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Instructions
This posttest has been designed to evaluate your readiness to take the certifica- tion examination for critical care nursing. Similar in form and content to the ac- tual examination, the posttest consists of 50 questions based on brief clinical situations. The questions will help sharpen your test-taking skills while assess- ing your knowledge of critical care nursing theory and practice.
Allow yourself 50 minutes to complete this posttest. To improve your chances for performing well, consider these suggestions:
● Read each clinical situation closely. Weigh the four options carefully, and then select the option that best answers the question. (Note: In this posttest, op- tions are lettered A, B, C, and D to aid in later identification of correct answers and rationales. These letters don’t appear on the certification examination.)
● If you have difficulty understanding a question or are unsure of the answer, mark it and, if time permits, return to it later. (For the actual examination, the computer tutorial will provide complete instructions on how to take the exami- nation, including how to select an answer, change it, or mark it for later re- view.)
● If you have no idea of the correct answer, make an educated guess. (Only correct answers are counted in scoring the certification examination.)
After you complete the posttest, or after the 50-minute time limit expires, check your responses against the correct answers and rationales provided on pages 302 to 308.
Now, select a quiet room where you’ll be undisturbed, set a timer for 50 minutes, and begin.
Questions
1. A patient is admitted to the surgical intensive care unit (ICU) with a sus- pected bowel obstruction. In performing the initial assessment, the nurse knows that auscultation of the abdomen:
A. should be performed after palpation.
B. is best done with the bell of the stethoscope.
C. should reveal hyperactive sounds above the obstruction and absent sounds below the obstruction.
D. should be performed after percussion.
2. A 36-year-old man who has had hypertension for 4 years was brought by family members to the emergency department. The patient complains of chest pain that is unrelieved by nitroglycerin. He states that he has had the pain for 3 hours and rates the pain at 8 on a scale of 1 to 10. His blood pressure is 178/98 mm Hg; heart rate, 116 beats/minute; respiratory rate, 26 breaths/
minute; and temperature, 98.9 F (37.2 C). A 12-lead electrocardiogram (ECG) shows an elevated ST segment in leads II, III and AVF. The medical diagnosis is myocardial infarction (MI). The physician orders O2by nasal cannula at 4 L/
minute nitroglycerin I.V. infusion titrated to a systolic blood pressure of 90 mm Hg and pain relief, tissue plasminogen activator (TPA) 100 mg over 3 hours (60 mg in the first hour, 20 mg/hour for the next two hours) followed by a heparin I.V. infusion to run at 1,000 U/hour, and morphine sulfate 2 to 4 mg slow I.V. push every 2 to 4 hours as needed for chest pain. Which of the follow- ing indicates that the TPA therapy is effective?
A. Prothrombin time/partial thromboplastin time ratio (PT/PTT) 2.5 times greater than normal
B. Relief of chest pain
C. Few premature ventricular contractions and a return of the ST seg- ment to normal
D. Blood pressure 120/85 mm Hg and heart rate 86 beats/minute 3. During an initial assessment, the nurse notices that the patient’s arterial systolic blood pressure decreases by 14 mm Hg on inspiration. When docu- menting this change, the nurse should note this drop as:
A. pulsus magnus.
B. pulsus alternans.
C. pulsus parvus.
D. pulsus paradoxus.
4. An unconscious patient is admitted to the emergency department (ED), and the nurse suspects an upper airway obstruction. What is the best initial action for the nurse to take?
A. Perform deep tracheal suctioning.
B. Begin mechanical ventilation.
C. Tilt the patient’s head and do a chin lift.
D. Perform 6 to 10 upward abdominal thrusts.
5. A 67-year-old woman is admitted to the ICU in a severely obtunded state.
She withdraws from painful stimuli and exhibits random movement of all ex- tremities. Her potassium level is 4.6 mEq/L; sodium, 135 mEq/L; hematocrit (HCT), 46%; blood urea nitrogen (BUN)–creatinine ratio, 46:2.1; and plasma glucose, 1,099 mg/dl. Arterial blood gas (ABG) values include pH, 7.31;, partial pressure of oxygen (PaO2). 92 mm Hg; partial pressure of arterial carbon diox- ide (PaCO2), 30 mm Hg; and HCO3–, 20 mEq/L. A medical diagnosis of hyper- osmolar hyperglycemic nonketotic syndrome (HHNS) is made. Which under- lying diagnosis places the patient at greatest risk of developing HHNS?
A. Insulin-dependent (type I) diabetes mellitus
B. Non-insulin-dependent (type II) diabetes mellitus
C. Long-term exogenous corticosteroid use
D. Chronic renal failure
6. A female patient is placed on oxygen via nasal cannula at a rate of 5 L/minute, with orders for repeat ABG sampling and serum glucose and electrolyte mea- surements in 1 hour. Urine output has dropped to 30 ml for the past hour, and the patient’s current blood pressure is 94/48 mm Hg. Which intervention should the nurse plan for this patient?
A. Potent diuretic therapy to increase urine flow.
B. Administration of large volumes of I.V. hypertonic solutions to in- crease urine flow.
C. Administration of large volumes of I.V. isotonic solutions, hypotonic solutions, or plasma expanders to increase circulating volume.
D. Administration of large volumes of hypotonic solutions to reverse hyperosmolality.
7. A 66-year-old woman is transferred to the ICU from the surgery unit after developing disseminated intravascular coagulation (DIC). The nurse develops a care plan, knowing that the care of a patient with a bleeding disorder usually includes:
A. close monitoring of body temperature.
B. ambulation twice daily.
C. strict bed rest.
D. avoidance of blood products that may cause reactions.
8. A 55-year-old man with chest pain is admitted to the ED. On the 12-lead ECG, the ED nurse notes ST-segment elevation and large Q waves in leads II, III, and aVFand ST-segment depression in leads I and aVL. What’s the diagno- sis?
A. Angina attack
B. Normal ECG
C. Inferior wall MI
D. Subendocardial MI
9. A patient post–cardiac arrest has an implantable cardioverter defibrillator (ICD) inserted. His wife is concerned about what to do if her husband collapses again. The nurse’s best response would be:
A. “Now that your husband has the ICD you need not worry.”
B. “Do you know how to access the emergency medical service (EMS) system?”
C. “Would you like to be taught cardiopulmonary resuscitation (CPR) to help ease your concern?”
D. “I’ll have the physician talk to you.”
10.A 38-year-old man is admitted to the ICU with a diagnosis of acute pancre- atitis. When assessing his condition, the nurse notes that he has a positive Trousseau’s sign. This sign is associated with what condition?
A. Hyperglycemia
B. Hypoglycemia
C. Hypercalcemia
D. Hypocalcemia
11.A woman is admitted to the ICU with a diagnosis of hepatic coma. She’s lethargic and responds only to painful stimuli. Which therapy would probably be used to lower her serum ammonia level?
A. Provide a high-protein diet and increase fluid intake.
B. Administer lactulose and neomycin.
C. Administer opioid analgesics and sedatives.
D. Administer digoxin (Lanoxin) and furosemide (Lasix).
12.A patient is diagnosed with acute transmural MI. While analyzing the pa- tient’s ECG strip, the nurse would find that the ST segment is:
A. isoelectric.
B. elevated.
C. prolonged.
D. depressed.
13.A patient’s ECG pattern changed from sinus rhythm, rate 80, to junctional escape rhythm, rate 46. Of the following medications available to the nurse, which would be the most appropriate to use to correct this pattern change?
A. Digoxin (Lanoxin) 0.25 mg I.V.
B. Atropine 1 mg I.V.
C. Lidocaine 100 mg I.V.
D. Verapamil 60 mg P.O.
14.A 78-year-old man with a diagnosis of dementia who has just undergone lung resection is admitted to the surgical ICU. He’s intubated, connected to a mechanical ventilator, and agitated. His blood pressure is 158/96 mm Hg; heart rate, 135 beats/minute; respiratory rate, 40 breaths/minute; and temperature, 97.8º F (36.6º C). The ventilator settings are fraction of inspired oxygen (FIO2), 0.40; synchronized intermittent mandatory ventilation, 8; and tidal volume, 800 ml. Other assessment data include pH, 7.5; PaCO2, 30 mm Hg; PaO2, 80 mm Hg; HCO3–, 24 mEq/L; and arterial oxygen saturation (SaO2), 94%. Ve- curonium, a nondepolarizing neuromuscular blocker, is prescribed to induce skeletal muscle relaxation during ventilation and to decrease oxygen consump- tion. What other medication would the nurse expect to administer in conjunc- tion with vecuronium?
A. Adenosine
B. Neostigmine
C. Diazepam
D. Furosemide
15.A patient is admitted with actively bleeding duodenal ulcers. What’s the most important goal of treatment for this condition?
A. Stabilizing the patient to prepare for surgery as soon as possible
B. Administering I.V. vasopressin to decrease blood flow to the area
C. Replacing fluid volume loss to prevent shock
D. Administering I.V. histamine inhibitors to decrease the acid level
16.The family of a critically ill patient in the trauma unit wishes to visit more frequently than policy allows. The nurse’s best action is to:
A. insist on adherence to the visiting policy.
B. allow only one family member to visit frequently.
C. allow the family to visit frequently and evaluate the patient’s re- sponse.
D. discourage any discussion with the family about visiting policy.
17.A rhythm strip from a patient’s ECG shows the following pattern:
How should the nurse interpret this pattern?
A. Sinus bradycardia
B. Junctional escape rhythm
C. Second-degree atrioventricular (AV) block, Mobitz type II
D. Ventricular escape rhythm
18.A man is admitted to the ICU with acute MI. Which nursing goal would have the highest priority in planning the patient’s care?
A. Maintain normal fluid and electrolyte balance.
B. Maintain adequate nutrition.
C. Prevent invasive infections.
D. Provide physical and psychological rest.
19.A patient with disseminated intravascular coagulation has a severe reaction to a unit of packed cells and develops a humoral immunity. The nurse knows that humoral immunity:
A. is produced by T-cell activity.
B. involves immunoglobulins.
C. occurs only in anaphylactic reactions.
D. involves the thymus.
20.A man attending a stressful business meeting complains of severe subster- nal chest pain. He rates the pain as 12 on a scale of 1 to 10. After his third sub- lingual nitroglycerin tablet, the man states that his pain has decreased to 3. His blood pressure is 146/90 mm Hg; heart rate, 113 beats/minute; respiratory rate, 28 breaths/minute; and temperature, 98.6 F (37 C). The patient is admitted to the cardiac care unit to rule out MI. Orders include MI profile, nitroglycerin I.V.
infusion titrated for relief of pain, oxygen at 2 L via nasal cannula, and one enteric-coated aspirin every day. The monitoring of which vital sign should re- ceive the highest priority?
A. Blood pressure
B. Heart rate
C. Respiratory rate
D. Temperature
21.A man who is having continuous, seizurelike movements is brought to the emergency department by the police. The patient has no identification, and his history is unknown. Which medication should the nurse administer first?
A. Naloxone
B. Sodium bicarbonate
C. Glucose
D. Diazepam
22.A patient in the ICU is intubated and connected to a mechanical ventilator.
She becomes extremely anxious, and the pressure alarm sounds with each in- spiration. What’s the best nursing intervention for this situation?
A. Increase the tidal volume.
B. Increase the oxygen concentration.
C. Disconnect the ventilator and manually ventilate the patient using a ventilator bag for a few breaths.
D. Administer the prescribed diazepam or morphine sulfate as needed.
23.A patient is admitted to the ICU with a diagnosis of acute upper GI bleed- ing. Which nursing diagnosis would have the highest priority?
A. Deficient fluid volume related to bleeding
B. Impaired tissue integrity related to mucosal damage
C. Disturbed sensory perception (visual) related to increased blood am- monia levels
D. Anxiety related to critical illness
24.Which laboratory values are most consistent with a medical diagnosis of hyperosmolar hyperglycemic nonketotic syndrome?
A. Glucose, 600 mg/dl; plasma osmolality, 300 mOsm/kg; serum potas- sium, 4.2 mEq/L
B. Glucose, 800 mg/dl; plasma osmolality, 365 mOsm/kg; pH, 7.3
C. Glucose, 450 mg/dl; pH, 7.2; potassium, 5.2 mEq/L
D. Glucose, 600 mg/dl; pH, 7.2; anion gap, 16
25.A patient in the ICU has just undergone surgery to remove a large brain tu- mor. He’s attached to an intracranial pressure (ICP) monitoring system using a subarachnoid screw. What’s the most important nursing responsibility when caring for this patient?
A. Periodically obtain samples of cerebrospinal fluid.
B. Keep the transducer below the level of the foramen of Monro.
C. Open the system to air to zero-balance it.
D. Use a continuous low-flow flush device to maintain patency.
26.When preparing to teach a patient about his illness, the nurse needs to real- ize that learning is most likely to occur under which condition:
A. Anxiety is mild and acceptance is congruent with the illness.
B. Anxiety is moderate and the patient is motivated.
C. Anxiety is high and the patient is highly motivated.
D. Anxiety is low and the patient denies the severity of the illness.
27.A 47-year-old woman is admitted to the ICU with a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH) after treatment for oat cell ade- nocarcinoma of the lung. What’s the most likely reason for the onset of SIADH in this patient?
A. Ectopic secretion of antidiuretic hormone (ADH) by the tumor cells.
B. Ingestion of large amounts of water after chemotherapy.
C. Inappropriate secretion of ADH by the posterior pituitary gland sec- ondary to the prolonged nausea and vomiting caused by chemo- therapy.
D. Diminished ADH secretion secondary to brain metastasis.
28.Laboratory values for a patient with SIADH would probably reflect which of the following?
A. Elevated serum sodium level, decreased urine osmolality, and elevat- ed plasma osmolality
B. Decreased serum sodium level, decreased urine sodium level, and el- evated plasma osmolality
C. Decreased serum sodium level, elevated urine sodium level, and ele- vated urine osmolality
D. Elevated serum sodium level, elevated urine sodium level, and ele- vated urine specific gravity
29.A patient with DIC is receiving I.V. albumin. The nurse knows that albu- min:
A. is isotonic.
B. decreases the intravascular volume.
C. increases the interstitial volume.
D. increases the intravascular volume.
30.A 34-year-old man is admitted to the ICU with severe respiratory difficulty and a diagnosis of Pneumocystis carinii pneumonia secondary to acquired im- munodeficiency syndrome. Which of the following is the most important factor in planning the patient’s care?
A. Pacing nursing care to avoid patient fatigue
B. Placing an “HIV positive” sign on the door so that laboratory and nursing personnel take appropriate precautions when handling blood and body fluids
C. Ensuring that the patient wears a mask and gloves outside the room to prevent the spread of infection
D. Restricting visitors to the immediate family to prevent contamination 31.A patient is admitted to the ICU with a blood pressure of 76/38 mm Hg and a diagnosis of septic shock. Which assessment finding would best confirm this diagnosis?
A. Hot, dry skin with poor skin turgor
B. ABG analysis revealing metabolic alkalosis
C. Temperature of 105 F (40.6 C) and a pulse rate of 122 beats/minute
D. Urine output of 30 ml/hour and central venous pressure of 8 cm H2O
32.A patient with head trauma is admitted to the ICU for observation and ex- hibits the following signs: decreased level of consciousness (LOC), altered res- piratory pattern with frequent yawns, small but reactive pupils, and positive bilateral Babinski’s reflex. Shortly after admission, Cheyne-Stokes respirations, decorticate posturing, and coma occur. What’s the most likely cause of this de- terioration?
A. Uncal herniation
B. Central herniation
C. Transcranial herniation
D. Nucleus pulposus herniation
33.For a patient with an acute, uncomplicated MI, the nurse should question which of the following physician’s orders?
A. Morphine 5 mg I.V. push every 2 hours p.r.n. for chest pain
B. Isoproterenol (Isuprel) infusion at 20 mcg/minute
C. Heparin 5,000 units S.C. every 12 hours
D. Diltiazem (Cardizem) 60 mg P.O. every 8 hours
34.A 53-year-old woman with a history of coronary artery disease and alcohol abuse is in the ICU with a diagnosis of bleeding esophageal varices. Her blood pressure is 105/60 mm Hg; heart rate, 130 beats/minute; respiratory rate, 28 breaths/minute; and temperature, 98 F (36.7 C). Significant laboratory values are hemoglobin 8 g/dl and HCT 26%. Burgundy-colored aspirate appears in the nasogastric (NG) tube. The patient is receiving cimetidine I.V. at a rate of 42 ml/hour, dextrose 5% in water in combination with 0.9% normal saline solu- tion, and 20 mEq potassium chloride I.V. at a rate of 150 ml/hour. After 1 hour, the nurse notices that NG tube drainage has changed from burgundy to bright red, the blood pressure has decreased to 90/50 mm Hg, and the heart rate is 142 beats/minute. The physician is notified and gives a verbal order to start a vasopressin infusion at 0.3 U/minute. After initiating the infusion, the nurse in- structs the patient to notify the nurse immediately if she experiences which of the following?
A. Increase in urinary urgency
B. Numbness or tingling
C. Metallic taste in the mouth
D. Chest pain
35.A patient experiencing transient confusion and drowsiness is scheduled for a lumbar puncture. Knowing that the spinal subarachnoid space is continuous with the cerebral subarachnoid space, the nurse discusses her concern with the physician about performing lumbar puncture when the patient’s LOC changes.
In what circumstances is lumbar puncture contraindicated?
A. If the patient’s blood pressure is 100/60 mm Hg
B. If the patient’s family reports that the patient recently had a severe viral cold
C. If the patient shows signs of increasing ICP
D. All of the above
36.A 30-year-old pregnant woman who is admitted to the emergency depart- ment has a history of sudden onset of severe headaches followed by seizures.
Bruits are heard over the patient’s carotid arteries and eyeballs. Nuchal rigidity is present. What’s the most likely diagnosis and what test can be used to con- firm this diagnosis?
A. Guillain-Barré syndrome and electromyography
B. Meningitis and lumbar puncture
C. Autonomic dysreflexia and spinal series
D. Arteriovenous malformation and computed tomography (CT) scan 37.An 84-year-old man is diagnosed with septic shock. Aggressive treatment is started in the ICU. Which is the most important action for the nurse to take during this therapy?
A. Placing the patient in the shock position to increase blood pressure
B. Keeping the patient on strict bed rest
C. Controlling the patient’s temperature by placing him on a hypother- mia blanket
D. Monitoring the patient’s vital signs and urine output every 4 hours for changes
38.A 24-year-old man has accidentally ingested about 200 ml of a lye-based liq- uid drain cleaner. Which of the following should the nurse be prepared to ad- minister when the patient arrives at the emergency department?
A. A cathartic to promote elimination of the caustic substance
B. 30 ml of ipecac syrup followed by 240 ml of water to induce vomiting
C. 150 ml of milk or water to dilute the caustic substance
D. 75 g of activated charcoal to absorb the ingested chemical
39.A 29-year-old man is brought to the emergency department by EMS person- nel after he was found sitting in his car in an enclosed garage with the motor running. He’s unresponsive and hypotensive, and his skin is bright red. Which nursing diagnosis is of the highest priority for this patient?
A. Ineffective coping related to depression
B. Ineffective cardiopulmonary tissue perfusion related to decreased car- diac output
C. Ineffective cerebral tissue perfusion related to depressed neurologic functioning
D. Ineffective breathing pattern related to suppressed respirations 40.A patient with burns on the face and neck is at risk for airway obstruction.
Which of the following would be most indicative of a potential airway obstruc- tion?
A. Singed nasal hairs
B. Neck and face pain
C. PaO2of 80 mm Hg
D. Coughing up large amounts of thick, white sputum
41.A 63-year-old man is admitted to the ICU with a diagnosis of a dissecting tho- racic aneurysm. His blood pressure is 180/110 mm Hg; heart rate, 110 beats/
minute; respiratory rate, 12 breaths/minute; and temperature, 99 F (37.2 C). The patient is anxious, and several family members are present. What medications will probably be ordered to lower the patient’s blood pressure and decrease his anxiety level?
A. Meperidine (Demerol) and propranolol (Inderal)
B. Midazolam (Versed) and nifedipine (Procardia)
C. Morphine and digoxin (Lanoxin)
D. Lorazepam (Ativan) and nitroprusside sodium
42.A 50-year-old woman comes to the ED complaining of “fluttering” in her chest, dyspnea, lethargy, and syncope. She’s barrel-chested, has a history of schizophrenia, and smokes two packs of cigarettes per day. Her blood pressure is 99/50 mm Hg; heart rate, 220 beats/minute; respiratory rate, 38 breaths/
minute; and temperature, 98.6 F (37 C). An ECG shows that she’s experienc- ing atrial fibrillation with a rapid ventricular response. Verapamil 2.5 mg I.V. is administered twice. To determine the desired therapeutic response, the nurse should watch for which of the following?
A. Decrease in blood pressure
B. Decrease in respiratory rate
C. Decrease in hallucinations
D. Decrease in heart rate
43.A patient with a closed head injury begins to show a decreased LOC and in- creased ICP. His arms extend and adduct, his wrists are hyperpronated, and his lower extremities extend stiffly, with the feet in plantar flexion. His ABG values show a PaO2of 90 mm Hg and a PaCO2of 50 mm Hg. He’s on a ventilator with a tidal volume of 900 ml; FIO2, 0.40; and respiratory rate, 14 breaths/minute.
What type of posturing is the patient displaying and what can be done to cor- rect this?
A. Opisthotonic posturing, increase tidal volume
B. Decorticate posturing, increase FIO2
C. Decerebrate posturing, increase ventilation rate
D. Temporary posturing, no changes necessary
44.A patient has suffered deep partial-thickness and full-thickness burns over 35% of his body. In what ambient environment would the patient be most com- fortable?
A. Room temperature is lower than skin surface temperature and hu- midity at 25% or lower.
B. Room temperature is lower than skin surface temperature and hu- midity at 50% or higher.
C. Room temperature is slightly higher than skin surface temperature and humidity at 25% or lower.
D. Room temperature is slightly higher than skin surface temperature and humidity at 40% to 50%.
45.A patient with myasthenia gravis arrives in the emergency department.
Based on the presenting symptoms, she appears to be in cholinergic crisis. The administration of which drug and which response to the drug would confirm the diagnosis?
A. Edrophonium (Tensilon); worsening of symptoms
B. Ambenonium (Mytelase); worsening of symptoms
C. Edrophonium; improvement of symptoms
D. Ambenonium; improvement of symptoms
46.A patient with chronic bronchitis requires tracheobronchial suctioning.
Which of the following nursing actions would best help prevent the potential complications of this procedure?
A. Hyperoxygenating the patient with 100% oxygen
B. Keeping the patient in a supine position
C. Inserting the suction catheter no farther than 43⁄4 (12 cm)
D. Giving an I.V. bolus dose of lidocaine to prevent ventricular ectopic beats
47.A patient is in the emergency department. His pH is 7.36; PaO2, 88 mm Hg;
PaCO2, 62 mm Hg; and HCO3–, 35 mEq/L. Which condition is reflected by these values?
A. Respiratory acidosis
B. Compensated respiratory acidosis
C. Metabolic alkalosis
D. Compensated metabolic alkalosis
48.A 35-year-old man with bacterial meningitis is at risk for increasing ICP.
Which measure is appropriate for preventing increased ICP?
A. Encouraging the patient to avoid straining or performing maneuvers similar to the Vasalva maneuver
B. Avoiding hyperoxygenation before and after suctioning by limiting suctioning to 5 to 10 seconds each time
C. Keeping the head of the bed flat
D. Encouraging hyperextension or hyperflexion of the neck and extremi- ties
49.A patient suffered deep partial-thickness and full-thickness burns over 40%
of his body approximately 12 hours ago. Urine output is 22 ml/hour and the hematocrit is 50%. ABG values show pH, 7.32; PaO2, 95 mm Hg; PaCO2, 35 mm Hg; and HCO3–, 18 mEq/L. Based on this data, the nurse would assume that the patient:
A. is dehydrated, developing renal failure, and in metabolic acidosis.
B. is in the early stages of heart failure caused by overhydration.
C. is adequately hydrated, but in acute renal failure and respiratory aci- dosis.
D. has developed a polycythemia as his body attempts to compensate for metabolic acidosis and renal failure.
50.After an insulin infusion is initiated, serial fingerstick blood glucose tests reveal a progressive decrease in the patient’s serum glucose level. At which of the following plasma glucose levels will the nurse probably begin adding dex- trose to the maintenance I.V. infusion?
A. 250 mg/dl
B. 200 mg/dl
C. 150 mg/dl
D. 100 mg/dl
