notify the physician
Assess vital signs and cardiac monitor (Correct answer)
Call respiratory therapy

Correct answer: Assess vital signs and cardiac monitor

When a patient on telemetry reports acute symptoms like chest pain and shortness of breath, the priority is to immediately assess their physiological status. This involves checking vital signs and observing the cardiac monitor for any changes, which provides critical information to guide subsequent interventions. This rapid assessment allows the nurse to determine the severity of the situation and initiate appropriate care.

Question 31: A progressive care nurse is caring for a patient who is 48 hours post-coronary artery bypass graft (CABG) surgery. The patient is hemodynamically stable and has been extubated. Which nursing intervention is crucial to prevent postoperative pulmonary complications?

Maintaining strict bed rest for 72 hours.
Encouraging the use of an incentive spirometer and splinting the incision when coughing. (Correct answer)
Administering cough suppressants to minimize incisional pain.
Limiting oral fluid intake to prevent fluid overload.

Correct answer: Encouraging the use of an incentive spirometer and splinting the incision when coughing.

Postoperative pulmonary complications, such as atelectasis and pneumonia, are significant risks after CABG surgery. Encouraging deep breathing and coughing is essential to keep the lungs clear. Using an incentive spirometer helps with deep breathing, and splinting the chest incision with a pillow provides support and reduces pain during coughing, making it more effective. Strict bed rest, cough suppression, and fluid restriction would increase the risk of pulmonary complications.

Question 32: A patient is admitted with acute decompensated heart failure (ADHF) and presents with dyspnea, orthopnea, and 3+ pitting edema in the lower extremities. The patient's blood pressure is 98/60 mmHg. Which of the following interventions is the priority for this patient?

Applying multi-layer compression wraps to the lower extremities.
Administering intravenous furosemide. (Correct answer)
Administering a bolus of intravenous normal saline.
Initiating an intravenous dobutamine infusion.

Correct answer: Administering intravenous furosemide.

The primary goal in treating acute decompensated heart failure with fluid overload is to reduce volume and relieve congestion. Intravenous loop diuretics, such as furosemide, are the first-line therapy to achieve this by promoting diuresis. Administering a fluid bolus would worsen the fluid overload. Compression wraps are contraindicated in hemodynamically unstable patients as they can shift fluid centrally and increase pulmonary congestion. While dobutamine (an inotrope) may be used if there is evidence of hypoperfusion, the initial priority is to address the severe fluid overload causing the patient's symptoms.

Question 33: Which ethical principle involves doing no harm to the patient?

Veracity
Autonomy
Nonmaleficence (Correct answer)
Justice

Correct answer: Nonmaleficence

Nonmaleficence is the ethical principle that means "do no harm." In nursing, this involves avoiding actions that could intentionally or unintentionally cause harm to a patient. It is a fundamental principle guiding all healthcare interventions and decisions, ensuring patient safety is prioritized.

Question 34: Which of the following pain scales is most appropriate for use with a nonverbal, intubated patient?

Numeric Rating Scale (NRS)
Visual Analog Scale (VAS)
Behavioral Pain Scale (BPS) (Correct answer)
Wong-Baker FACES scale

Correct answer: Behavioral Pain Scale (BPS)

The Behavioral Pain Scale (BPS) is specifically designed for assessing pain in critically ill, nonverbal, and intubated patients. It evaluates observable behaviors such as facial expression, upper limb movements, and compliance with ventilation, providing an objective measure of pain when self-report is not possible. Other scales require verbal or cognitive ability.

Question 35: What is the correct sequence for donning personal protective equipment (PPE)?

Gown, mask, goggles, gloves (Correct answer)
Gloves, gown, mask, goggles
Mask, gown, gloves, goggles
Gown, gloves, mask, goggles

Correct answer: Gown, mask, goggles, gloves

The correct sequence for donning personal protective equipment (PPE) is designed to protect the healthcare worker from contamination, starting with the body and moving to the hands. Donning the gown first covers the body, followed by the mask and goggles for facial protection, and finally gloves as the last barrier for direct contact. This order ensures maximum protection and minimizes self-contamination.

Question 36: A patient with aplastic anemia is in protective isolation. Which visitor instruction is most important?

Avoid visiting if experiencing any illness or infection (Correct answer)
Wear an N95 respirator when entering the room
Bring fresh flowers to improve patient mood
Limit visits to 30 minutes

Correct answer: Avoid visiting if experiencing any illness or infection

Visitors with any illness can transmit infection to an immunocompromised patient with aplastic anemia; exclusion of sick visitors is essential.

Question 37: Which blood product is most appropriate for a patient with hemophilia A experiencing an acute bleed?

Cryoprecipitate or Factor VIII concentrate (Correct answer)
Packed red blood cells
Fresh frozen plasma
Platelets

Correct answer: Cryoprecipitate or Factor VIII concentrate

Hemophilia A is caused by Factor VIII deficiency; cryoprecipitate or recombinant Factor VIII concentrate replaces the missing factor.

Question 38: Which of the following medications is classified as a beta-1 selective blocker and commonly used in heart failure management?

Propranolol
Metoprolol (Correct answer)
Labetalol
Carvedilol

Correct answer: Metoprolol

Metoprolol is a beta-1 selective blocker, meaning it primarily blocks beta-1 adrenergic receptors in the heart, reducing heart rate and myocardial contractility. This action helps to decrease myocardial oxygen demand and is beneficial in managing heart failure. Propranolol, carvedilol, and labetalol are non-selective or have additional alpha-blocking properties.

Question 39: Which of the following best describes the mechanism of action of ACE inhibitors?

Promotes reabsorption of sodium in renal tubules
Inhibits conversion of angiotensin I to angiotensin II (Correct answer)
Inhibits beta-adrenergic receptors
Blocks calcium channels in myocardial cells

Correct answer: Inhibits conversion of angiotensin I to angiotensin II

ACE inhibitors (Angiotensin-Converting Enzyme inhibitors) block the enzyme responsible for converting angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor and stimulates aldosterone release, so inhibiting its formation leads to vasodilation, reduced blood pressure, and decreased fluid retention. This mechanism makes them effective in treating hypertension and heart failure.

Question 40: A nurse caring for a patient with a nasogastric (NG) tube notes abdominal distention and high residual volumes. What is the priority nursing action?

Flush the NG tube with air
Position the patient in supine
Hold the feeding and notify the provider (Correct answer)
Increase the feeding rate

Correct answer: Hold the feeding and notify the provider

Abdominal distention and high residual volumes in a patient with an NG tube receiving feedings indicate delayed gastric emptying or intolerance to the feeding. Continuing the feeding could lead to aspiration, nausea, vomiting, or further abdominal discomfort. The priority is to stop the feeding to prevent complications and then notify the provider for further assessment and orders.

Question 41: Which laboratory finding is most consistent with disseminated intravascular coagulation (DIC)?

Normal PTT and low INR
Elevated fibrinogen and low D-dimer
Elevated platelets and normal PT
Low fibrinogen and elevated D-dimer (Correct answer)

Correct answer: Low fibrinogen and elevated D-dimer

DIC is characterized by consumption of clotting factors and fibrinogen, along with elevated D-dimer from fibrinolysis.

Question 42: The nurse is differentiating between delirium, dementia, and depression ('the 3 Ds') in a progressive care patient. Which feature is MOST characteristic of delirium compared to the other two?

Intact short-term memory with personality changes
Persistent low mood with anhedonia
Acute onset with fluctuating level of consciousness (Correct answer)
Gradual onset over months to years

Correct answer: Acute onset with fluctuating level of consciousness

Delirium is distinguished by its acute onset (hours to days), fluctuating course, and impaired consciousness, distinguishing it from the gradual progression of dementia and the mood-focused presentation of depression.

Question 43: Which condition is characterized by a sudden onset of sharp chest pain and dyspnea, often associated with a pneumothorax?

Pulmonary edema
Pleural effusion
Pulmonary embolism
Pneumothorax (Correct answer)

Correct answer: Pneumothorax

A pneumothorax is the presence of air in the pleural space, which causes the lung to collapse. This condition typically presents with a sudden onset of sharp, pleuritic chest pain (pain that worsens with breathing) and dyspnea (shortness of breath) as the lung's ability to expand is compromised. The other options have different primary presentations.

Question 44: A patient with crush injury from a building collapse develops tea-colored urine and rising creatinine. The nurse recognizes these findings as indicative of:

Hepatic failure
Rhabdomyolysis with acute kidney injury (Correct answer)
Urinary tract infection
Contrast-induced nephropathy

Correct answer: Rhabdomyolysis with acute kidney injury

Myoglobinuria from muscle breakdown causes tea-colored urine and tubular nephrotoxicity, leading to acute kidney injury in rhabdomyolysis.

Question 45: Which complication is most associated with persistent ST-segment elevation following a myocardial infarction?

Pericarditis
Complete heart block
Ventricular aneurysm (Correct answer)
Atrial fibrillation

Correct answer: Ventricular aneurysm

Persistent ST-segment elevation weeks or months after a myocardial infarction, especially in the same leads, is highly suggestive of a ventricular aneurysm. This complication occurs when the infarcted myocardial wall thins and bulges outward during systole. It can lead to heart failure, arrhythmias, and thrombus formation.

Question 46: Which intervention is a core component of sepsis bundle completion within 3 hours of identification?

Obtain blood cultures before antibiotics (Correct answer)
Perform a lumbar puncture
Initiate vasopressors immediately
Insert a central venous catheter

Correct answer: Obtain blood cultures before antibiotics

Obtaining blood cultures before antibiotic administration is a mandatory component of the Surviving Sepsis 1-hour bundle.

Question 47: A patient with atrial fibrillation is started on warfarin. What is the primary lab value used to monitor its therapeutic effect?

INR (Correct answer)
Fibrinogen level
Platelet count
aPTT

Correct answer: INR

The International Normalized Ratio (INR) is the standard laboratory test used to monitor the therapeutic effect of warfarin. It measures the extrinsic pathway of coagulation and helps ensure the patient's blood is adequately thinned to prevent clots without increasing the risk of bleeding. Maintaining the INR within the therapeutic range is crucial for patient safety and efficacy.

Question 48: A nurse is preparing to suction a patient’s endotracheal tube. What is the most appropriate action before suctioning?

Turn off the ventilator
Hyperoxygenate the patient (Correct answer)
Increase suction pressure to maximum
Instill normal saline into the airway

Correct answer: Hyperoxygenate the patient

Hyperoxygenating the patient before suctioning is a crucial step to prevent hypoxemia, which can occur during the procedure due to the removal of oxygen from the airway. This action helps to maintain adequate oxygen saturation and minimize the risk of complications such as arrhythmias or cardiac arrest. It ensures the patient has a reserve of oxygen during the temporary interruption of ventilation.

Question 49: When preparing to transfuse irradiated blood products, the nurse understands this measure prevents which complication?

Transfusion-associated graft-versus-host disease (Correct answer)
Allergic urticarial reaction
Febrile non-hemolytic reaction
Hyperkalemia

Correct answer: Transfusion-associated graft-versus-host disease

Irradiation inactivates donor T lymphocytes, preventing transfusion-associated graft-versus-host disease in immunocompromised patients.

Question 50: A 68-year-old male with a history of type 2 diabetes is admitted to the progressive care unit with altered mental status. His laboratory results show a blood glucose of 850 mg/dL, serum osmolality of 340 mOsm/kg, and a negative urine ketone test. Which of the following interventions is the highest priority?

Placing the patient on a cardiac monitor.
Initiating fluid resuscitation with an isotonic solution. (Correct answer)
Administering an intravenous insulin bolus.
Obtaining a STAT head CT scan.

Correct answer: Initiating fluid resuscitation with an isotonic solution.

The patient's presentation is consistent with Hyperosmolar Hyperglycemic State (HHS). The most critical initial intervention is aggressive fluid resuscitation to correct the profound dehydration and hyperosmolality, which are the primary causes of the altered mental status. While insulin will be administered, correcting the fluid deficit is the first priority to restore tissue perfusion.

Question 51: The nurse is assessing a patient for alcohol withdrawal using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Which finding would indicate the most severe level of withdrawal?

Moderate tremor and nausea with a score of 15
Severe agitation, hallucinations, and seizures with a score of 22 (Correct answer)
Mild diaphoresis and anxiety with a score of 8
Tachycardia and hypertension only with a score of 10

Correct answer: Severe agitation, hallucinations, and seizures with a score of 22

A CIWA-Ar score ≥20 indicates severe withdrawal requiring aggressive pharmacologic intervention; scores with seizures and hallucinations represent the highest risk category.

Question 52: A patient with liver cirrhosis is at risk for hepatic encephalopathy. Which assessment finding most supports this diagnosis?

Right upper quadrant pain
Hypoactive bowel sounds
Asterixis (flapping hand tremor) (Correct answer)
Clay-colored stools

Correct answer: Asterixis (flapping hand tremor)

Hepatic encephalopathy is a neurological complication of liver cirrhosis caused by the accumulation of toxins, primarily ammonia, in the bloodstream. Asterixis, often called a 'liver flap,' is a characteristic motor disturbance seen in patients with this condition. It indicates impaired neurological function due to the liver's inability to detoxify harmful substances.

Question 53: What is the most important early goal in managing hemorrhagic shock following trauma?

Insert a pulmonary artery catheter
Control the source of bleeding (Correct answer)
Administer high-dose corticosteroids
Achieve a MAP > 90 mmHg with crystalloid

Correct answer: Control the source of bleeding

Definitive hemorrhage control is the primary goal because ongoing blood loss cannot be corrected by fluid resuscitation alone.

Question 54: A nurse is caring for a patient with a chest tube. Which finding should be reported immediately?

Constant bubbling in the water seal chamber (Correct answer)
Intermittent tidaling in the water seal
Drainage of 50 mL serosanguinous fluid in 2 hours
Gentle bubbling in the suction chamber

Correct answer: Constant bubbling in the water seal chamber

Constant bubbling in the water seal chamber, especially if it's a new finding or persists after an initial air leak has resolved, indicates a persistent air leak in the chest tube system or from the patient's lung. This requires immediate investigation and intervention as it suggests ongoing air leakage from the pleural space or a problem with the tubing integrity. Gentle bubbling in the suction chamber is normal.

Question 55: A patient has a central venous catheter. Which sign most suggests a catheter-related bloodstream infection?

Tachypnea and wheezing
Edema around the insertion site
Phlebitis and vein discoloration
Fever with no obvious source (Correct answer)

Correct answer: Fever with no obvious source

Fever with no obvious source is a hallmark sign of a catheter-related bloodstream infection (CRBSI). While local signs like redness or edema can occur, a systemic fever without another identifiable cause strongly suggests that the central line is the source of infection. Prompt investigation and management are crucial to prevent severe sepsis.

Question 56: In a patient with chronic obstructive pulmonary disease (COPD), which symptom suggests the need for hospitalization?

Use of accessory muscles to breathe (Correct answer)
Dyspnea on exertion
Barrel-shaped chest
Cough with white sputum

Correct answer: Use of accessory muscles to breathe

The use of accessory muscles to breathe signifies increased work of breathing and severe respiratory distress, indicating a significant exacerbation of COPD. This symptom suggests that the patient's respiratory system is struggling to maintain adequate oxygenation and ventilation. It is a critical sign requiring immediate medical attention and likely hospitalization to prevent respiratory failure.

Question 57: A progressive care nurse is educating a patient being discharged after an asthma exacerbation. Which statement by the patient indicates a need for further teaching?

"I will use my albuterol inhaler 15 minutes before I exercise."
"If I feel short of breath, I will take my oral prednisone immediately." (Correct answer)
"I need to use my inhaled corticosteroid every day, even when I feel fine."
"I should use my rescue inhaler more often if my symptoms get worse."

Correct answer: "If I feel short of breath, I will take my oral prednisone immediately."

Oral corticosteroids like prednisone are not rescue medications for acute shortness of breath. They are used for managing more severe, prolonged exacerbations, typically as a prescribed tapering course. The patient should have a clear action plan that involves using their short-acting beta-agonist (rescue inhaler) for acute symptoms and seeking medical attention if symptoms do not improve. The other statements demonstrate correct understanding of asthma self-management.

Question 58: A patient with polycythemia vera is most at risk for which complication in the progressive care unit?

Severe anemia
Opportunistic infections
Thromboembolic events (Correct answer)
Spontaneous hemorrhage

Correct answer: Thromboembolic events

Polycythemia vera causes increased blood viscosity due to excess RBCs, significantly elevating risk for thrombosis and embolic events.

Question 59: A patient in obstructive shock due to a massive pulmonary embolism is hemodynamically unstable. The nurse anticipates which intervention?

Intravenous heparin and observation
Oral anticoagulation initiation
Systemic thrombolysis with alteplase (Correct answer)
Immediate surgical embolectomy

Correct answer: Systemic thrombolysis with alteplase

Massive PE with hemodynamic instability is an indication for systemic thrombolytic therapy to rapidly dissolve the clot and restore perfusion.

Question 60: A trauma patient develops hypotension, distended neck veins, and absent breath sounds on the left. The nurse should prepare for:

Endotracheal intubation
Needle decompression of the left chest (Correct answer)
Pericardiocentesis
Immediate blood transfusion

Correct answer: Needle decompression of the left chest

Absent breath sounds with hypotension and JVD after trauma indicates tension pneumothorax requiring emergency needle decompression.

Question 61: A nurse is caring for a patient experiencing opioid withdrawal. Which cluster of symptoms should the nurse expect?

Hypertension, fever, hallucinations, and seizures
Bradypnea, hypothermia, constipation, and euphoria
Bradycardia, hypotension, miosis, and sedation
Tachycardia, diaphoresis, piloerection, and yawning (Correct answer)

Correct answer: Tachycardia, diaphoresis, piloerection, and yawning

Opioid withdrawal produces a hyperadrenergic state characterized by tachycardia, diaphoresis, piloerection (goosebumps), yawning, lacrimation, and muscle aches.

Question 62: In monitoring a patient with a myocardial infarction, which cardiac marker rises first?

CK-MB
Troponin I
BNP
Myoglobin (Correct answer)

Correct answer: Myoglobin

Myoglobin is one of the earliest cardiac markers to rise following myocardial injury, typically within 1-4 hours after symptom onset. While it is sensitive for muscle damage, it is not specific to cardiac muscle. Troponin I and CK-MB rise later but are more specific for myocardial damage.

Question 63: Which action is appropriate when administering IV potassium chloride?

Use a central line for concentrations above 10 mEq/hr (Correct answer)
Administer via IV push for rapid replacement
Mix with dextrose 5% in water (D5W) only
Give with loop diuretics simultaneously

Correct answer: Use a central line for concentrations above 10 mEq/hr

Intravenous potassium chloride is a high-alert medication that can cause severe irritation and damage to peripheral veins, especially at higher concentrations or rapid infusion rates. Therefore, concentrations exceeding 10 mEq/hr are typically administered via a central venous catheter. This allows for greater dilution and minimizes the risk of phlebitis, pain, and tissue damage.

Question 64: A patient with MODS (multiple organ dysfunction syndrome) has the following: creatinine 3.1, bilirubin 4.2, PaO2/FiO2 ratio of 180, and GCS of 12. How many organ systems are affected?

Five
Four (Correct answer)
Three
Two

Correct answer: Four

Renal (creatinine), hepatic (bilirubin), pulmonary (PaO2/FiO2 < 300), and neurological (GCS) dysfunction indicate four organ systems are failing.

Question 65: A patient on heparin infusion has a PTT of 210 seconds (goal 60–100 seconds). What is the priority nursing action?

Hold the infusion and notify the provider (Correct answer)
Administer vitamin K
Increase the heparin rate
Obtain a platelet count only

Correct answer: Hold the infusion and notify the provider

A supratherapeutic PTT significantly above goal indicates over-anticoagulation; the infusion should be stopped and the provider notified immediately.

Question 66: The nurse is caring for a patient admitted with Diabetic Ketoacidosis (DKA). The initial potassium level was 5.8 mEq/L. After several hours of treatment with intravenous fluids and an insulin infusion, the patient's potassium level is now 3.2 mEq/L. What is the nurse's priority action?

Administer intravenous potassium as ordered. (Correct answer)
Administer a dose of sodium polystyrene sulfonate (Kayexalate).
Continue to monitor the patient without intervention.
Decrease the rate of the insulin infusion.

Correct answer: Administer intravenous potassium as ordered.

Insulin therapy in DKA drives potassium from the extracellular fluid into the cells, which can lead to a rapid drop in serum potassium levels and cause hypokalemia. A potassium level of 3.2 mEq/L is low and requires replacement to prevent cardiac dysrhythmias and other complications. Administering potassium is the priority.

Question 67: Which arterial blood gas (ABG) finding is most consistent with respiratory acidosis?

pH 7.32, PaCO₂ 50 mmHg (Correct answer)
pH 7.50, PaCO₂ 30 mmHg
pH 7.36, PaCO₂ 40 mmHg
pH 7.48, HCO₃ 30 mEq/L

Correct answer: pH 7.32, PaCO₂ 50 mmHg

Respiratory acidosis is characterized by a low pH (acidic) and an elevated PaCO₂ (carbon dioxide, which is an acid). In this option, the pH of 7.32 is acidic (normal 7.35-7.45), and the PaCO₂ of 50 mmHg is elevated (normal 35-45 mmHg). This combination directly indicates respiratory acidosis.

Question 68: Confidentiality is best maintained in the progressive care setting by:

Sharing information only with friends or family
Discussing patient cases during breaks in the lounge
Speaking quietly during handoff at the nurses' station (Correct answer)
Using only initials on whiteboards

Correct answer: Speaking quietly during handoff at the nurses' station

Maintaining patient confidentiality is paramount in healthcare. Speaking quietly during handoff reports at the nurses' station minimizes the risk of unauthorized individuals overhearing sensitive patient information. Discussing cases in public areas, using only initials, or sharing information with friends/family are breaches of confidentiality and HIPAA violations.

Question 69: Which action is most important when administering leukocyte-reduced blood products?

Ensure the product is used to prevent CMV transmission (Correct answer)
Administer slowly over 6 hours
Use a standard blood filter (170–260 microns)
Warm the blood to 40°C before infusion

Correct answer: Ensure the product is used to prevent CMV transmission

Leukocyte reduction reduces the risk of CMV transmission and febrile non-hemolytic reactions in at-risk patients.

Question 70: Which symptom is most specific for myocardial infarction (MI) in older adult women?

Bradycardia
Jaw pain and fatigue (Correct answer)
Crushing chest pain
Left arm numbness

Correct answer: Jaw pain and fatigue

Older adult women often experience atypical symptoms of myocardial infarction (MI) compared to the classic crushing chest pain. Their symptoms can be more subtle and non-specific, including unusual fatigue, shortness of breath, nausea, and pain in the jaw, neck, or back. Recognizing these atypical presentations is crucial for timely diagnosis and intervention in this population.

Question 71: Which electrolyte imbalance is most associated with mental status changes and muscle cramps?

Hypocalcemia
Hypernatremia
Hyponatremia (Correct answer)
Hyperkalemia

Correct answer: Hyponatremia

Hyponatremia, a low serum sodium level, significantly affects neurological function because sodium is critical for nerve impulse transmission and maintaining fluid balance in brain cells. Symptoms often include mental status changes such as confusion, lethargy, and disorientation, as well as muscle cramps, weakness, and seizures in severe cases.

Question 72: A patient is brought to the unit with suspected adrenal crisis (Addisonian crisis). Which of the following assessment findings would be most consistent with this diagnosis?

Tachycardia, hypertension, and hypercalcemia
Hypotension, hypoglycemia, and hyperkalemia (Correct answer)
Bradycardia, fluid overload, and hypokalemia
Hypertension, hyperglycemia, and hypernatremia

Correct answer: Hypotension, hypoglycemia, and hyperkalemia

Adrenal crisis is a life-threatening condition caused by an acute deficiency of cortisol. The classic presentation includes severe hypotension (due to loss of vascular tone and volume), hypoglycemia (due to decreased gluconeogenesis), and hyperkalemia (due to aldosterone deficiency).

Question 73: What is the primary action of nitroglycerin when used in acute coronary syndrome (ACS)?

Decreases heart rate
Increases myocardial oxygen demand
Dilates coronary arteries (Correct answer)
Promotes platelet aggregation

Correct answer: Dilates coronary arteries

Nitroglycerin primarily acts as a vasodilator, relaxing smooth muscle in both veins and arteries, including the coronary arteries. In acute coronary syndrome, this dilation increases blood flow to the ischemic myocardium, improving oxygen supply. It also reduces preload by venous dilation, which decreases myocardial oxygen demand.

Question 74: A nurse is providing culturally competent care to a patient from a culture where direct eye contact is considered disrespectful. Which approach should the nurse take?

Insist on eye contact to ensure the patient is engaged and understands instructions
Avoid all eye contact and communicate only through written materials
Adapt communication style to avoid prolonged direct eye contact while continuing to provide complete care (Correct answer)
Defer all communication to a family member who acts as a cultural intermediary

Correct answer: Adapt communication style to avoid prolonged direct eye contact while continuing to provide complete care

Culturally competent care requires adapting communication practices — including non-verbal behaviors like eye contact — to respect cultural norms while still providing complete, individualized patient care.

Question 75: Which of the following rhythms requires immediate defibrillation?

Second-degree AV block type II
Ventricular fibrillation (Correct answer)
Atrial flutter
Sinus tachycardia

Correct answer: Ventricular fibrillation

Ventricular fibrillation (VFib) is a chaotic, life-threatening arrhythmia characterized by disorganized electrical activity in the ventricles, leading to ineffective cardiac contraction and immediate loss of consciousness. Immediate defibrillation is crucial to terminate VFib and restore a perfusing rhythm, as it is a pulseless rhythm requiring immediate electrical intervention.

Question 76: What principle of ethical practice is demonstrated by respecting a patient’s right to refuse treatment?

Autonomy (Correct answer)
Nonmaleficence
Justice
Fidelity

Correct answer: Autonomy

Autonomy is the ethical principle that respects an individual's right to make their own decisions about their healthcare, free from coercion. Allowing a patient to refuse treatment, even if it goes against medical advice, upholds their right to self-determination and their personal values. This principle is fundamental to patient-centered care.

Question 77: A patient is prescribed a fentanyl patch for chronic pain. Which of the following instructions is most important?

Change the patch every 12 hours
Apply over broken skin for better absorption
Apply only to the upper chest
Avoid exposing the patch to heat (Correct answer)

Correct answer: Avoid exposing the patch to heat

Fentanyl patches release medication systemically, and heat (from heating pads, hot baths, or fever) can significantly increase the rate of fentanyl absorption. This accelerated absorption can lead to dangerously high serum fentanyl levels, increasing the risk of severe respiratory depression and overdose. Patients must be educated to avoid heat exposure to the patch.

Question 78: Which laboratory result requires immediate reporting in a patient suspected of having thrombotic thrombocytopenic purpura (TTP)?

Hemoglobin of 11 g/dL
BUN of 22 mg/dL
Platelet count of 150,000/mm³
Peripheral smear showing schistocytes (Correct answer)

Correct answer: Peripheral smear showing schistocytes

Schistocytes (fragmented RBCs) on peripheral smear indicate microangiopathic hemolytic anemia, a hallmark finding of TTP.

Question 79: A patient with a history of adrenal insufficiency presents with hypotension, weakness, and hyperpigmentation. What is the likely diagnosis?

Addisonian crisis (Correct answer)
Myxedema coma
Cushing syndrome
Graves’ disease

Correct answer: Addisonian crisis

Addisonian crisis is a severe, life-threatening emergency caused by acute adrenal insufficiency. The classic symptoms of hypotension, weakness, and hyperpigmentation, especially in a patient with a history of adrenal insufficiency, are indicative of this condition. These manifestations result from critical deficiencies in cortisol and aldosterone, leading to circulatory collapse and electrolyte imbalances.

Question 80: Which action best reflects the ethical principle of justice in nursing?

Spending more time with the most agreeable patient
Providing equal care and resources to all patients (Correct answer)
Prioritizing care based on who arrives first
Choosing to help the family of a VIP patient first

Correct answer: Providing equal care and resources to all patients

The ethical principle of justice in nursing dictates that all patients should receive fair and equitable care, regardless of their background, socioeconomic status, or personal characteristics. This means distributing resources and care impartially and without discrimination. Prioritizing based on personal preference or arrival time does not align with justice.

Question 81: A patient receiving morphine sulfate IV begins to experience respiratory depression. What is the most appropriate immediate intervention?

Administer naloxone (Correct answer)
Reposition the patient and observe
Place in Trendelenburg position
Increase IV fluid rate

Correct answer: Administer naloxone

Morphine sulfate is an opioid analgesic, and respiratory depression is a serious adverse effect. Naloxone is an opioid antagonist that rapidly reverses the effects of opioids by competing for receptor sites. Administering naloxone is the immediate and most appropriate intervention to counteract life-threatening respiratory depression.

Question 82: A nurse forgets to document a dose of medication but gave it. What is the appropriate action?

Alter the MAR to show it was given earlier
Chart a late entry with the correct time and explanation (Correct answer)
Create a new entry with the current time
Ignore it to avoid getting in trouble

Correct answer: Chart a late entry with the correct time and explanation

If a medication was given but not documented, the nurse must make a late entry in the patient's chart. This entry should accurately reflect the time the medication was administered and include an concise explanation for the delay in documentation. This ensures the medical record is accurate and complete, reflecting the actual care provided and maintaining legal integrity.

Question 83: Which assessment finding indicates the progressive care patient with systemic inflammatory response is developing organ hypoperfusion?

Temperature of 38.4°C
Urine output of 0.3 mL/kg/hr for 3 hours (Correct answer)
Heart rate of 96 bpm
WBC of 13,000/mm³

Correct answer: Urine output of 0.3 mL/kg/hr for 3 hours

Oliguria (< 0.5 mL/kg/hr) is an early indicator of renal hypoperfusion and impending organ dysfunction in sepsis.

Question 84: A patient with asthma is experiencing wheezing and shortness of breath. Which medication should the nurse expect to administer first?

Montelukast
Oral leukotriene inhibitor
Inhaled corticosteroid
Albuterol nebulizer (Correct answer)

Correct answer: Albuterol nebulizer

Albuterol is a short-acting beta-2 agonist (SABA) and a bronchodilator. It works rapidly to relax the smooth muscles of the airways, opening them up and relieving acute symptoms like wheezing and shortness of breath during an asthma exacerbation. It is considered a 'rescue' medication and is the first-line treatment for acute asthma attacks.

Question 85: Which sign is most associated with increased intracranial pressure (ICP)?

Hypotension
Tachycardia
Widening pulse pressure and bradycardia (Correct answer)
Diaphoresis

Correct answer: Widening pulse pressure and bradycardia

Widening pulse pressure and bradycardia are two key components of Cushing's triad, which is a classic physiological response to increased intracranial pressure (ICP). Cushing's triad also includes irregular respirations. These signs indicate the body's attempt to maintain cerebral perfusion in the face of rising ICP, making them critical indicators of neurological deterioration.

Question 86: A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation with a low tidal volume strategy. What is the primary rationale for this intervention?

To reduce the risk of barotrauma and volutrauma. (Correct answer)
To facilitate sedation and neuromuscular blockade.
To prevent hypotension and cardiovascular collapse.
To decrease the patient's work of breathing and improve comfort.

Correct answer: To reduce the risk of barotrauma and volutrauma.

The primary goal of a low tidal volume ventilation strategy (typically 4-8 mL/kg of predicted body weight) in ARDS is to minimize ventilator-induced lung injury (VILI). High tidal volumes can overdistend and injure the less-affected alveoli, leading to volutrauma and barotrauma. Keeping plateau pressures below 30 cm H2O is a key component of this protective strategy.

Question 87: A patient is admitted with acute decompensated heart failure. Which medication class is most appropriate to reduce preload and relieve pulmonary congestion?

Loop diuretics (Correct answer)
Beta blockers
ACE inhibitors
Calcium channel blockers

Correct answer: Loop diuretics

Loop diuretics, such as furosemide, are highly effective in acute decompensated heart failure because they promote rapid diuresis. By inhibiting sodium and chloride reabsorption in the loop of Henle, they reduce circulating blood volume. This action directly decreases preload and alleviates pulmonary congestion, which are key goals in managing acute heart failure.

Question 88: Which of the following is a key nursing intervention for a patient admitted with a suspected pulmonary embolism (PE)?

Placing the patient in a high Fowler's position. (Correct answer)
Administering anticoagulation therapy as ordered.
Encouraging frequent ambulation to improve circulation.
Initiating a fluid bolus to improve cardiac output.

Correct answer: Placing the patient in a high Fowler's position.

Placing the patient in a high Fowler's position helps to maximize chest expansion and alleviate dyspnea, which is a common and distressing symptom of a pulmonary embolism. While anticoagulation is the cornerstone of treatment, immediate positioning to improve breathing is a critical initial nursing action. Ambulation is contraindicated as it could dislodge more clots. Fluid boluses should be given with caution as they can worsen right ventricular strain.

Question 89: A patient with a spinal cord injury at the level of T4 is at risk for which potentially life-threatening complication?

Seizures
Cerebral aneurysm
Autonomic dysreflexia (Correct answer)
Brain herniation

Correct answer: Autonomic dysreflexia

Autonomic dysreflexia is a potentially life-threatening condition that can occur in patients with spinal cord injuries at or above T6. It is characterized by an exaggerated sympathetic response to noxious stimuli below the level of injury, leading to severe hypertension, bradycardia, and headache. A T4 injury places the patient at high risk for this emergency, requiring immediate recognition and management.

Question 90: A patient in the progressive care unit develops an acute kidney injury (AKI) following a severe hypotensive episode. Their urine output is 20 mL/hr, BUN is 45 mg/dL, and creatinine is 2.8 mg/dL. Which classification of AKI is most likely?

Chronic
Intrarenal
Prerenal (Correct answer)
Postrenal

Correct answer: Prerenal

Prerenal AKI is caused by decreased blood flow to the kidneys. A severe hypotensive episode leads to renal hypoperfusion. This is characterized by a high BUN to creatinine ratio (in this case >20:1 is suggested but not explicitly calculated without a baseline) and oliguria, as the kidneys attempt to conserve volume.

Question 91: Which of the following best reflects proper technique when inserting an indwelling urinary catheter in a female patient?

Insert catheter 1 inch beyond urine flow return
Use clean gloves and clean technique
Inflate the balloon before advancing the catheter
Use sterile gloves and sterile technique (Correct answer)

Correct answer: Use sterile gloves and sterile technique

Inserting an indwelling urinary catheter is a sterile procedure that requires the use of sterile gloves and strict sterile technique. This is crucial to prevent the introduction of microorganisms into the urinary tract, thereby minimizing the risk of catheter-associated urinary tract infections (CAUTIs). Maintaining sterility throughout the procedure is paramount for patient safety.

Question 92: A nurse assesses a tracheostomy patient and notes a sudden drop in oxygen saturation and the sound of air escaping. What should the nurse suspect?

Tracheal stenosis
Cuff leak or tracheostomy dislodgement (Correct answer)
Mucus plug
Bronchospasm

Correct answer: Cuff leak or tracheostomy dislodgement

A sudden drop in oxygen saturation combined with the sound of air escaping around a tracheostomy tube strongly suggests a problem with the cuff or the tube's position. A cuff leak means air is escaping past the cuff instead of going into the lungs, reducing ventilation. Dislodgement means the tube is no longer correctly positioned in the trachea, leading to ineffective ventilation and air leakage, both requiring immediate intervention.

Question 93: Post-intensive care syndrome (PICS) includes which combination of long-term sequelae that progressive care nurses should educate patients and families about?

Cognitive impairment, psychological disturbances (PTSD/depression/anxiety), and physical weakness (Correct answer)
Cardiac arrhythmias, neuropathy, and visual changes
Chronic pain, insomnia, and weight gain only
Hypertension, diabetes, and renal failure

Correct answer: Cognitive impairment, psychological disturbances (PTSD/depression/anxiety), and physical weakness

PICS encompasses a constellation of new or worsening impairments in cognitive function, mental health (PTSD, depression, anxiety), and physical/functional status that persist after critical illness.

Question 94: Which clinical finding is most indicative of heparin-induced thrombocytopenia (HIT)?

Platelet count drop of >50% after 5–14 days of heparin (Correct answer)
Platelet count of 400,000/mm³
Immediate platelet drop after first heparin dose
Bleeding from IV sites within 24 hours

Correct answer: Platelet count drop of >50% after 5–14 days of heparin

HIT classically presents with a >50% decline in platelets occurring 5–14 days after heparin exposure due to antibody formation.

Question 95: A 68-year-old male with a history of heart failure is admitted with a diagnosis of community-acquired pneumonia. He presents with a productive cough, fever of 38.9°C, and crackles in the right lower lobe. Which of the following orders should the nurse prioritize?

Obtain blood and sputum cultures.
Administer intravenous antibiotics.
Administer PRN antipyretics.
Titrate oxygen to maintain SpO2 > 92%. (Correct answer)

Correct answer: Titrate oxygen to maintain SpO2 > 92%.

While all orders are important, ensuring adequate oxygenation is the immediate priority according to the ABCs (Airway, Breathing, Circulation). Hypoxia is a common and life-threatening complication of pneumonia. Once oxygenation is stabilized, the nurse should proceed with obtaining cultures before administering antibiotics to ensure the correct pathogen is identified.

Question 96: A nurse notices that a colleague is documenting vital signs without actually taking them. What is the most appropriate first step?

Report the behavior to the nurse manager (Correct answer)
Confront the colleague in front of others
Ignore the situation
Document your own vital signs over theirs

Correct answer: Report the behavior to the nurse manager

Falsifying documentation is a serious breach of professional ethics and patient safety. The most appropriate first step is to report the behavior to the nurse manager, who has the authority and responsibility to address such misconduct. This ensures patient safety is maintained and professional standards are upheld, without directly confronting the colleague in a potentially unprofessional manner.

Question 97: Which of the following medication classes is considered first-line for rate control in a stable patient newly diagnosed with atrial fibrillation and a rapid ventricular response?

Amiodarone
Sodium channel blockers
Beta-blockers (Correct answer)
Digoxin

Correct answer: Beta-blockers

For stable patients with atrial fibrillation and a rapid ventricular response, beta-blockers (e.g., metoprolol) or non-dihydropyridine calcium channel blockers (e.g., diltiazem) are recommended as first-line agents for rate control. Amiodarone is typically used for rhythm control or in specific situations like heart failure. Digoxin is generally considered a second-line agent as it is less effective at controlling heart rate during exercise. Sodium channel blockers are used for rhythm control, not rate control.

Question 98: Which cranial nerve is responsible for pupillary constriction in response to light?

Cranial Nerve III (Oculomotor) (Correct answer)
Cranial Nerve V (Trigeminal)
Cranial Nerve II (Optic)
Cranial Nerve VII (Facial)

Correct answer: Cranial Nerve III (Oculomotor)

Cranial Nerve III, the Oculomotor nerve, is responsible for several eye movements, including pupillary constriction (miosis) in response to light. It carries parasympathetic fibers that innervate the sphincter pupillae muscle, causing the pupil to constrict. Cranial Nerve II (Optic) is responsible for vision, but not the motor function of pupillary constriction.

Question 99: A progressive care patient becomes acutely agitated, is pulling at lines, and poses a safety risk. Before applying physical restraints, the nurse should FIRST:

Administer IV haloperidol without waiting for a physician order in an emergency
Attempt less restrictive alternatives such as re-orientation, removing triggers, and involving family (Correct answer)
Obtain a physician's order and apply four-point restraints immediately
Document the behavior and consult psychiatry before taking any action

Correct answer: Attempt less restrictive alternatives such as re-orientation, removing triggers, and involving family

The least-restrictive approach must be attempted before restraints; non-pharmacologic de-escalation techniques including reorientation, removing offending stimuli, and family presence should be tried first.

Question 100: A progressive care patient meets SIRS criteria and has a suspected infection. According to current definitions, this patient has:

Sepsis (Correct answer)
Septic shock
Bacteremia
SIRS without sepsis

Correct answer: Sepsis

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection; SIRS + infection meets the older sepsis definition and warrants treatment.

Question 101: A patient receiving IV heparin has an aPTT that is significantly above the therapeutic range. What is the appropriate reversal agent?

Protamine sulfate (Correct answer)
Desmopressin
Fresh frozen plasma
Vitamin K

Correct answer: Protamine sulfate

Protamine sulfate is the specific antidote for heparin overdose. It works by forming a stable complex with heparin, neutralizing its anticoagulant effects. When a patient's aPTT is significantly elevated above the therapeutic range, indicating excessive anticoagulation, protamine sulfate is administered to reverse the effects and reduce bleeding risk.

Question 102: A progressive care patient has a platelet count of 18,000/mm³. Which intervention is the highest priority?

Administer aspirin for pain
Encourage ambulation
Initiate bleeding precautions (Correct answer)
Apply compression stockings

Correct answer: Initiate bleeding precautions

A platelet count below 20,000/mm³ carries a high risk of spontaneous bleeding, requiring immediate bleeding precautions.

Question 103: A patient is admitted with a diagnosis of Syndrome of Inappropriate Antidiuretic Hormone (SIADH). The nurse would expect which of the following laboratory findings?

Hyponatremia and decreased serum osmolality (Correct answer)
Hyponatremia and increased serum osmolality
Hypernatremia and decreased serum osmolality
Hypernatremia and increased serum osmolality

Correct answer: Hyponatremia and decreased serum osmolality

In SIADH, there is an excessive release of antidiuretic hormone (ADH), leading to water retention by the kidneys. This results in a dilutional hyponatremia (low serum sodium) and a decreased serum osmolality because the excess water dilutes the blood solutes.

Question 104: What is the primary concern when administering IV potassium chloride to a patient?

Nausea and vomiting
Renal insufficiency
Hypotension
Arrhythmias (Correct answer)

Correct answer: Arrhythmias

Administering IV potassium chloride too rapidly or in excessive amounts can lead to hyperkalemia, which significantly affects cardiac electrical activity. This can cause life-threatening arrhythmias, including bradycardia, heart block, and even cardiac arrest. Therefore, it must be administered slowly and carefully, often diluted, with close cardiac monitoring.

Question 105: Which hemodynamic profile is characteristic of early distributive (septic) shock?

High SVR, low CO, high PCWP
High SVR, high CO, normal PCWP
Low SVR, low CO, high PCWP
Low SVR, high CO, low PCWP (Correct answer)

Correct answer: Low SVR, high CO, low PCWP

Septic shock causes vasodilation (low SVR), compensatory high cardiac output, and low filling pressures (low PCWP) in early stages.

Question 106: A patient in neurogenic shock following a cervical spine injury presents with hypotension and bradycardia. This pattern is caused by:

Loss of sympathetic nervous system tone below injury level (Correct answer)
Increased intracranial pressure
Massive hemorrhage from cord injury
Parasympathetic overstimulation due to pain

Correct answer: Loss of sympathetic nervous system tone below injury level

Cervical cord injury disrupts sympathetic outflow, causing loss of vasomotor tone and cardiac acceleration, resulting in hypotension and bradycardia.

Question 107: A nurse is caring for a patient who was recently extubated after several days of mechanical ventilation. Which of the following parameters is the BEST indicator of the patient's readiness to be weaned from mechanical ventilation?

Maximal inspiratory pressure (MIP) of -20 cm H2O
A rapid shallow breathing index (RSBI) of 95 (Correct answer)
Tidal volume of 450 mL with a respiratory rate of 18 breaths/min
PaO2 of 85 mmHg on FiO2 of 40%

Correct answer: A rapid shallow breathing index (RSBI) of 95

The rapid shallow breathing index (RSBI), which is the ratio of respiratory frequency to tidal volume (f/VT), is a strong predictor of weaning success. An RSBI of less than 105 is a commonly accepted parameter indicating that a patient is likely to be successfully weaned. The other values, while important, are not as comprehensively predictive as the RSBI.

Question 108: Which finding is most consistent with a left hemispheric stroke?

Left-sided weakness and visual neglect
Intact speech with right-sided weakness
Impulsive behavior and neglect
Right-sided hemiparesis and aphasia (Correct answer)

Correct answer: Right-sided hemiparesis and aphasia

The left cerebral hemisphere controls the right side of the body and is typically dominant for language in most individuals. Therefore, a left hemispheric stroke commonly results in right-sided weakness or paralysis (hemiparesis/hemiplegia) and language disturbances such as aphasia (difficulty with speech or understanding). This pattern of deficits helps localize the stroke to the left hemisphere.

Question 109: A patient receiving multiple blood transfusions develops hypocalcemia. The nurse recognizes this is caused by:

Citrate preservative in stored blood chelating calcium (Correct answer)
Dilution of plasma proteins
Excess calcium binding by albumin in stored blood
Hemolysis releasing excess potassium

Correct answer: Citrate preservative in stored blood chelating calcium

Citrate is used as a preservative in stored blood and chelates (binds) free calcium, causing hypocalcemia with massive transfusions.

Question 110: A patient receiving heparin begins to develop signs of heparin-induced thrombocytopenia (HIT). What is the most appropriate action?

Increase the heparin dose
Discontinue heparin and notify the provider (Correct answer)
Administer vitamin K
Administer platelet transfusion

Correct answer: Discontinue heparin and notify the provider

If a patient develops signs of heparin-induced thrombocytopenia (HIT), such as a significant drop in platelet count or new thrombosis, the most appropriate and immediate action is to discontinue all heparin products. Notifying the provider is crucial for initiating alternative anticoagulation and further management, as HIT is a serious, potentially life-threatening condition.

Question 111: What is the most appropriate intervention for a patient in atrial fibrillation with a rapid ventricular response and signs of hemodynamic instability?

Administer digoxin
Initiate synchronized cardioversion (Correct answer)
Start metoprolol IV drip
Perform carotid sinus massage

Correct answer: Initiate synchronized cardioversion

For a patient in atrial fibrillation with a rapid ventricular response who is hemodynamically unstable (e.g., hypotension, altered mental status), immediate synchronized cardioversion is the most appropriate intervention. This electrical therapy rapidly converts the rhythm to restore hemodynamic stability. Medications are used for rate control in stable patients, not for unstable rhythms.

Question 112: Which intervention best addresses sleep deprivation in a progressive care patient?

Encouraging napping throughout the day to make up for nighttime disruptions
Restricting family visitation during evening hours only
Clustering care activities, minimizing nighttime interruptions, and reducing lighting and noise at night (Correct answer)
Administering nightly sedative-hypnotics routinely for all patients

Correct answer: Clustering care activities, minimizing nighttime interruptions, and reducing lighting and noise at night

Evidence-based sleep promotion bundles in the PCU include clustering care to reduce overnight interruptions, lowering light and noise levels at night, and minimizing unnecessary monitoring, which prevents delirium and promotes recovery.

Question 113: A patient recovering from septic shock develops bilateral pulmonary infiltrates, PaO2/FiO2 ratio of 150, and respiratory failure without cardiac cause. The nurse recognizes this as:

Cardiogenic pulmonary edema
Hospital-acquired pneumonia
Acute respiratory distress syndrome (ARDS) (Correct answer)
Pulmonary embolism

Correct answer: Acute respiratory distress syndrome (ARDS)

Bilateral infiltrates, severe hypoxemia (P/F < 200), and non-cardiac etiology following sepsis meet the Berlin criteria for ARDS.

Question 114: What is the priority nursing action after inserting a nasogastric (NG) tube for feeding?

Confirm placement with an abdominal X-ray (Correct answer)
Clamp the tube and reassess in 30 minutes
Start the feeding immediately
Ask the patient if they can feel the tube in their throat

Correct answer: Confirm placement with an abdominal X-ray

Confirming nasogastric (NG) tube placement with an abdominal X-ray is the most reliable and gold standard method to ensure the tube is correctly positioned in the stomach or small intestine. This critical step prevents serious complications such as aspiration pneumonia if the tube were inadvertently placed in the lungs. Never initiate feeding until placement is radiographically confirmed.

Question 115: Which clinical manifestation is most concerning in a patient with suspected sepsis?

White blood cell count of 11,000/mm³
Heart rate of 88 bpm
Warm, flushed skin
Blood pressure 86/52 mmHg (Correct answer)

Correct answer: Blood pressure 86/52 mmHg

A blood pressure of 86/52 mmHg indicates hypotension, which is a critical sign of septic shock. Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Hypotension in sepsis signifies inadequate tissue perfusion and is a medical emergency requiring immediate fluid resuscitation and vasopressors to prevent irreversible organ damage and death.

Question 116: Which assessment tool is specifically validated for measuring delirium in acute care settings?

Confusion Assessment Method (CAM) (Correct answer)
Montreal Cognitive Assessment (MoCA)
Glasgow Coma Scale (GCS)
Mini-Mental State Examination (MMSE)

Correct answer: Confusion Assessment Method (CAM)

The Confusion Assessment Method (CAM) is the gold-standard validated tool for delirium assessment in acute/progressive care; the CAM-ICU is adapted for non-verbal/intubated patients.

Question 117: A patient with a known seizure disorder experiences a tonic-clonic seizure lasting 8 minutes. What is the priority nursing action?

Apply soft wrist restraints
Prepare for lumbar puncture
Record the seizure activity in the chart
Administer IV lorazepam (Correct answer)

Correct answer: Administer IV lorazepam

A tonic-clonic seizure lasting 8 minutes is considered status epilepticus, a medical emergency requiring immediate intervention to prevent brain damage. IV lorazepam is a benzodiazepine that is the first-line treatment to abort prolonged seizures by enhancing GABAergic inhibition in the brain. Administering it promptly is the priority to stop the seizure activity.

Question 118: Which action by the nurse demonstrates advocacy for a critically ill patient?

Communicating the patient’s wishes to the care team (Correct answer)
Reassuring the patient’s family that everything is fine
Administering medications on time
Avoiding conflict with the healthcare provider

Correct answer: Communicating the patient’s wishes to the care team

Patient advocacy involves speaking up for the patient, ensuring their rights are respected, and their needs and wishes are communicated effectively to the healthcare team. This empowers the patient, especially when they are critically ill and may not be able to advocate for themselves. Administering medications or reassuring family are important but do not solely define advocacy.

Question 119: Which breath sound is most commonly associated with fluid in the alveoli?

Rhonchi
Fine crackles (Correct answer)
Stridor
Wheezes

Correct answer: Fine crackles

Fine crackles, also known as rales, are short, high-pitched, popping sounds heard during inspiration. They are produced when collapsed alveoli or small airways suddenly open, often due to the presence of fluid. This makes them a characteristic finding in conditions like pulmonary edema or pneumonia where fluid accumulates in the alveoli.

Question 120: Which lactate level is most consistent with significant tissue hypoperfusion in a critically ill patient?

4.5 mmol/L (Correct answer)
0.8 mmol/L
1.5 mmol/L
2.2 mmol/L

Correct answer: 4.5 mmol/L

A lactate ≥ 4 mmol/L indicates severe tissue hypoperfusion and is associated with increased mortality, meeting the threshold for septic shock workup.

Question 121: A patient returns to the progressive care unit after a percutaneous coronary intervention (PCI) via the right radial artery. Which of the following assessment findings requires immediate nursing intervention?

The patient reports a pain level of 2/10 at the access site.
A small amount of bruising is noted around the insertion site.
The patient complains of numbness and tingling in the right fingers. (Correct answer)
Capillary refill in the right hand is less than 3 seconds.

Correct answer: The patient complains of numbness and tingling in the right fingers.

Numbness and tingling in the affected extremity after a radial artery PCI can indicate nerve compromise or impaired circulation, possibly due to hematoma formation or nerve compression. This is a serious complication that requires immediate assessment and intervention to prevent permanent damage. Mild pain, brisk capillary refill, and minor bruising are expected findings after this procedure.

Question 122: Which of the following best describes the nurse's role in supporting a patient's spiritual needs in the progressive care setting?

Providing direct spiritual guidance and counseling based on the nurse's own religious beliefs
Assessing spiritual needs, facilitating access to chaplaincy services, and respecting the patient's beliefs without imposing the nurse's own (Correct answer)
Avoiding spiritual topics to maintain professional boundaries
Referring all spiritual concerns to the patient's family to handle outside the hospital

Correct answer: Assessing spiritual needs, facilitating access to chaplaincy services, and respecting the patient's beliefs without imposing the nurse's own

Nurses assess and acknowledge spiritual needs using open, non-judgmental approaches and facilitate chaplaincy or other appropriate resources while respecting the patient's beliefs without imposing personal views.

Question 123: What is the primary goal of thrombolytic therapy in patients with acute myocardial infarction (MI)?

Prevent platelet aggregation
Dissolve the existing blood clot (Correct answer)
Decrease heart rate
Reduce myocardial oxygen demand

Correct answer: Dissolve the existing blood clot

The primary goal of thrombolytic therapy in acute myocardial infarction (MI) is to dissolve the blood clot (thrombus) that is obstructing blood flow in the coronary artery. By restoring blood flow (reperfusion) to the ischemic myocardial tissue, thrombolytics aim to limit infarct size, preserve cardiac function, and improve patient outcomes.

Question 124: Which medication is used to reverse the anticoagulant effects of warfarin in case of major bleeding?

Protamine sulfate
Idarucizumab
Vitamin K (Correct answer)
Vitamin D

Correct answer: Vitamin K

Warfarin is an anticoagulant that works by inhibiting vitamin K-dependent clotting factors. Therefore, in cases of major bleeding or significant overdose, administering Vitamin K (phytonadione) can reverse its anticoagulant effects by promoting the synthesis of these clotting factors. Protamine sulfate reverses heparin, and idarucizumab reverses dabigatran.

Question 125: Which of the following is a key differentiating feature between Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS)?

The degree of hyperglycemia
The level of consciousness
The presence of significant ketosis and metabolic acidosis (Correct answer)
The presence of severe dehydration

Correct answer: The presence of significant ketosis and metabolic acidosis

While both DKA and HHS involve hyperglycemia and dehydration, the hallmark of DKA is the presence of significant ketosis (leading to ketone bodies in the blood and urine) and a subsequent metabolic acidosis. In HHS, there is enough insulin to prevent ketosis, but not enough to prevent severe hyperglycemia.

PCCN® Exam (Progressive Care Certified Nurse)

The PCCN® exam certifies registered nurses who provide direct care to acutely ill adult patients in progressive care, telemetry, and other intermediate care settings.

125

Questions

150 min

Time Limit

69%

To Pass

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