Free CCRN Practice Test

Get ready for the 2026 CCRN exam by testing your skills with our free practice test.

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QUESTION COUNT:

125 Questions

TIME LIMIT:

160 Minutes

FORMAT:

Multiple Choice

About Our CCRN Practice Test

This CCRN (Adult) practice test checks your understanding of the critical care nursing knowledge and clinical judgment skills commonly tested on the exam. It is designed to help you review key adult acute and critical care topics, including cardiovascular, pulmonary, neurological, endocrine, renal, gastrointestinal, hematologic, and multisystem concepts, while strengthening your ability to apply nursing knowledge in realistic patient-care scenarios.

Each question reflects the types of clinical situations and decision-making skills you may encounter on the CCRN (Adult) exam in 2026. At the end of our interactive practice test, you will receive a score of your performance by category, giving you the chance to assess your readiness, identify areas for improvement, and build confidence before exam day. All our questions and rationales have been reviewed by an experienced registered nurse (RN) to support accurate, exam-relevant practice.

Maegan Baker, BSN, RN, CCM Avatar
Questions reviewed by
Maegan Baker, BSN, RN, CCM
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Full Question Bank & Rationales

Below, you will find the complete list of 125 questions from our CCRN (Adult) practice test. We have included a detailed rationale for every question to help you understand the why behind the correct answer.

These questions are grouped by exam category.

Some questions are marked as Challenging. These questions are designed to be a bit harder than the rest and usually include more detailed scenarios. Use them to build confidence with tougher exam-style questions and to pinpoint which skills or concepts to revisit before test day.

Note: The answer and rationale are hidden by default. Click “Show Answer & Rationale” after you answer the question to see if you got it right.

Jump to Exam Category:

Cardiovascular

1. Question

A patient with symptomatic third-degree atrioventricular block is being treated with transcutaneous pacing. The monitor shows pacing spikes, but most spikes are not followed by QRS complexes. The patient’s blood pressure is 78/40 mm Hg. What is the priority nursing action?

  1. Administer an intravenous bolus of amiodarone.
  2. Increase the pacing rate (bpm).
  3. Increase the electrical output (mA).
  4. Change the pacing mode to asynchronous.
Show Answer & Rationale

Correct Answer: C.

Pacing spikes without consistent QRS complexes indicate failure to capture. The pacer is delivering impulses, but the current is not sufficient to depolarize the myocardium. The nurse should increase the electrical output in milliamperes until each pacing spike produces ventricular capture. Increasing the rate would only create more pacing spikes without correcting the capture problem.

Category: Cardiovascular

2. Question

A patient in the ICU suddenly develops supraventricular tachycardia (SVT) at a rate of 190 beats/minute. The patient quickly becomes lethargic, with cool, clammy skin and a blood pressure of 72/40 mm Hg. What is the most appropriate immediate action?

  1. Administer intravenous adenosine 6 mg rapid push.
  2. Prepare for immediate asynchronous defibrillation.
  3. Administer intravenous amiodarone 150 mg over 10 minutes.
  4. Perform synchronized electrical cardioversion.
Show Answer & Rationale

Correct Answer: D.

This patient has SVT with signs of hemodynamic instability, including hypotension, altered mental status, and poor perfusion. According to ACLS guidelines, unstable tachyarrhythmias require immediate synchronized cardioversion. Adenosine may be used for stable narrow-complex SVT, but in this unstable patient, it would delay the needed electrical intervention.

Category: Cardiovascular

3. Question

A patient presents to the emergency department with intense, crushing chest discomfort. A 12-lead ECG shows 3 mm ST-segment elevation in leads II, III, and aVF. The blood pressure is 88/50 mm Hg, and the heart rate is 60 beats/minute. Which intervention should the nurse expect?

  1. Immediate administration of intravenous metoprolol
  2. Administration of sublingual nitroglycerin
  3. Administration of an intravenous fluid bolus
  4. Initiation of a continuous amiodarone infusion
Show Answer & Rationale

Correct Answer: C.

ST-segment elevation in leads II, III, and aVF indicates an inferior myocardial infarction, which may involve the right ventricle. Right ventricular infarction depends heavily on adequate preload to maintain cardiac output. Because this patient is hypotensive, an IV fluid bolus is appropriate to support right ventricular filling. Nitroglycerin is contraindicated as it would reduce preload and worsen the hypotension.

Category: Cardiovascular

4. Question

A patient is admitted to the ICU with worsening shortness of breath and right ventricular failure. Pulmonary artery (PA) catheter measurements show:
Pulmonary Arterial Pressure (PAP): 65/30 mm Hg
Pulmonary Artery Wedge Pressure (PAWP): 10 mm Hg
Central Venous Pressure (CVP): 16 mm Hg
Which condition best fits these hemodynamic findings?

  1. Mitral valve stenosis
  2. Cardiac tamponade
  3. Pulmonary arterial hypertension
  4. Left ventricular failure
Show Answer & Rationale

Correct Answer: C.

The elevated pulmonary artery pressure and elevated CVP indicate increased right-sided pressure and strain. The PAWP is normal (generally 8-12 mm Hg), which suggests the elevated pulmonary pressure is not due to left ventricular failure or increased left-sided filling pressures. This hemodynamic pattern is most consistent with precapillary pulmonary hypertension, such as pulmonary arterial hypertension. Left ventricular failure and mitral stenosis would usually increase PAWP.

Category: Cardiovascular

5. Question

An ICU patient is recovering after a coronary artery bypass graft (CABG) procedure. During the past 30 minutes, chest tube output has suddenly ceased, and the patient’s blood pressure has fallen from 115/70 mm Hg to 85/45 mm Hg. The heart rate has climbed to 120 beats/minute, and the central venous pressure (CVP) has increased from 8 mm Hg to 18 mm Hg. Which nursing action is the priority?

  1. Prepare for echocardiography and emergency sternotomy.
  2. Administer a 500 mL normal saline fluid bolus.
  3. Strip the chest tubes aggressively to clear the suspected clot.
  4. Increase the positive end-expiratory pressure (PEEP) on the ventilator.
Show Answer & Rationale

Correct Answer: A.

These findings strongly suggest cardiac tamponade: falling blood pressure, rising heart rate, elevated CVP, and an abrupt cessation of chest tube drainage, which may indicate obstruction. The priority is to prepare for urgent evaluation through echocardiography and surgical decompression, such as emergency sternotomy, to relieve the pressure around the heart. A fluid bolus may provide brief hemodynamic support, but it does not correct the obstructive cause of the shock.

Category: Cardiovascular

6. Question (Challenging)

A patient is admitted to the ICU with an acute Stanford Type B aortic dissection. Vital signs show a blood pressure of 210/115 mm Hg and a heart rate of 112 beats/minute. The provider prescribes esmolol and nitroprusside infusions. Which medication administration sequence is essential?

  1. Start the esmolol first to reduce the heart rate, then start the nitroprusside.
  2. Start both infusions simultaneously to achieve the fastest hemodynamic control.
  3. Start the nitroprusside first to lower the blood pressure rapidly, then start the esmolol.
  4. Administer a fluid bolus before starting either medication to prevent severe hypotension.
Show Answer & Rationale

Correct Answer: A.

In acute aortic dissection, treatment must reduce both blood pressure and the force of left ventricular contraction to limit further tearing. Esmolol should be started first because beta-blockers lower the heart rate and contractility, reducing shear stress on the aortic wall. Starting nitroprusside (a vasodilator) first can trigger reflex tachycardia and increase the force of contraction, potentially worsening the dissection.

Category: Cardiovascular

7. Question

A critically ill patient has a central venous catheter in place for continuous central venous oxygen saturation (ScvO2) monitoring. During the last hour, the ScvO2 has fallen from 72% to 54%. The patient’s SpO2 is 98%, and hemoglobin is 10 g/dL. Which clinical change most likely accounts for the decrease in ScvO2?

  1. The patient developed new-onset atrial fibrillation with rapid ventricular response.
  2. The patient’s fraction of inspired oxygen (FiO2) was increased to 100%.
  3. The patient’s core body temperature decreased from 37.0°C to 35.5°C.
  4. The patient received a 2-unit packed red blood cell transfusion.
Show Answer & Rationale

Correct Answer: A.

ScvO2 reflects the balance between oxygen delivery and tissue oxygen use. With normal oxygen saturation and adequate hemoglobin, a sudden drop suggests reduced oxygen delivery or increased oxygen consumption. Atrial fibrillation with rapid ventricular response can reduce ventricular filling time, decrease stroke volume, and lower cardiac output, which decreases oxygen delivery and lowers ScvO2. Transfusion, increased FiO2, or reduced temperature would be expected to maintain or raise ScvO2.

Category: Cardiovascular

8. Question

A patient with a known history of intravenous drug use is admitted to the ICU with a temperature of 39.2°C, blood cultures positive for Staphylococcus aureus, and a new holosystolic murmur heard at the apex. The nurse also observes small, erythematous, painless lesions on the patient’s palms. Which complication is this patient most likely to develop?

  1. Acute respiratory distress syndrome (ARDS)
  2. Embolic stroke
  3. Cardiac tamponade
  4. Deep vein thrombosis
Show Answer & Rationale

Correct Answer: B.

Fever, positive blood cultures, a new murmur, and painless palmar lesions are consistent with infective endocarditis. A holosystolic murmur at the apex suggests mitral valve involvement, indicating left-sided disease. Vegetations on the left side of the heart can embolize into the systemic circulation and travel to the brain, making embolic stroke a major risk.

Category: Cardiovascular

9. Question

A patient in the ICU is being treated for acute decompensated heart failure. After placement of a pulmonary artery (PA) catheter, the following hemodynamic values are obtained:
Cardiac Index (CI): 1.6 L/min/m2
Pulmonary Artery Wedge Pressure (PAWP): 24 mm Hg
Systemic Vascular Resistance (SVR): 1800 dynes/sec/cm-5
Mean Arterial Pressure (MAP): 65 mm Hg

Given this profile, which medication infusion should the nurse expect to begin first?

  1. Phenylephrine
  2. Dobutamine
  3. Normal saline
  4. Norepinephrine
Show Answer & Rationale

Correct Answer: B.

This pattern is consistent with cardiogenic shock, shown by a low cardiac index, elevated PAWP, and increased SVR. Dobutamine improves myocardial contractility, which helps raise cardiac output, and it can also reduce afterload through mild vasodilation. Norepinephrine or phenylephrine would further increase SVR, worsening left ventricular afterload and cardiac output.

Category: Cardiovascular

10. Question

A patient receiving targeted temperature management (TTM) after cardiac arrest has a target core temperature of 33°C. The nurse observes fine muscle twitching in the face and arms, and the patient’s ScvO2 has decreased from 70% to 58%. What is the most likely reason for the ScvO2 decrease, and what intervention is appropriate?

  1. The patient is waking up; decrease the continuous sedation infusion.
  2. The patient is seizing; administer intravenous lorazepam.
  3. The patient is shivering; initiate active external rewarming.
  4. The patient is hypovolemic; administer warmed intravenous normal saline.
Show Answer & Rationale

Correct Answer: C.

Fine muscle activity during TTM is most consistent with shivering, which increases metabolic demand and oxygen consumption. As tissues extract more oxygen, ScvO2 decreases. The appropriate response is to address the shivering through active external rewarming, along with sedation, analgesia, and neuromuscular blockade if needed. Seizure activity is a consideration after cardiac arrest, but the described pattern and oxygen-use change are most consistent with shivering.

Category: Cardiovascular

11. Question

While awaiting central venous access, a patient is receiving a continuous norepinephrine infusion through a peripheral IV in the right forearm. The nurse finds that the IV site is pale, cool, and edematous. After stopping the infusion, what should the nurse do next?

  1. Apply a warm compress and elevate the arm.
  2. Locally inject phentolamine into the extravasated area.
  3. Administer an intravenous bolus of atropine.
  4. Flush the IV catheter vigorously with normal saline.
Show Answer & Rationale

Correct Answer: B.

Norepinephrine extravasation can cause intense local vasoconstriction because of its alpha-adrenergic effects, placing the tissue at risk for ischemia and necrosis. Phentolamine is the appropriate antidote because it blocks alpha-mediated vasoconstriction and promotes local blood flow when injected locally into the affected area. Warm compresses or elevation alone do not reverse the medication’s vasoconstrictive effect.

Category: Cardiovascular

12. Question

A nurse reviews the 12-lead ECG of a patient who reports intermittent chest heaviness. The tracing shows a prolonged PR interval of 0.32 seconds along with a bundle branch block. The patient’s heart rate is 55 beats/minute. Which coronary artery is most likely experiencing ischemia or occlusion?

  1. Left main coronary artery (LMCA)
  2. Left anterior descending artery (LAD)
  3. Circumflex artery (Cx)
  4. Right coronary artery (RCA)
Show Answer & Rationale

Correct Answer: D.

The right coronary artery (RCA) supplies the sinoatrial (SA) node in about 60% of people and the atrioventricular (AV) node in about 90% of people. Ischemia involving the RCA can therefore produce bradycardia and AV conduction delays, such as a prolonged PR interval. Although LAD disease may be associated with septal involvement and bundle branch blocks, AV nodal conduction abnormalities are classically linked to RCA ischemia.

Category: Cardiovascular

13. Question (Challenging)

A patient in severe cardiogenic shock is supported with an intra-aortic balloon pump (IABP). When assessing the arterial pressure waveform, the nurse observes that balloon inflation occurs before the dicrotic notch. What physiological effect will result from this timing problem?

  1. Decreased oxygen demand due to assisted left ventricular emptying
  2. Retrograde flow of blood from the descending aorta into the left ventricle
  3. Suboptimal coronary artery perfusion
  4. Premature aortic valve closure and increased left ventricular afterload
Show Answer & Rationale

Correct Answer: D.

Balloon inflation before the dicrotic notch means the IABP is inflating too early. Since the dicrotic notch corresponds to aortic valve closure, early inflation occurs while the valve is still open or just closing. This can force the aortic valve to close prematurely and increase resistance against left ventricular ejection, raising afterload and myocardial oxygen demand.

Category: Cardiovascular

14. Question

Four hours after a percutaneous coronary intervention (PCI) performed through the right femoral artery, a patient reports severe lower back pain. Vital signs are: blood pressure 86/48 mm Hg, heart rate 118 beats/minute, and respiratory rate 22 breaths/minute. No hematoma is visible at the right groin site, and pedal pulses remain palpable. Which complication should the nurse suspect?

  1. Vasovagal reaction
  2. Aortic dissection
  3. Acute arterial occlusion
  4. Retroperitoneal hemorrhage
Show Answer & Rationale

Correct Answer: D.

Retroperitoneal bleeding can occur after femoral artery access and may not produce obvious bleeding or swelling at the groin site. Blood collects internally, often causing severe back or flank pain along with hypotension and tachycardia. Preserved pedal pulses reduce the likelihood of acute arterial occlusion, since this complication typically causes a cool, pulseless extremity.

Category: Cardiovascular

15. Question

A patient with severe left ventricular dysfunction has been receiving a continuous infusion of sodium nitroprusside for afterload reduction. On the third day of therapy, the patient develops confusion, agitation, and hyperreflexia. Which complication should the nurse suspect?

  1. Thiocyanate toxicity
  2. Hypokalemia
  3. Cerebral hypoperfusion
  4. Acute ischemic stroke
Show Answer & Rationale

Correct Answer: A.

Prolonged sodium nitroprusside therapy can lead to accumulation of toxic metabolites, especially thiocyanate, particularly with extended infusions or impaired renal clearance. Neurologic changes such as confusion, agitation, hyperreflexia, and seizures are characteristic warning signs. Although cerebral hypoperfusion can alter mental status, hyperreflexia more specifically points toward toxicity.

Category: Cardiovascular

16. Question

A patient admitted with acute pericarditis reports sharp, stabbing chest pain radiating to the left shoulder. Which assessment finding and intervention best match this diagnosis?

  1. The pain is relieved with the administration of nitroglycerin.
  2. The pain is relieved when the patient sits up and leans forward.
  3. The pain is relieved when the patient holds their breath.
  4. The pain is relieved when the patient lies flat.
Show Answer & Rationale

Correct Answer: B.

Pericarditis commonly causes sharp, pleuritic chest pain that worsens with lying flat or deep inspiration. Sitting upright and leaning forward often reduces the pain by decreasing contact and irritation between the inflamed pericardial surfaces and surrounding structures. Because this pain is inflammatory rather than ischemic, nitroglycerin is not expected to provide relief.

Category: Cardiovascular

Respiratory

17. Question (Challenging)

A patient intubated for a severe asthma exacerbation has ventilator graphics showing that expiratory flow does not return to baseline before the next breath starts. The patient’s blood pressure then suddenly decreases to 78/40 mm Hg. What should the nurse do immediately?

  1. Increase the set respiratory rate
  2. Administer a continuous nebulized bronchodilator
  3. Increase the tidal volume setting
  4. Disconnect the patient from the ventilator briefly
Show Answer & Rationale

Correct Answer: D.

Failure of expiratory flow to return to baseline indicates incomplete exhalation, breath stacking, and auto-PEEP. The resulting dynamic hyperinflation raises intrathoracic pressure, reduces venous return, and can cause severe hypotension. Briefly disconnecting the ventilator allows trapped air to escape and can rapidly improve hemodynamics. Distractor A is dangerous because increasing the respiratory rate further shortens expiratory time and worsens auto-PEEP.

Category: Respiratory

18. Question

An adult patient is admitted to the intensive care unit for acute respiratory failure. The arterial blood gas (ABG) results on room air are: pH 7.28, PaCO2 58 mm Hg, HCO3 24 mEq/L, and PaO2 65 mm Hg. Which interpretation of these ABG findings is correct?

  1. Mixed respiratory and metabolic acidosis
  2. Uncompensated respiratory acidosis
  3. Partially compensated respiratory acidosis
  4. Uncompensated metabolic acidosis
Show Answer & Rationale

Correct Answer: B.

The low pH indicates acidemia, and the elevated PaCO2 identifies the cause as respiratory. Because the bicarbonate level is still within the expected normal range, there is no evidence of metabolic compensation. Distractor C may seem plausible because the patient also has impaired oxygenation, but PaO2 does not determine whether acid-base compensation is present.

Category: Respiratory

19. Question

A patient with severe acute respiratory distress syndrome (ARDS) continues to have profound hypoxemia with an SpO2 of 84% despite pressure-control ventilation with an FiO2 of 0.80 and PEEP of 15 cm H2O. The patient’s hemodynamic status is stable. Which intervention should the nurse anticipate to improve oxygenation while limiting the risk of oxygen toxicity and barotrauma?

  1. Administer a continuous infusion of a loop diuretic
  2. Increase the PEEP to 24 cm H2O
  3. Increase the FiO2 to 1.0
  4. Prepare to place the patient in the prone position
Show Answer & Rationale

Correct Answer: D.

In severe ARDS with refractory hypoxemia, prone positioning can improve oxygenation by recruiting dependent lung regions and improving V/Q matching without relying solely on higher FiO2 or more aggressive pressure settings. Distractor C may seem like the quickest way to increase oxygenation, but prolonged exposure to very high FiO2 increases the risk of oxygen toxicity and absorption atelectasis.

Category: Respiratory

20. Question

A patient with severe acute respiratory distress syndrome (ARDS) has a PaO2/FiO2 ratio of 85 and is turned to the prone position. Which physiologic effect of prone positioning is primarily responsible for the improvement in oxygenation?

  1. Improving the matching of ventilation and perfusion
  2. Increasing overall chest wall compliance
  3. Decreasing atelectrauma by stabilizing alveolar opening
  4. Redistributing extravascular lung water into the interstitium
Show Answer & Rationale

Correct Answer: A.

Prone positioning enhances oxygenation mainly by improving ventilation-perfusion (V/Q) matching. It helps open dependent dorsal lung regions that are often collapsed or consolidated and allows perfusion to better align with ventilated lung areas. Distractor C may seem reasonable because limiting atelectrauma is important in ARDS, but alveolar stabilization is more directly related to appropriate PEEP rather than proning alone.

Category: Respiratory

21. Question

A patient with acute respiratory distress syndrome (ARDS) is being managed with lung-protective ventilation using a tidal volume of 6 mL/kg of predicted body weight. The current ABG results are: pH 7.27, PaCO2 56 mm Hg, and PaO2 68 mm Hg. The plateau pressure is 26 cm H2O. Which collaborative intervention should the nurse expect?

  1. Administering an intravenous infusion of sodium bicarbonate
  2. Increasing the tidal volume to 8 mL/kg to correct the hypercapnia
  3. Switching to pressure-controlled ventilation to increase minute ventilation
  4. Maintaining the current settings to allow permissive hypercapnia
Show Answer & Rationale

Correct Answer: D.

Lung-protective ventilation in ARDS prioritizes low tidal volumes and safe plateau pressures to reduce ventilator-induced lung injury. A moderate elevation in PaCO2 and mild acidemia may be accepted as permissive hypercapnia when pH remains within a tolerable range, and plateau pressure is below 30 cm H2O. Distractor B may seem logical for correcting CO2 retention, but increasing tidal volume can raise alveolar pressures and increase the risk of volutrauma and barotrauma.

Category: Respiratory

22. Question

A patient with COPD is admitted for acute hypercapnic respiratory failure and is placed on noninvasive positive pressure ventilation (BiPAP). After one hour, the ABG shows pH 7.31 (previously 7.24), PaCO2 66 mm Hg (previously 82 mm Hg), and PaO2 68 mm Hg. The patient is drowsy but awakens easily. Which action is most appropriate?

  1. Continue current settings and monitor closely
  2. Increase the expiratory positive airway pressure (EPAP) setting
  3. Discontinue BiPAP and apply a high-flow nasal cannula
  4. Prepare for immediate endotracheal intubation
Show Answer & Rationale

Correct Answer: A.

The ABG trend shows that BiPAP is improving ventilation: the pH is rising, and the PaCO2 is falling. Mild drowsiness can occur with hypercapnia, but the patient remains easily arousable and is demonstrating objective improvement. Distractor D may seem appropriate because the patient is not yet fully normalized, but intubation is not indicated when the patient is clinically stable and gas exchange is improving.

Category: Respiratory

23. Question (Challenging)

A ventilator high-pressure alarm sounds, and the peak inspiratory pressure (PIP) is 48 cm H2O. During an inspiratory hold maneuver, the nurse notes a plateau pressure (Pplat) of 22 cm H2O. What do these pressure findings indicate?

  1. Increased airway resistance
  2. Alveolar consolidation
  3. Decreased lung compliance
  4. Tension pneumothorax
Show Answer & Rationale

Correct Answer: A.

An elevated PIP with a normal plateau pressure indicates that pressure is increased in the conducting airways but not at the alveolar level. This pattern is most consistent with increased airway resistance, such as mucus plugging, bronchospasm, or a kinked endotracheal tube. Distractor C may seem likely because high pressures are often associated with stiff lungs, but reduced compliance would elevate both PIP and Pplat.

Category: Respiratory

24. Question

During a spontaneous breathing trial (SBT) for a mechanically ventilated patient, which assessment finding shows that the trial is unsuccessful and that full ventilatory support should be restarted immediately?

  1. The rapid shallow breathing index (RSBI) is 135
  2. The oxygen saturation fluctuates between 94% and 96%
  3. The heart rate increases from 82 to 96 beats/min
  4. The respiratory rate increases from 14 to 22 breaths/min
Show Answer & Rationale

Correct Answer: A.

The rapid shallow breathing index is calculated by dividing the respiratory rate by the tidal volume in liters. A value greater than 105 suggests rapid, shallow breathing and is associated with a high risk of weaning failure. Distractor D may raise concern because the respiratory rate increased, but a rate of 22 breaths/min alone is generally acceptable unless other signs of intolerance are present.

Category: Respiratory

25. Question

A patient with a massive pulmonary embolism is hypotensive, tachycardic, and severely hypoxemic. Echocardiography shows marked right ventricular dilation with hypokinesis. Which mechanism is the primary cause of the patient’s hypotension?

  1. Profound systemic vasodilation
  2. Increased left ventricular afterload
  3. Decreased left ventricular preload
  4. Severe hypoxemia causing vagal-induced bradycardia
Show Answer & Rationale

Correct Answer: C.

A massive pulmonary embolism creates an acute rise in pulmonary vascular resistance, which overloads the right ventricle and impairs forward blood flow. As the failing right ventricle sends less blood to the left side of the heart, left ventricular preload falls, causing reduced cardiac output and hypotension. Distractor A may appeal to learners’ thinking of distributive shock, but the shock pattern in massive PE is obstructive.

Category: Respiratory

26. Question

A critically ill patient presents with bilateral pulmonary infiltrates and severe hypoxemia. A pulmonary artery catheter is inserted to help distinguish acute respiratory distress syndrome (ARDS) from cardiogenic pulmonary edema. Which pulmonary artery wedge pressure (PAWP) finding best supports ARDS?

  1. 30 mm Hg
  2. 22 mm Hg
  3. 10 mm Hg
  4. 26 mm Hg
Show Answer & Rationale

Correct Answer: C.

ARDS is caused by noncardiogenic pulmonary edema, so left-sided filling pressures are usually normal or low. A PAWP below 18 mm Hg supports ARDS rather than pulmonary edema caused by left-sided heart failure. Distractor B may seem reasonable because elevated wedge pressure can occur with pulmonary congestion, but that finding points toward a cardiogenic cause rather than ARDS.

Category: Respiratory

27. Question

While caring for a patient receiving mechanical ventilation, the nurse notes that the high-pressure limit alarm is sounding. The patient is coughing, and the ventilator waveform shows a sharp increase in peak inspiratory pressure (PIP), while the plateau pressure (Pplat) is unchanged. What should the nurse do first?

  1. Empty water condensation from the ventilator circuit
  2. Administer a nebulized bronchodilator
  3. Obtain a stat portable chest radiograph
  4. Suction the patient’s artificial airway
Show Answer & Rationale

Correct Answer: D.

When PIP is elevated, but Pplat remains normal, the problem is usually increased airway resistance rather than decreased lung compliance. Common causes include secretions, coughing, biting the tube, or a kinked airway. Suctioning is the priority because it addresses a likely obstruction in the artificial airway. Distractor B may be attractive if bronchospasm is suspected, but a bronchodilator will not immediately remove secretions or a physical blockage.

Category: Respiratory

28. Question

A mechanically ventilated patient becomes increasingly agitated shortly after transport from the emergency department. Oxygen saturation decreases from 98% to 88%. Assessment reveals absent breath sounds over the left lung field and coarse breath sounds over the right lung. The trachea is midline, blood pressure is stable, and the endotracheal tube marking at the lip has increased from 22 cm to 27 cm. What is the most likely cause of these findings?

  1. Tension pneumothorax
  2. Right mainstem bronchus intubation
  3. Massive mucus plugging of the left bronchus
  4. Acute pulmonary embolism
Show Answer & Rationale

Correct Answer: B.

The increased depth of the endotracheal tube, combined with absent breath sounds on the left, strongly suggests that the tube has migrated into the right mainstem bronchus. This results in ventilation of only the right lung, causing hypoxemia and unilateral breath sounds. Distractor C could cause unilateral breath sounds, but would not explain the increased endotracheal tube depth.

Category: Respiratory

29. Question

The nurse is evaluating a chest drainage system for a patient with a traumatic pneumothorax and observes continuous bubbling in the water-seal chamber. When the nurse briefly clamps the chest tube close to the patient’s chest dressing, the bubbling stops immediately. What does this finding indicate?

  1. Resolution of the patient’s pneumothorax
  2. An air leak originating from the patient’s lung or insertion site
  3. A crack or leak in the chest drainage system tubing
  4. Normal functioning of the active suction control chamber
Show Answer & Rationale

Correct Answer: B.

Persistent bubbling in the water-seal chamber reflects an ongoing air leak. If clamping the tube near the patient’s chest stops the bubbling, the leak must be coming from the patient side, such as the lung or insertion site. Distractor C may be tempting, but a leak in the drainage system or tubing beyond the clamp would continue to bubble even after clamping near the patient.

Category: Respiratory

30. Question

A patient is in the ICU two days after surgical tracheostomy placement. During repositioning, the tracheostomy tube is accidentally displaced, and the patient develops severe respiratory distress. What is the nurse’s immediate priority?

  1. Apply a high-flow oxygen mask directly over the open stoma
  2. Cover the stoma with a sterile dressing and ventilate with a bag-valve-mask
  3. Insert a Yankauer suction tip into the stoma to maintain patency
  4. Reinsert the tracheostomy tube blindly using the obturator
Show Answer & Rationale

Correct Answer: B.

A tracheostomy tract is not mature during the first week after placement. Blind reinsertion during this period can create a false passage and worsen airway obstruction. The safest immediate approach is to occlude the stoma and ventilate the patient through the upper airway with a bag-valve-mask. Distractor D may appear appropriate because an obturator is used for tracheostomy insertion, but it should not be used blindly in a fresh tracheostomy.

Category: Respiratory

31. Question

Which nursing action is considered an important evidence-based element of a ventilator-associated pneumonia (VAP) prevention bundle?

  1. Maintaining the head of the bed flat to prevent aspiration
  2. Changing the ventilator circuit tubing every 24 hours
  3. Performing regular oral care with an antiseptic solution
  4. Providing deep, continuous sedation to prevent spontaneous breathing
Show Answer & Rationale

Correct Answer: C.

Consistent oral care with an antiseptic solution helps reduce bacterial colonization in the mouth and oropharynx, lowering the risk of pathogens being aspirated into the lower airway. Distractor B may seem infection-prevention focused, but routine ventilator circuit changes can disrupt the closed system and are not recommended as a daily practice to prevent VAP.

Category: Respiratory

Endocrine, Hematology, Gastrointestinal, Renal, Integumentary

32. Question

A patient with chronic kidney disease presents to the emergency department with weakness after missing three scheduled hemodialysis treatments. The cardiac monitor shows a regular rhythm at 55 beats/min, absent P waves, and a widened QRS complex. The serum potassium level is 7.4 mEq/L. What is the most appropriate initial medication to administer?

  1. Inhaled albuterol
  2. Oral sodium polystyrene sulfonate (Kayexalate)
  3. Intravenous calcium gluconate
  4. Intravenous regular insulin and 50% dextrose
Show Answer & Rationale

Correct Answer: C.

This patient has severe hyperkalemia with dangerous ECG changes, including absent P waves and QRS widening. The first medication priority is intravenous calcium gluconate because it stabilizes the cardiac membrane and reduces the risk of fatal dysrhythmias. Insulin with dextrose and albuterol shift potassium intracellularly, but they do not provide immediate myocardial stabilization.

Category: Renal

33. Question

A patient with small cell lung cancer is admitted to the ICU after developing confusion and generalized seizures. Laboratory findings include a serum sodium of 114 mEq/L, serum osmolality of 245 mOsm/kg, and urine osmolality of 600 mOsm/kg. The patient is started on a 3% hypertonic saline infusion. Which of the following represents the safest goal for serum sodium correction in the first 24 hours?

  1. Increase serum sodium to a normal value of 135 mEq/L within 24 hours.
  2. Increase serum sodium by 6 to 8 mEq/L in 24 hours.
  3. Increase serum sodium by no more than 4 mEq/L in 24 hours.
  4. Increase serum sodium by 15 to 20 mEq/L in 24 hours.
Show Answer & Rationale

Correct Answer: B.

This patient has symptomatic severe hyponatremia, likely related to SIADH from small cell lung cancer, and hypertonic saline is appropriate because seizures are present. However, the sodium level must be corrected slowly and carefully. Raising the serum sodium too quickly, especially beyond 6 to 8 mEq/L in 24 hours, increases the risk of osmotic demyelination syndrome and permanent neurologic injury.

Category: Endocrine

34. Question

A mechanically ventilated patient has deep full-thickness burns that completely encircle the torso. During the past hour, the nurse observes that peak inspiratory pressure (PIP) has increased from 25 cm H2O to 45 cm H2O, tidal volumes are decreasing, and SpO2 has fallen to 88%. Breath sounds are diminished bilaterally. Which of the following is the most appropriate anticipated intervention?

  1. Performance of an escharotomy at the bedside.
  2. Insertion of bilateral thoracostomy tubes.
  3. Administration of a neuromuscular blocking agent.
  4. Transition to high-frequency oscillatory ventilation.
Show Answer & Rationale

Correct Answer: A.

Circumferential full-thickness burns create a rigid eschar that cannot expand as edema develops. When the torso is involved, this restriction can prevent chest wall expansion, causing rising peak pressures, falling tidal volumes, and worsening oxygenation. Escharotomy releases the constricting burn tissue, allowing the chest wall to expand more effectively.

Category: Integumentary

35. Question

A patient with severe sepsis from a bowel perforation begins bleeding around their intravenous catheter sites and the endotracheal tube. Laboratory results show a platelet count of 35,000/mm3, an INR of 2.8, an elevated D-dimer, and a fibrinogen level of 80 mg/dL (normal 200-400 mg/dL). Which of the following blood products is the highest priority for this patient’s specific coagulopathy?

  1. Albumin 5%
  2. Packed red blood cells (PRBCs)
  3. Cryoprecipitate
  4. Fresh frozen plasma (FFP)
Show Answer & Rationale

Correct Answer: C.

The laboratory results and signs of active bleeding are consistent with disseminated intravascular coagulation. Although several blood components may be required, the fibrinogen level is critically low. Cryoprecipitate is the preferred product for rapid fibrinogen replacement and clot formation, directly addressing this specific deficit better than PRBCs, albumin, or FFP alone.

Category: Hematology

36. Question

A trauma patient is in the ICU after an exploratory laparotomy and massive transfusion. The nurse observes that the patient’s abdomen has become firm and markedly distended. The ventilator alarms for a peak inspiratory pressure (PIP) of 48 cm H2O. Urine output has fallen to 5 mL/hr, and blood pressure is 85/45 mm Hg. Bladder pressure measurement is 28 mm Hg. What is the most appropriate intervention?

  1. Prepare the patient for emergency surgical decompression of the abdomen.
  2. Administer intravenous furosemide to increase urine output.
  3. Administer a 1 L bolus of 0.9% normal saline.
  4. Increase the positive end-expiratory pressure (PEEP) on the ventilator.
Show Answer & Rationale

Correct Answer: A.

The elevated bladder pressure with hypotension, oliguria, abdominal distention, and increased airway pressures indicates abdominal compartment syndrome. This condition occurs when increased intra-abdominal pressure impairs organ perfusion and ventilation. With organ dysfunction already present, definitive management is urgent surgical decompression rather than additional fluids, diuretics, or ventilator adjustments.

Category: Gastrointestinal

37. Question

A 55-year-old patient being treated for severe community-acquired pneumonia develops distributive shock that does not respond to treatment. The patient remains hypotensive (BP 75/40 mm Hg) despite aggressive fluid resuscitation and increasing doses of norepinephrine and vasopressin. Morning laboratory results show hyponatremia, hyperkalemia, and eosinophilia. Which of the following interventions should the nurse anticipate next?

  1. Initiation of continuous renal replacement therapy (CRRT).
  2. Initiation of a continuous epinephrine infusion.
  3. Administration of intravenous hydrocortisone.
  4. Administration of intravenous levothyroxine.
Show Answer & Rationale

Correct Answer: C.

Persistent septic shock despite fluids and multiple vasopressors raises concern for adrenal insufficiency, especially when accompanied by hyponatremia, hyperkalemia, and eosinophilia. Intravenous hydrocortisone is used in this setting to replace corticosteroid activity, support vascular responsiveness to catecholamines, and treat possible adrenal crisis.

Category: Endocrine

38. Question

During the initial assessment of a patient transferred from a long-term care facility, the critical care nurse observes a localized area of intact skin over the sacrum that is deep purple, feels boggy compared with nearby tissue, and is warmer than the surrounding skin. How should the nurse document this finding?

  1. Deep tissue pressure injury
  2. Stage 2 pressure injury
  3. Stage 1 pressure injury
  4. Unstageable pressure injury
Show Answer & Rationale

Correct Answer: A.

Intact skin with persistent deep purple or maroon discoloration, bogginess, and temperature change compared with surrounding tissue is characteristic of a deep tissue pressure injury. This finding suggests injury to deeper soft tissue from pressure or shear. Stage 1 pressure injuries involve nonblanchable redness, while unstageable wounds have slough or eschar obscuring the wound bed.

Category: Integumentary

39. Question

A 60-year-old patient with alcohol-associated cirrhosis is admitted to the ICU after massive hematemesis. The patient is tachycardic, hypotensive, and lethargic. While the team prepares for urgent endoscopy, the provider orders a continuous IV octreotide infusion. What is the primary rationale for this medication in this clinical scenario?

  1. To directly induce coagulation and platelet aggregation at the bleeding site.
  2. To reduce splanchnic arterial blood flow and decrease portal venous pressure.
  3. To neutralize gastric acid and stabilize the formed clot.
  4. To reduce the risk of hepatic encephalopathy by binding ammonia.
Show Answer & Rationale

Correct Answer: B.

In a patient with cirrhosis and massive upper gastrointestinal bleeding, variceal hemorrhage is a major concern. Octreotide decreases splanchnic blood flow, which lowers portal venous pressure and helps reduce bleeding from esophageal or gastric varices. It does not neutralize gastric acid, promote clotting directly, or bind ammonia.

Category: Gastrointestinal

40. Question

A 45-year-old patient is brought to the ICU for treatment of diabetic ketoacidosis (DKA). For the last 6 hours, the patient has been receiving a continuous IV infusion of regular insulin at 0.1 units/kg/hr, along with 0.9% normal saline at 250 mL/hr. The latest basic metabolic panel shows a blood glucose level of 210 mg/dL, an anion gap of 18 mEq/L, and a potassium level of 4.2 mEq/L. Which of the following is the most appropriate next intervention?

  1. Administer 50 mEq of sodium bicarbonate intravenously and maintain current fluids.
  2. Discontinue the regular insulin infusion and transition to subcutaneous glargine.
  3. Add 5% dextrose to the intravenous fluid infusion and continue the insulin drip.
  4. Decrease the regular insulin infusion to 0.05 units/kg/hr and switch fluids to 0.45% normal saline.
Show Answer & Rationale

Correct Answer: C.

In DKA management, insulin must be continued until ketosis resolves and the anion gap closes. Once the glucose level drops to approximately 200-250 mg/dL while the anion gap remains elevated, dextrose is added to the IV fluids to prevent hypoglycemia and allow the insulin infusion to continue safely. Stopping insulin too early can allow ketone production to resume.

Category: Endocrine

41. Question (Challenging)

A patient is undergoing Continuous Veno-Venous Hemofiltration (CVVH). Over the past two hours, the nurse observes that the transmembrane pressure (TMP) has continued to rise and has now reached the high-pressure alarm threshold. The return (venous) pressure and access (arterial) pressure remain normal. What does this specific pressure trend indicate, and what is the best required action?

  1. The venous catheter is kinked; the nurse should reposition the patient.
  2. The hemofilter is becoming clotted; the nurse should prepare to change the circuit.
  3. The replacement fluid bag is empty; the nurse should hang a new bag.
  4. The patient is profoundly hypovolemic; the nurse should administer a fluid bolus.
Show Answer & Rationale

Correct Answer: B.

TMP reflects the pressure needed to move fluid across the hemofilter membrane. A steadily increasing TMP with normal access and return pressures suggests the filter itself is becoming clogged or clotted rather than a catheter or patient-volume problem. The circuit should be changed, and blood returned to the patient, if possible, before the filter clots completely.

Category: Renal

42. Question

A patient is receiving packed red blood cells (PRBCs) for a hemoglobin level of 6.5 g/dL. After 1 hour of transfusion, the patient suddenly develops severe dyspnea, tachypnea, and frothy sputum. Vital signs are BP 90/50 mm Hg, HR 120 beats/min, and SpO2 84% on room air. A STAT chest radiograph demonstrates bilateral pulmonary infiltrates. Echocardiography shows an ejection fraction of 60% with normal right and left ventricular function. What is the most likely cause of this patient’s deterioration?

  1. Acute hemolytic transfusion reaction
  2. Transfusion-related acute lung injury (TRALI)
  3. Transfusion-associated circulatory overload (TACO)
  4. Anaphylactic transfusion reaction
Show Answer & Rationale

Correct Answer: B.

Acute respiratory distress, hypoxemia, bilateral infiltrates, and hypotension soon after transfusion with normal cardiac function are most consistent with TRALI. This is noncardiogenic pulmonary edema caused by an inflammatory capillary leak. TACO is more commonly associated with circulatory overload, hypertension, and cardiac dysfunction than with hypotension and preserved ventricular function.

Category: Hematology

43. Question

A patient with acute myeloid leukemia undergoes induction chemotherapy. Two days later, the patient develops muscle cramps, oliguria, and cardiac dysrhythmias. Laboratory results reveal a potassium of 6.2 mEq/L, phosphorus of 8.5 mg/dL, calcium of 6.8 mg/dL, and uric acid of 12 mg/dL. In addition to aggressive intravenous hydration, which medication should the nurse anticipate administering to specifically target the uric acid level?

  1. Calcium gluconate
  2. Sodium bicarbonate
  3. Sevelamer
  4. Rasburicase
Show Answer & Rationale

Correct Answer: D.

The combination of hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, oliguria, and dysrhythmias after chemotherapy indicates tumor lysis syndrome. Rasburicase specifically lowers uric acid by converting it into allantoin, which is more soluble and easier to excrete. This helps reduce the risk of uric acid crystal deposition and acute kidney injury.

Category: Hematology

44. Question

A 72-year-old patient with type 2 diabetes arrives with marked lethargy. Vital signs are BP 78/45 mm Hg, HR 122 beats/min, and RR 22 breaths/min. Laboratory results reveal a blood glucose of 1,050 mg/dL, serum sodium of 156 mEq/L, potassium of 4.8 mEq/L, and serum osmolality of 365 mOsm/kg. Which of the following is the highest priority initial intervention?

  1. Administer a 1 L bolus of 0.9% normal saline.
  2. Initiate an intravenous regular insulin infusion at 0.1 units/kg/hr.
  3. Administer 1 L of 5% dextrose in water (D5W) to correct hypernatremia.
  4. Administer a 1 L bolus of 0.45% normal saline.
Show Answer & Rationale

Correct Answer: A.

The patient’s findings are consistent with hyperosmolar hyperglycemic state (HHS) with severe intravascular volume depletion and shock. In a hypotensive, hemodynamically unstable patient, the immediate priority is restoration of circulating volume with isotonic crystalloid, such as 0.9% normal saline. Insulin or hypotonic fluids are delayed until perfusion is improved because they may worsen intravascular depletion.

Category: Endocrine

45. Question

A patient with septic shock is admitted to the ICU. During the past 24 hours, the patient’s serum creatinine has risen from 0.8 mg/dL to 2.4 mg/dL. Urinalysis shows muddy brown granular casts. The fractional excretion of sodium (FeNa) is 3.5%, and urine sodium is 55 mEq/L. These findings are most consistent with which of the following mechanisms of acute kidney injury?

  1. Prerenal azotemia due to hypovolemia
  2. Acute interstitial nephritis
  3. Postrenal obstruction
  4. Acute tubular necrosis (intrarenal injury)
Show Answer & Rationale

Correct Answer: D.

Muddy brown granular casts strongly point to acute tubular necrosis, an intrinsic renal injury often caused by ischemia or nephrotoxins. In ATN, damaged tubules lose the ability to reabsorb sodium effectively, resulting in elevated urine sodium and FeNa greater than 2%. Prerenal azotemia usually shows avid sodium retention and a low FeNa.

Category: Renal

46. Question

An 80-kg patient is admitted to the burn ICU after sustaining deep partial-thickness and full-thickness thermal burns involving 50% of total body surface area (TBSA). Using the American Burn Association consensus formula of 2 mL/kg/%TBSA, what is the correct hourly rate of Lactated Ringer’s for the first 8 hours post-injury?

  1. 2000 mL/hr
  2. 250 mL/hr
  3. 500 mL/hr
  4. 1000 mL/hr
Show Answer & Rationale

Correct Answer: C.

Using the formula 2 mL x body weight in kg x percent TBSA, the total fluid estimate is 2 x 80 x 50 = 8000 mL in the first 24 hours. Half of that amount, or 4000 mL, is given during the first 8 hours after the burn injury. Dividing 4000 mL by 8 hours gives an hourly rate of 500 mL/hr.

Category: Integumentary

47. Question (Challenging)

A 34-year-old patient with Graves’ disease is admitted to the ICU with agitation, profuse sweating, a temperature of 39.8°C (103.6°F), and a heart rate of 165 beats/min. The provider prescribes propylthiouracil (PTU), Lugol’s iodine solution, esmolol, and hydrocortisone. To avoid worsening the patient’s condition, how should the nurse sequence the administration of the antithyroid medications?

  1. Administer PTU first, followed by Lugol’s iodine at least 1 hour later.
  2. Withhold the medications until the esmolol has reduced the heart rate below 100 beats/min.
  3. Administer PTU and Lugol’s iodine simultaneously.
  4. Administer Lugol’s iodine first, followed by PTU 1 hour later.
Show Answer & Rationale

Correct Answer: A.

In thyroid storm, the thionamide is given before iodine. PTU inhibits new thyroid hormone synthesis, while iodine decreases the release of preformed hormone. If iodine is given first, it can provide a substrate for additional hormone production. Giving PTU at least 1 hour before Lugol’s iodine helps prevent this worsening effect.

Category: Endocrine

48. Question

A patient with end-stage liver disease is admitted with hepatic encephalopathy. The patient is confused, lethargic, and has pronounced asterixis. The provider prescribes lactulose through a nasogastric tube. Which of the following assessment findings best indicates that the lactulose therapy is achieving its primary therapeutic goal?

  1. The patient produces three soft bowel movements in 24 hours.
  2. The patient’s serum ammonia level decreases from 120 to 110 mcg/dL.
  3. The patient becomes alert, oriented, and asterixis resolves.
  4. The patient’s bowel sounds become hyperactive in all four quadrants.
Show Answer & Rationale

Correct Answer: C.

Lactulose is used in hepatic encephalopathy to reduce ammonia absorption and improve neurologic function. Although the medication is commonly titrated to produce several soft stools daily and ammonia levels may be followed, the best evidence that treatment is working is clinical improvement. Resolution of confusion and asterixis shows that the encephalopathy is improving.

Category: Gastrointestinal

49. Question

A patient being treated for hypovolemic shock has received 6 liters of 0.9% normal saline over the last 12 hours. The current arterial blood gas shows a pH of 7.29, PaCO2 of 35 mm Hg, and HCO3 of 16 mEq/L. The basic metabolic panel shows sodium 140 mEq/L, potassium 4.0 mEq/L, and chloride 115 mEq/L. Which of the following best describes this acid-base disturbance?

  1. High anion gap metabolic acidosis secondary to lactic acid production.
  2. Normal anion gap metabolic acidosis secondary to hyperchloremia.
  3. Metabolic alkalosis secondary to volume contraction.
  4. Respiratory acidosis with attempted metabolic compensation.
Show Answer & Rationale

Correct Answer: B.

The low pH and low bicarbonate indicate metabolic acidosis. The anion gap is 140 – (115 + 16), which equals 9 mEq/L and is within the normal range. After large-volume 0.9% normal saline administration, excess chloride can produce a hyperchloremic normal anion gap metabolic acidosis by lowering bicarbonate concentration.

Category: Renal

50. Question

A patient hospitalized with a deep vein thrombosis has been receiving a continuous unfractionated heparin infusion for 6 days. The platelet count has fallen from 260,000/mm3 at admission to 110,000/mm3 today. The nurse also observes that the patient’s right foot is newly cool and pulseless. Which of the following is the most appropriate initial action?

  1. Decrease the heparin infusion rate by 50%.
  2. Stop the heparin infusion and prepare to administer protamine sulfate.
  3. Administer a platelet transfusion immediately.
  4. Stop the heparin infusion and notify the provider to initiate argatroban.
Show Answer & Rationale

Correct Answer: D.

A platelet decrease of more than 50% after several days of heparin therapy, especially with a suspected new arterial thrombus, strongly suggests heparin-induced thrombocytopenia. HIT is a prothrombotic immune reaction, so all heparin must be stopped immediately and replaced with a non-heparin anticoagulant such as argatroban. Platelet transfusion is generally avoided because it may worsen thrombosis.

Category: Hematology

51. Question

A high-risk patient with a baseline serum creatinine of 1.6 mg/dL requires an emergent CT scan with intravenous contrast. Which of the following interventions is the most proven, evidence-based method to prevent contrast-induced acute kidney injury?

  1. Administration of an intravenous loop diuretic immediately after the procedure.
  2. Administration of oral N-acetylcysteine (Mucomyst) prior to the procedure.
  3. Administration of a prophylactic dose of intravenous sodium bicarbonate.
  4. Administration of intravenous isotonic crystalloids before and after the procedure.
Show Answer & Rationale

Correct Answer: D.

The most consistently supported prevention strategy for contrast-associated kidney injury is adequate volume expansion with isotonic IV fluids before and after contrast exposure. Hydration improves renal perfusion and helps reduce tubular exposure to concentrated contrast. Loop diuretics can worsen volume depletion, and N-acetylcysteine or bicarbonate has not shown the same consistent benefit.

Category: Renal

52. Question

An 82-year-old patient with permanent atrial fibrillation and heart failure develops sudden, severe, diffuse abdominal pain. On examination, the abdomen remains soft and non-distended, and the intensity of the pain appears disproportionate to the relatively benign abdominal findings. Laboratory testing shows an increasing serum lactate level. Which of the following conditions should the nurse most strongly suspect?

  1. Ruptured abdominal aortic aneurysm
  2. Acute mesenteric ischemia
  3. Acute appendicitis
  4. Acute calculous cholecystitis
Show Answer & Rationale

Correct Answer: B.

Sudden severe abdominal pain that is out of proportion to a relatively benign abdominal examination is a classic finding in acute mesenteric ischemia. Atrial fibrillation increases the risk of embolic occlusion of mesenteric vessels. The rising lactate further supports tissue hypoperfusion and bowel ischemia, making this a time-sensitive surgical emergency.

Category: Gastrointestinal

53. Question

A patient is recovering after transsphenoidal removal of a pituitary macroadenoma and has had 800 mL of pale urine output in the last hour. Current vital signs are BP 105/65 mm Hg and HR 110 beats/min. Laboratory results show a serum sodium of 150 mEq/L and a urine specific gravity of 1.002. Which of the following medications should the nurse anticipate administering?

  1. Furosemide
  2. Conivaptan
  3. Hydrocortisone
  4. Desmopressin
Show Answer & Rationale

Correct Answer: D.

Large amounts of dilute urine, rising serum sodium, and very low urine specific gravity after pituitary surgery indicate central diabetes insipidus from inadequate antidiuretic hormone release. Desmopressin is a synthetic form of ADH and is used to reduce urine output, improve water retention, and increase urine concentration.

Category: Endocrine

54. Question (Challenging)

A patient admitted with right lower extremity cellulitis has rapidly worsened over the last 4 hours. The patient now reports severe pain that is far greater than expected based on the visible skin findings. The leg is becoming more edematous, with new blisters, spreading dusky erythema, and palpable crepitus. Vital signs now show hypotension. What is the absolute highest priority intervention for this patient?

  1. Administration of intravenous broad-spectrum antibiotics within 1 hour.
  2. Immediate preparation for emergent surgical debridement.
  3. Application of hyperbaric oxygen therapy.
  4. Elevation of the extremity above the level of the heart.
Show Answer & Rationale

Correct Answer: B.

Rapid progression, severe pain out of proportion to the exam, bullae, dusky skin changes, crepitus, and hypotension are highly concerning for necrotizing fasciitis. This infection spreads quickly through fascial planes and cannot be controlled with antibiotics alone. Emergent surgical debridement is the definitive, life-saving intervention and must not be delayed.

Category: Integumentary

55. Question

Fifteen minutes after a packed red blood cell (PRBC) transfusion is started, the patient reports lower back pain, chills, and shortness of breath. The nurse notices dark reddish-brown urine in the Foley catheter tubing. What is the nurse’s immediate priority action?

  1. Stop the transfusion and disconnect the blood tubing from the patient.
  2. Administer intravenous diphenhydramine and acetaminophen.
  3. Flush the current intravenous tubing with 0.9% normal saline.
  4. Slow the transfusion rate and notify the blood bank.
Show Answer & Rationale

Correct Answer: A.

Back pain, chills, dyspnea, and hemoglobinuria shortly after starting PRBCs indicate a possible acute hemolytic transfusion reaction. The first priority is to stop the transfusion and disconnect the blood tubing to prevent further incompatible blood from entering the patient. IV access should then be maintained with new tubing and normal saline while the reaction is managed.

Category: Hematology

56. Question

A patient is pulled from a collapsed building after being trapped for 12 hours. The patient’s right leg is swollen and tense. After Foley catheter placement, dark, tea-colored urine is noted. Serum creatine kinase (CK) is 85,000 U/L. Which of the following is the primary goal of fluid resuscitation in this patient?

  1. Maintain a urine output of 200 to 300 mL/hr.
  2. Prevent the development of hypercalcemia.
  3. Alkalinize the urine to a pH greater than 8.0.
  4. Normalize the serum creatine kinase within 24 hours.
Show Answer & Rationale

Correct Answer: A.

Crush injury with markedly elevated CK and tea-colored urine indicates rhabdomyolysis with myoglobin release. Myoglobin can obstruct and injure renal tubules, causing acute kidney injury. Aggressive IV fluid resuscitation is used to maintain high urine flow, typically about 200 to 300 mL/hr, to help clear myoglobin from the kidneys.

Category: Renal

57. Question

A patient is being treated in the ICU for severe acute pancreatitis. On hospital day 2, the nurse notes bluish discoloration around the umbilicus and observes that the patient’s hands contract inward when the blood pressure cuff is inflated. Which of the following pathophysiological mechanisms best explains the hand spasm?

  1. Autodigestion of local blood vessels causing retroperitoneal hemorrhage.
  2. Massive fluid sequestration leading to hypovolemic shock.
  3. Systemic inflammatory response causing acute respiratory distress syndrome.
  4. Saponification of fat tissue in the abdomen binds circulating calcium.
Show Answer & Rationale

Correct Answer: D.

Hand spasm triggered by inflation of a blood pressure cuff is Trousseau’s sign and reflects hypocalcemia. In severe pancreatitis, enzymatic fat necrosis releases fatty acids that bind calcium through saponification, lowering circulating calcium levels. Cullen’s sign (bruising around the umbilicus) may indicate hemorrhagic pancreatitis, but the carpal spasm is explained by hypocalcemia.

Category: Gastrointestinal

Musculoskeletal, Neurology, Psychosocial

58. Question (Challenging)

A patient with bilateral femur fractures from a motor vehicle collision suddenly develops severe hypoxemia, agitation, and a petechial rash across the chest and axillae on the second hospital day. Which pathophysiologic process is responsible for this presentation?

  1. Disseminated intravascular coagulation consuming clotting factors
  2. Massive inflammatory response to skeletal muscle necrosis
  3. Thrombus migration from the deep veins of the lower extremities
  4. Marrow fat droplets entering the systemic circulation
Show Answer & Rationale

Correct Answer: D.

The combination of respiratory distress, neurologic changes, and petechiae after long-bone fractures is characteristic of fat embolism syndrome. Fat globules from bone marrow enter the circulation, lodge in the pulmonary vasculature, and trigger inflammation that contributes to hypoxemia and systemic findings. A thrombotic pulmonary embolism may also cause hypoxemia, but the petechial rash and timing after femur fractures strongly support fat embolism.

Category: Musculoskeletal

59. Question

A patient with a large right-sided subdural hematoma suddenly develops a right pupil that is dilated and nonreactive. During motor assessment, the patient withdraws from painful stimulation only on the left side. These assessment findings are most consistent with which condition?

  1. Tonsillar herniation
  2. Subfalcine herniation
  3. Central herniation
  4. Uncal herniation
Show Answer & Rationale

Correct Answer: D.

Uncal herniation occurs when the temporal lobe shifts downward and compresses nearby structures. Compression of cranial nerve III causes an ipsilateral dilated pupil, while pressure on the cerebral peduncle produces motor weakness on the opposite side. This pattern of a right fixed pupil with left-sided motor impairment is therefore most consistent with right uncal herniation rather than central, subfalcine, or tonsillar herniation.

Category: Neurology

60. Question

After a severe fall, a patient is admitted to the emergency department with ecchymosis over the mastoid process (Battle’s sign) and periorbital ecchymosis (raccoon eyes). The provider orders gastric tube placement for decompression. Which nursing action is safest?

  1. Request to insert an orogastric tube instead of a nasogastric tube
  2. Advance the nasogastric tube while the patient swallows water
  3. Ask the provider to prescribe an intravenous antiemetic instead
  4. Insert a nasogastric tube using an anesthetic lubricant
Show Answer & Rationale

Correct Answer: A.

Battle’s sign and raccoon eyes suggest a basilar skull fracture. With this injury, nasal insertion of tubes or airways is contraindicated because the device could pass through a fractured cranial base and enter the cranial vault. If gastric decompression is needed, the safer route is oral placement with an orogastric tube.

Category: Neurology

61. Question

A patient in myasthenic crisis is admitted to the ICU. The patient is awake, alert, and able to manage secretions but reports profound weakness. Which assessment finding is the most reliable indicator that endotracheal intubation will be needed?

  1. A trending decrease in serum cholinesterase levels
  2. A trending decrease in forced vital capacity (FVC)
  3. Ptosis and diplopia developing late in the day
  4. An oxygen saturation of 93% on room air
Show Answer & Rationale

Correct Answer: B.

In myasthenic crisis, respiratory failure results from weakening of the respiratory muscles rather than from an initial oxygenation problem. Serial measurements such as forced vital capacity and negative inspiratory force provide the best warning of declining ventilatory strength before hypoxemia becomes apparent. Ocular symptoms are common in myasthenia gravis but do not reliably determine the need for intubation.

Category: Neurology

62. Question

A mechanically ventilated patient with a catastrophic brain injury is undergoing apnea testing to evaluate for brain death. Baseline ABG values are pH 7.42, PaCO2 40 mm Hg, and PaO2 110 mm Hg. After 8 minutes off the ventilator with oxygen delivered through a tracheal catheter, no spontaneous respirations are observed. Repeat ABG results are pH 7.28, PaCO2 62 mm Hg, and PaO2 95 mm Hg. What action should be taken next?

  1. Abort the test due to hemodynamic instability and hypoxia
  2. Reconnect the patient to the ventilator and document a positive apnea test
  3. Continue the apnea test for another 2 minutes and draw a third ABG
  4. Reconnect the patient to the ventilator and prepare for a stat EEG
Show Answer & Rationale

Correct Answer: B.

A positive apnea test requires absent respiratory effort despite an adequate rise in carbon dioxide, typically a PaCO2 of at least 60 mm Hg or an increase of 20 mm Hg or more from baseline. This patient has no spontaneous respirations and a PaCO2 of 62 mm Hg, meeting the required threshold. Oxygenation remained adequate, so the test can be completed by reconnecting the ventilator and documenting/reporting the positive result.

Category: Neurology

63. Question

A patient arrives in the ICU with ongoing status epilepticus. The seizure activity has continued for 15 minutes despite midazolam administration by emergency medical services. Which intravenous medication should the nurse expect to be ordered immediately?

  1. Vecuronium
  2. Phenytoin
  3. Lorazepam
  4. Propofol
Show Answer & Rationale

Correct Answer: C.

Active status epilepticus requires rapid termination with an intravenous benzodiazepine, and lorazepam is commonly used because of its reliable anticonvulsant effect. Longer-acting antiseizure medications such as phenytoin or fosphenytoin may be used to prevent recurrence, but they are not the immediate first step for stopping the current seizure. Propofol is generally reserved for refractory status epilepticus, and vecuronium would only suppress visible motor activity without treating the cerebral seizure.

Category: Neurology

64. Question

For a mechanically ventilated patient recovering from sepsis, which interdisciplinary intervention should the nurse advocate for to reduce the risk of intensive care unit-acquired weakness (ICUAW)?

  1. Maintaining deep sedation to reduce metabolic demand
  2. Administration of daily intravenous neuromuscular blockade
  3. Implementation of early, progressive mobility protocols
  4. Prolonged bed rest to preserve skeletal muscle mass
Show Answer & Rationale

Correct Answer: C.

ICU-acquired weakness is associated with immobility, deep sedation, critical illness, and prolonged mechanical ventilation. Early, progressive mobility helps preserve muscle function and reduce functional decline when performed safely as part of an interdisciplinary plan. Deep sedation, bed rest, and neuromuscular blockade increase the risk of muscle atrophy and weakness rather than preventing it.

Category: Musculoskeletal

65. Question (Challenging)

A patient with a severe traumatic brain injury has an intracranial pressure (ICP) of 26 mm Hg and a blood pressure of 92/44 mm Hg. Given these assessment findings, which initial intervention is most appropriate?

  1. Hyperventilate the patient to a PaCO2 of 30 mm Hg
  2. Administer intravenous labetalol
  3. Initiate a continuous infusion of norepinephrine
  4. Administer intravenous mannitol
Show Answer & Rationale

Correct Answer: C.

The patient’s mean arterial pressure (MAP) is 60 mm Hg [((2 x 44) + 92) / 3]. Because the ICP is 26 mm Hg, the cerebral perfusion pressure (CPP) is only 34 mm Hg (MAP – ICP), which is critically inadequate. The priority is to increase MAP with a vasopressor, such as norepinephrine, to raise CPP toward the desired range of 60-70 mm Hg. Mannitol may appear appropriate for elevated ICP, but in a hypotensive patient, it can worsen intravascular volume depletion and further compromise cerebral perfusion.

Category: Neurology

66. Question

An intubated, mechanically ventilated patient is unable to self-report pain. The patient’s face is relaxed, the body is resting normally, the patient is compliant with the ventilator, and there is no muscle tension with passive movement. What is the nurse’s best action?

  1. Perform a spontaneous awakening trial (SAT)
  2. Document a Critical-Care Pain Observation Tool (CPOT) score of 0
  3. Administer a scheduled dose of intravenous fentanyl
  4. Assess the patient using the Glasgow Coma Scale
Show Answer & Rationale

Correct Answer: B.

The described findings match the lowest possible score on the Critical-Care Pain Observation Tool: relaxed facial expression, normal body movement, ventilator tolerance, and no muscle tension. These observations indicate no behavioral evidence of pain at the time of assessment. The nurse should document a CPOT score of 0 rather than administer additional opioid medication or use an unrelated neurologic assessment tool.

Category: Psychosocial

67. Question

A patient is admitted to the ICU with severe traumatic brain injury following a motor vehicle collision. Over the past hour, the nurse notes a decline in neurologic status. The patient now has a blood pressure of 188/72 mm Hg, a heart rate of 42 beats/min, and irregular respirations. The right pupil is dilated and sluggishly reactive. Which intervention should the nurse anticipate implementing immediately?

  1. Administration of intravenous mannitol
  2. Administration of intravenous labetalol
  3. Placement of the patient in the Trendelenburg position
  4. Administration of a 1 L bolus of 0.9% normal saline
Show Answer & Rationale

Correct Answer: A.

The patient is demonstrating signs of increased intracranial pressure with impending brain herniation, including altered neurologic status, unilateral pupillary dilation, and Cushing’s triad (hypertension with widened pulse pressure, bradycardia, and irregular respirations). Osmotic therapy with mannitol is used to reduce cerebral edema and lower intracranial pressure while definitive neurosurgical management is arranged. Labetalol may lower blood pressure, but it does not address the underlying intracranial hypertension. Trendelenburg positioning can worsen intracranial pressure. A large fluid bolus is not indicated and may exacerbate cerebral edema.

Category: Neurology

68. Question

During the night shift, a 78-year-old patient in the medical ICU becomes suddenly confused, inattentive, and agitated. The patient has a positive Confusion Assessment Method for the ICU (CAM-ICU). What is the most appropriate first action by the nurse?

  1. Request a prescription for a continuous midazolam infusion
  2. Apply soft wrist restraints to prevent device removal
  3. Administer intravenous haloperidol
  4. Assess the patient for underlying physiological triggers
Show Answer & Rationale

Correct Answer: D.

A positive CAM-ICU indicates delirium, which is frequently caused or worsened by reversible conditions such as hypoxemia, infection, pain, urinary retention, medication effects, or metabolic abnormalities. The nurse should first identify and address these underlying contributors rather than immediately resorting to restraints or sedative medications. Benzodiazepines can worsen delirium in many ICU patients and are mainly appropriate when treating conditions such as alcohol withdrawal.

Category: Psychosocial

69. Question

A mechanically ventilated patient is sedated with a continuous intravenous dexmedetomidine infusion. The nurse observes that the heart rate has gradually decreased from 85 beats/min to 60 beats/min, while blood pressure remains stable at 110/65 mm Hg. What is the most appropriate nursing action?

  1. Continue to monitor the patient
  2. Immediately discontinue the infusion
  3. Administer intravenous atropine
  4. Prepare to initiate transcutaneous pacing
Show Answer & Rationale

Correct Answer: A.

Dexmedetomidine commonly produces bradycardia because of its central alpha-2 agonist and sympatholytic effects. Since the patient remains hemodynamically stable with an adequate blood pressure, this asymptomatic decrease in heart rate does not require immediate intervention. The appropriate response is continued monitoring, with escalation only if instability or symptomatic bradycardia develops.

Category: Psychosocial

70. Question

After prolonged extrication from a collapsed building, a patient is admitted to the trauma ICU with crush injuries to both lower extremities. Urine output is 20 mL/hr and dark reddish-brown, and the serum creatine kinase (CK) level is 55,000 U/L. Which intervention should the nurse expect to be prioritized?

  1. Administering sodium bicarbonate to acidify the urine
  2. Preparing the patient for emergency hemodialysis
  3. Initiating aggressive intravenous crystalloid hydration
  4. Administering a loop diuretic to increase urine output
Show Answer & Rationale

Correct Answer: C.

Crush injury with markedly elevated CK, oliguria, and dark urine is consistent with rhabdomyolysis and myoglobinuria. The most important initial intervention is aggressive crystalloid fluid administration to maintain renal perfusion and promote myoglobin clearance through the kidneys. Diuretics should not be used before adequate volume resuscitation, dialysis is reserved for severe renal failure or refractory electrolyte abnormalities, and bicarbonate would be used to alkalinize urine rather than acidify it.

Category: Musculoskeletal

71. Question

Three weeks after sustaining a T4 spinal cord injury, a patient suddenly reports a severe throbbing headache. Assessment reveals diaphoresis above the injury level, a heart rate of 48 beats/min, and blood pressure of 210/110 mm Hg. What should the nurse do first?

  1. Prepare to administer intravenous atropine for bradycardia
  2. Elevate the head of the bed to 90 degrees
  3. Administer a PRN intravenous antihypertensive medication
  4. Place the patient in a supine position to protect the airway
Show Answer & Rationale

Correct Answer: B.

This presentation is consistent with autonomic dysreflexia, a life-threatening hypertensive emergency seen after spinal cord injury. The immediate action is to sit the patient upright, which helps reduce blood pressure through orthostatic pooling while the nurse identifies and removes the trigger, such as bladder distention or bowel impaction. Antihypertensive therapy may be needed if blood pressure remains dangerously elevated, but positioning and trigger removal come first; placing the patient supine can worsen hypertension.

Category: Neurology

72. Question (Challenging)

A patient with severe acute respiratory distress syndrome (ARDS) has received continuous fentanyl and midazolam infusions for 14 days. As the patient improves, sedation is rapidly decreased. The nurse observes frequent yawning, tearing, active bowel sounds, and shivering. Which condition should the nurse suspect?

  1. Re-emergence of systemic sepsis
  2. Unmasked anoxic brain injury
  3. Iatrogenic opioid withdrawal syndrome
  4. Intensive care unit delirium
Show Answer & Rationale

Correct Answer: C.

Prolonged opioid exposure in the ICU can lead to physical dependence, especially after continuous fentanyl infusions over many days. Rapid tapering can cause iatrogenic opioid withdrawal, which may present with yawning, lacrimation, increased gastrointestinal activity, shivering, and other signs of sympathetic activation. These findings are more specific for withdrawal than for delirium, recurrent sepsis, or anoxic brain injury.

Category: Psychosocial

73. Question

A patient with a severely comminuted tibial fracture receives internal surgical repair and is admitted to the ICU. Six hours later, the patient reports severe, persistent leg pain that is not relieved by intravenous opioids. Which assessment finding indicates a late sign of this complication?

  1. Absence of a dorsalis pedis pulse
  2. Capillary refill of 2 seconds
  3. Erythema over the fracture site
  4. Edema of the affected limb
Show Answer & Rationale

Correct Answer: A.

Severe pain that is disproportionate to the injury and worsens despite intervention suggests acute compartment syndrome. Loss of a distal pulse is a late finding that indicates severe vascular compromise and possible irreversible ischemic injury. Early recognition should occur before pulselessness develops, because delaying treatment until pulses are absent can jeopardize limb viability.

Category: Musculoskeletal

74. Question

A patient comes to the emergency department after being hit in the temporal area with a baseball. Witnesses report that the patient briefly lost consciousness, then awakened and spoke normally for 45 minutes before becoming unresponsive with a dilated right pupil. Which injury should the nurse suspect?

  1. Epidural hematoma
  2. Chronic subdural hematoma
  3. Subarachnoid hemorrhage
  4. Diffuse axonal injury
Show Answer & Rationale

Correct Answer: A.

A brief loss of consciousness followed by a lucid interval and then rapid deterioration is the classic pattern of an epidural hematoma. This injury often results from temporal bone trauma that tears the middle meningeal artery, causing arterial bleeding that expands quickly. The resulting mass effect can compress cranial nerve III, producing a dilated pupil and requiring urgent neurosurgical intervention.

Category: Neurology

75. Question

On day 6 after an aneurysmal subarachnoid hemorrhage, a patient in the intensive care unit develops mild aphasia and a right arm drift. Vital signs are stable, and the latest CT scan shows no evidence of new bleeding. Which intervention should the nurse expect?

  1. Optimizing hemodynamics to induce hypertension
  2. Initiating an intravenous heparin infusion
  3. Administering an anticonvulsant medication
  4. Preparing the patient for immediate surgical clipping
Show Answer & Rationale

Correct Answer: A.

New focal neurologic deficits occurring several days after a subarachnoid hemorrhage are highly concerning for cerebral vasospasm, which most often occurs between days 3 and 14. For symptomatic vasospasm, treatment focuses on augmenting cerebral blood flow by optimizing hemodynamics, often through fluids and vasopressors to increase blood pressure. Heparin is unsafe after recent intracranial bleeding, and surgical clipping treats the aneurysm itself rather than delayed vasospasm.

Category: Neurology

76. Question

A mechanically ventilated patient in the surgical ICU becomes increasingly agitated, is breathing out of synchrony with the ventilator, and is attempting to pull at the endotracheal tube. The patient’s heart rate is 125 beats/min, and blood pressure is 160/90 mm Hg. What should the nurse do first?

  1. Change the ventilator mode to a mandatory controlled setting
  2. Administer a bolus of an intravenous analgesic
  3. Increase the propofol infusion to achieve deep sedation
  4. Request a prescription for a neuromuscular blocking agent
Show Answer & Rationale

Correct Answer: B.

Pain is a common and treatable cause of agitation, sympathetic activation, and ventilator dyssynchrony, particularly in surgical ICU patients. Current critical care practice emphasizes assessing and treating pain before simply deepening sedation. An analgesic bolus addresses a likely underlying cause, whereas increasing sedatives or inducing skeletal muscle paralysis may hide distress without providing adequate pain control.

Category: Psychosocial

77. Question

One hour after completing an intravenous alteplase (tPA) infusion for acute ischemic stroke, a patient’s blood pressure is 195/110 mm Hg. What is the nurse’s priority action?

  1. Immediately stop the tPA infusion
  2. Place the patient in a reverse Trendelenburg position
  3. Document the finding, as permissive hypertension is expected
  4. Administer an intravenous antihypertensive medication as prescribed
Show Answer & Rationale

Correct Answer: D.

Following alteplase administration, blood pressure must be tightly controlled to lower the risk of intracranial hemorrhage. A pressure of 195/110 mm Hg exceeds the usual post-thrombolytic target of less than 180/105 mm Hg, so prescribed intravenous antihypertensive therapy should be administered promptly. Permissive hypertension may be acceptable in some ischemic stroke patients who do not receive thrombolysis, but it is not appropriate after tPA.

Category: Neurology

78. Question

A patient admitted to the ICU with suspected Guillain-Barré syndrome has bilateral lower extremity weakness and paresthesia. Which nursing intervention should be prioritized?

  1. Administering prescribed intravenous corticosteroids
  2. Assessing deep tendon reflexes every hour
  3. Performing passive range of motion exercises
  4. Monitoring serial negative inspiratory force (NIF) and vital capacity
Show Answer & Rationale

Correct Answer: D.

Guillain-Barré syndrome can progress rapidly from limb weakness to respiratory muscle involvement. Serial assessment of pulmonary mechanics, including negative inspiratory force and vital capacity, helps identify impending ventilatory failure before oxygen saturation falls. Range of motion and neurologic assessments are important supportive measures, but respiratory monitoring is the priority; corticosteroids are not considered effective standard therapy for GBS.

Category: Neurology

79. Question

A patient with chronic alcohol abuse is being treated in the ICU for acute pancreatitis. On the third hospital day, the patient develops marked diaphoresis, a heart rate of 135 beats/min, coarse tremors, and visual hallucinations. Which intervention has the highest priority?

  1. Initiate a protocol-driven intravenous benzodiazepine regimen
  2. Administer intravenous haloperidol for hallucinations
  3. Administer a beta-blocker to control the heart rate
  4. Prepare for emergency endotracheal intubation
Show Answer & Rationale

Correct Answer: A.

The patient is showing signs of severe alcohol withdrawal, including autonomic hyperactivity, tremors, diaphoresis, and hallucinations. Benzodiazepines are the primary treatment because they reduce withdrawal-related CNS excitability, help control agitation, and prevent seizures. Haloperidol may control hallucinations but does not treat the withdrawal process and can lower the seizure threshold, while beta-blockers may mask symptoms without correcting the underlying problem.

Category: Psychosocial

80. Question

A patient with a traumatic brain injury has an external ventricular drain and an ICP of 12 mm Hg. During repositioning, the ICP increases to 28 mm Hg but returns to 13 mm Hg two minutes after the patient is left undisturbed with the head midline and the head of the bed elevated 30 degrees. How should the nurse interpret these findings?

  1. The patient requires immediate administration of hypertonic saline
  2. The patient has lost cerebral autoregulation
  3. The patient demonstrated a normal response to physical stimulation
  4. The patient requires a stat CT scan of the head
Show Answer & Rationale

Correct Answer: C.

Brief ICP elevations can occur during stimulation such as repositioning, suctioning, or coughing. Because the ICP returned close to baseline within a few minutes after stimulation stopped and positioning was optimized, this reflects an expected physiologic response rather than sustained intracranial hypertension. Emergent imaging or hyperosmolar therapy would be considered if the elevation persisted or was accompanied by neurologic deterioration.

Category: Neurology

Multisystem

81. Question

A patient with severe acute pancreatitis requires intubation for acute respiratory distress syndrome (ARDS) on hospital day 2. By day 5, urine output has decreased to 10 mL/hr, serum creatinine has increased from 0.9 to 3.1 mg/dL, and the platelet count has dropped to 45,000/mm3. Which pathophysiologic process best describes this clinical trajectory?

  1. Disseminated intravascular coagulation (DIC) leading to hypovolemia
  2. Uncomplicated systemic inflammatory response syndrome (SIRS)
  3. Secondary multiple organ dysfunction syndrome (MODS)
  4. Primary multiple organ dysfunction syndrome (MODS)
Show Answer & Rationale

Correct Answer: C.

The patient is developing progressive dysfunction in multiple organ systems after an initial inflammatory insult from pancreatitis. Secondary MODS occurs when an uncontrolled systemic inflammatory response leads to injury in organs that were not directly damaged at the start. The sequence of pancreatitis followed by ARDS, acute kidney injury, and thrombocytopenia fits this pattern. Primary MODS would be more consistent with direct injury to the affected organs from the original event.

Category: Multisystem

82. Question

A patient is admitted to the ICU with septic shock and has a pulmonary artery catheter in place. Despite receiving 4 liters of intravenous fluids, the patient remains hypotensive. Current hemodynamic measurements are:

Cardiac Output (CO): 9.2 L/min
Cardiac Index (CI): 5.0 L/min/m²
Systemic Vascular Resistance (SVR): 450 dynes/sec/cm⁵
Pulmonary Capillary Wedge Pressure (PCWP): 8 mm Hg

Which of the following best explains the patient’s persistent hypotension?

  1. Left ventricular failure causing cardiogenic shock
  2. Excessive vasodilation resulting in decreased systemic vascular resistance
  3. Hypovolemia resulting in inadequate preload
  4. Obstruction of pulmonary blood flow causing right ventricular failure
Show Answer & Rationale

Correct Answer: B.

This patient demonstrates the classic hemodynamic profile of distributive shock. The cardiac output and cardiac index are elevated, indicating the heart is pumping effectively. The wedge pressure is not elevated, making cardiogenic shock unlikely. However, the systemic vascular resistance is profoundly decreased, reflecting widespread vasodilation and loss of vascular tone. Even with adequate cardiac output, severe vasodilation can prevent maintenance of blood pressure and tissue perfusion, necessitating vasopressor therapy.

Category: Multisystem

83. Question

An ICU patient has sustained massive blood loss after a motor vehicle collision. The patient has received 6 units of packed red blood cells, 6 units of fresh frozen plasma, and 1 unit of platelets. The nurse now notes oozing from intravenous access sites, a core temperature of 34.5°C (94.1°F), and an arterial pH of 7.21. Which intervention is the highest priority?

  1. Administer a continuous tranexamic acid (TXA) infusion
  2. Rapidly infuse 2 L of warmed Lactated Ringer’s solution
  3. Administer cryoprecipitate and apply a forced-air warming blanket
  4. Administer calcium gluconate and actively warm the blood products
Show Answer & Rationale

Correct Answer: C.

The findings indicate trauma-related coagulopathy with hypothermia and acidosis, the classic “lethal triad”. Oozing from puncture sites suggests impaired clot formation, and hypofibrinogenemia is a major concern during massive transfusion. Cryoprecipitate provides fibrinogen to support clot formation, while active external warming helps reverse hypothermia, which worsens coagulopathy. Calcium replacement is important in massive transfusion, but choice C best addresses the most urgent combined problems in this scenario.

Category: Multisystem

84. Question

A patient with deep partial-thickness burns covering 45% of total body surface area (TBSA) is receiving Lactated Ringer’s solution according to standard burn resuscitation formulas. During the past two hours, urine output has been 15 mL/hr and 20 mL/hr. The blood pressure is 95/60 mm Hg, and the heart rate is 120 bpm. What is the most appropriate intervention?

  1. Maintain the current fluid rate and continue strict monitoring
  2. Increase the rate of the Lactated Ringer’s infusion
  3. Add a low-dose norepinephrine infusion to support perfusion
  4. Administer an intravenous loop diuretic to stimulate renal function
Show Answer & Rationale

Correct Answer: B.

In early major burn resuscitation, urine output is a key indicator of adequate circulating volume and renal perfusion. Adult targets are generally about 0.5 to 1.0 mL/kg/hr, often approximated as 30-50 mL/hr. This patient’s urine output is below target, indicating inadequate resuscitation, so the Lactated Ringer’s infusion rate should be increased. Diuretics would worsen volume depletion, and vasopressors are not the first response to under-resuscitation.

Category: Multisystem

85. Question

A 75-kg patient is being treated for septic shock caused by severe pneumonia and has already received 30 mL/kg of intravenous Lactated Ringer’s solution. The current assessment shows BP 82/45 mm Hg (MAP 57 mm Hg), HR 118 bpm, SpO2 93%, and a central venous pressure (CVP) of 12 mm Hg. Which intervention should the nurse anticipate next?

  1. Administer intravenous hydrocortisone
  2. Initiate a norepinephrine infusion
  3. Administer an additional 500 mL crystalloid bolus
  4. Start a dobutamine infusion
Show Answer & Rationale

Correct Answer: B.

This patient has already received the recommended initial crystalloid volume, and the CVP suggests that additional preload is not the immediate need. Because the MAP remains below 65 mm Hg, the priority is to begin vasopressor support to improve vascular tone and perfusion. Norepinephrine is the preferred first-line vasopressor in septic shock. Giving more fluid may increase the risk for volume overload without correcting the persistent vasodilatory hypotension.

Category: Multisystem

86. Question

A nurse is teaching a patient who is preparing for discharge after surviving a 3-week ICU admission for severe sepsis and acute respiratory distress syndrome (ARDS). Which combination of long-term complications should the nurse monitor for as part of Post-Intensive Care Syndrome (PICS)?

  1. Cognitive impairment, severe physical weakness, and psychological distress
  2. Chronic kidney disease, hepatic failure, and chronic coagulopathy
  3. Central sleep apnea, heart failure, and idiopathic pulmonary fibrosis
  4. Recurrent septic shock, poor wound healing, and profound malnutrition
Show Answer & Rationale

Correct Answer: A.

Post-Intensive Care Syndrome refers to persistent problems that may follow critical illness and ICU treatment. The major domains are physical impairment, such as ICU-acquired weakness; cognitive impairment, such as memory or executive function problems; and mental health concerns, such as anxiety, depression, or post-traumatic stress symptoms. Other organ problems may occur after critical illness, but the cognitive, physical, and psychological triad best defines PICS.

Category: Multisystem

87. Question

After being rescued from a house fire, a patient is admitted to the ICU awake but confused, with soot visible around the mouth and nares. The pulse oximeter reads SpO2 99% on room air, and the arterial carboxyhemoglobin level is 25%. What is the priority nursing action?

  1. Maintain room air and monitor neurological status closely
  2. Administer albuterol via a continuous nebulizer
  3. Prepare for immediate endotracheal intubation
  4. Apply 100% oxygen via a non-rebreather mask
Show Answer & Rationale

Correct Answer: D.

Carbon monoxide poisoning causes tissue hypoxia by binding strongly to hemoglobin and reducing oxygen delivery. Pulse oximetry may appear falsely normal because it cannot reliably distinguish oxyhemoglobin from carboxyhemoglobin. The priority is to administer high-concentration oxygen, which speeds dissociation of carbon monoxide from hemoglobin and reduces the carboxyhemoglobin half-life. Intubation is reserved for patients with airway compromise, inability to protect the airway, or severe respiratory failure.

Category: Multisystem

88. Question

A patient presents to the ICU 12 hours after intentionally taking a very large amount of acetaminophen. The patient reports nausea and right upper quadrant abdominal pain. Which specific medication should the nurse anticipate administering to prevent acute liver failure?

  1. Flumazenil
  2. Naloxone
  3. Acetylcysteine
  4. Sodium bicarbonate
Show Answer & Rationale

Correct Answer: C.

Acetylcysteine is the antidote for acetaminophen overdose and is most effective when given early, though it may still provide benefit later depending on the clinical situation. It replenishes hepatic glutathione, allowing the toxic metabolite NAPQI to be detoxified and reducing the risk of hepatic necrosis. Naloxone treats opioid toxicity, flumazenil reverses benzodiazepines, and sodium bicarbonate is used for selected poisonings such as tricyclic antidepressant toxicity.

Category: Multisystem

89. Question

A mechanically ventilated patient with several rib fractures suddenly becomes hypotensive with a blood pressure of 70/30 mm Hg and a heart rate of 145 bpm. The nurse notes absent breath sounds on the right and an abrupt increase in peak inspiratory pressures. What is the immediate priority action?

  1. Prepare for an immediate needle thoracostomy
  2. Disconnect the patient from the ventilator and manually ventilate
  3. Obtain an urgent portable chest x-ray
  4. Administer a 1 L rapid crystalloid bolus
Show Answer & Rationale

Correct Answer: A.

Sudden hypotension, tachycardia, unilateral absent breath sounds, and increased ventilator pressures strongly indicate a tension pneumothorax. This is an obstructive shock state caused by intrathoracic pressure impairing venous return and cardiac output. Because the patient is unstable, treatment must not be delayed for imaging. Immediate needle decompression, followed by definitive chest tube placement, is required.

Category: Multisystem

90. Question

A trauma patient arrives in the ICU after a motor vehicle collision with severe pelvic pain and mechanical instability of the pelvis on palpation. Vital signs show BP 75/40 mm Hg and HR 135 bpm, and the FAST exam is negative for intra-abdominal free fluid. What is the priority mechanical intervention?

  1. Insert a Foley catheter to rapidly decompress the bladder
  2. Prepare the patient for an immediate exploratory laparotomy
  3. Elevate the lower extremities to facilitate venous return
  4. Apply a pelvic binder or tight sheet wrap centered over the greater trochanters
Show Answer & Rationale

Correct Answer: D.

An unstable pelvic fracture can produce life-threatening retroperitoneal hemorrhage, often from venous bleeding and disrupted pelvic vessels. A pelvic binder or tightly applied sheet at the level of the greater trochanters decreases pelvic volume, stabilizes the fracture, and helps tamponade bleeding. A negative FAST exam makes intraperitoneal bleeding less likely, so exploratory laparotomy is not the priority and may disrupt retroperitoneal tamponade.

Category: Multisystem

91. Question

During a contrast-enhanced CT scan, a patient abruptly develops severe shortness of breath, expiratory wheezes, facial swelling, and hypotension with a blood pressure of 75/40 mm Hg. What is the nurse’s immediate priority action?

  1. Administer intravenous diphenhydramine
  2. Administer intravenous methylprednisolone
  3. Start a continuous albuterol nebulizer
  4. Administer intramuscular epinephrine
Show Answer & Rationale

Correct Answer: D.

This presentation is consistent with anaphylactic shock, including airway involvement, bronchospasm, angioedema, and severe hypotension. Intramuscular epinephrine is the first-line, life-saving treatment because it rapidly supports blood pressure, reduces airway edema, and treats bronchospasm. Antihistamines, corticosteroids, and bronchodilators may be used as adjuncts, but they do not reverse cardiovascular collapse quickly enough to be the immediate priority.

Category: Multisystem

92. Question

A patient undergoing the cooling phase of targeted temperature management (TTM) has a target temperature of 33°C (91.4°F). The nurse observes visible shivering, an increase in heart rate from 55 to 95 bpm, and a rise in core temperature to 33.8°C. What is the most appropriate action?

  1. Increase the room temperature to 95°F (35°C).
  2. Administer dexmedetomidine or propofol infusion.
  3. Increase the target temperature setting to 34°C (93.2°F)
  4. Stop the cooling device temporarily until the shivering stops
Show Answer & Rationale

Correct Answer: B.

Shivering during TTM increases oxygen consumption, metabolic demand, heat production, and sympathetic activity, making it harder to maintain the target temperature and potentially undermining neuroprotection. The nurse should follow the anti-shivering protocol, which may include sedatives or analgesics such as dexmedetomidine or propofol. Stopping cooling or raising the target temperature would reduce the effectiveness of the prescribed therapy.

Category: Multisystem

93. Question (Challenging)

A patient with late, refractory septic shock is receiving high-dose norepinephrine and vasopressin. The blood pressure is 88/50 mm Hg, the serum lactate has increased from 4.0 to 8.5 mmol/L, and the central venous oxygen saturation (ScvO2) is 88% (normal 70-75%). How should the nurse interpret this ScvO2 value?

  1. The patient likely has unrecognized bleeding, causing an elevated reading
  2. The patient has adequate oxygen delivery and tissue perfusion
  3. The patient requires an immediate decrease in the ventilator’s FiO2
  4. The patient is experiencing cellular dysoxia and an inability to extract oxygen
Show Answer & Rationale

Correct Answer: D.

In advanced septic shock, a high ScvO2 does not always indicate adequate tissue oxygenation. When ScvO2 is elevated while lactate continues to rise, it suggests that oxygen is being delivered but not effectively extracted or used by the tissues. This may occur because of microcirculatory shunting and mitochondrial dysfunction, resulting in cellular dysoxia. The rising lactate confirms ongoing tissue-level metabolic failure despite the high venous oxygen saturation.

Category: Multisystem

94. Question

A patient with septic shock remains hypotensive despite receiving norepinephrine at 0.5 mcg/kg/min. The patient’s MAP is 58 mm Hg. According to current sepsis guidelines, what is the most appropriate next step in hemodynamic management?

  1. Add a vasopressin infusion at 0.03 units/min
  2. Increase the norepinephrine infusion to 1.0 mcg/kg/min
  3. Administer 100 mL of 25% human albumin
  4. Add an epinephrine infusion at 0.1 mcg/kg/min
Show Answer & Rationale

Correct Answer: A.

When a patient remains hypotensive despite a moderate to high norepinephrine dose, vasopressin is commonly added at a fixed dose of 0.03 units/min to help raise MAP or reduce the norepinephrine requirement. This approach limits the need for continued norepinephrine escalation, which can increase the risk of tachyarrhythmias and ischemic complications. Albumin and epinephrine may have roles in selected cases, but vasopressin is the appropriate next adjunct here.

Category: Multisystem

95. Question

A patient who underwent targeted temperature management (TTM) at 33°C (91.4°F) for 24 hours after cardiac arrest is now being actively rewarmed. Which physiological change should the nurse closely monitor for during the rewarming phase?

  1. Rebound hyperkalemia
  2. Severe hypokalemia
  3. Decreased metabolic demand
  4. Profound bradycardia
Show Answer & Rationale

Correct Answer: A.

Cooling during TTM shifts potassium into the cells, which can produce hypokalemia. As the patient is rewarmed, potassium moves back into the extracellular space. If potassium was replaced aggressively during the cooling phase, the patient may develop rebound hyperkalemia during rewarming. Bradycardia and reduced metabolic demand are more closely associated with hypothermia itself rather than the rewarming phase.

Category: Multisystem

96. Question

A patient in the cardiac ICU was admitted with profound cardiogenic shock and has improved after 48 hours of milrinone therapy. New laboratory findings show an AST of 2,400 U/L, ALT of 2,650 U/L, and a rising INR. The patient has no known liver disease. What is the most likely cause of these laboratory findings?

  1. Acetaminophen toxicity
  2. Ischemic hepatopathy
  3. Acute biliary obstruction
  4. Undiagnosed chronic viral hepatitis
Show Answer & Rationale

Correct Answer: B.

Severe cardiogenic shock can cause marked hepatic injury from reduced forward blood flow and hepatic congestion. This pattern, often called ischemic hepatopathy or shock liver, produces abrupt and very high aminotransferase elevations, frequently into the thousands, and may be accompanied by impaired synthetic function such as a rising INR. Although acetaminophen toxicity can also cause severe transaminase elevation, the timing and context of profound shock make ischemic hepatopathy the most likely cause.

Category: Multisystem

97. Question

A patient with a body mass index (BMI) of 55 needs emergency endotracheal intubation for severe hypercapnic respiratory failure. To improve airway alignment and make intubation safer, which positioning strategy should the nurse utilize?

  1. Place the patient in a ramped position with the sternal notch aligned with the external ear
  2. Place the patient supine with the head of the bed completely flat
  3. Place the patient in the prone position prior to induction
  4. Place the patient in a slight Trendelenburg position
Show Answer & Rationale

Correct Answer: A.

Patients with severe obesity are at high risk for difficult ventilation, difficult laryngoscopy, and rapid oxygen desaturation when lying flat. The ramped position elevates the head and upper torso so that the external auditory meatus aligns horizontally with the sternal notch. This improves airway alignment, laryngoscopic view, and respiratory mechanics while increasing safe apnea time. Supine, prone, or Trendelenburg positioning worsens airway and ventilation challenges.

Category: Multisystem

98. Question (Challenging)

An unresponsive patient arrives in the ICU after intentionally ingesting an unknown amount of amitriptyline, a tricyclic antidepressant. The patient’s blood pressure is 85/50 mm Hg, and the ECG shows sinus tachycardia at 130 bpm with a QRS duration of 160 ms. Which intervention should the nurse anticipate?

  1. Administer intravenous flumazenil
  2. Prepare for immediate transcutaneous pacing
  3. Administer intravenous amiodarone
  4. Administer intravenous sodium bicarbonate
Show Answer & Rationale

Correct Answer: D.

Tricyclic antidepressant overdose can cause severe sodium channel blockade, producing QRS widening, hypotension, and dangerous dysrhythmias. Intravenous sodium bicarbonate is the key treatment because it helps overcome the sodium channel blockade and narrow the QRS complex. Amiodarone can worsen conduction abnormalities and is not appropriate for this toxicity. Flumazenil is used for benzodiazepine reversal and does not treat TCA cardiotoxicity.

Category: Multisystem

99. Question

A patient with multi-organ failure is being placed on comfort measures only. During withdrawal of mechanical ventilation, the nurse observes tachypnea, accessory muscle use, and facial grimacing. What is the most appropriate action by the nurse?

  1. Administer a propofol bolus until all spontaneous respirations cease
  2. Administer a neuromuscular blocking agent to prevent visible distress
  3. Titrate an intravenous opioid and/or benzodiazepine to relieve dyspnea
  4. Prepare to re-intubate the patient to ensure comfort and airway patency
Show Answer & Rationale

Correct Answer: C.

During withdrawal of mechanical ventilation, the priority is relief of suffering. Opioids are used to treat dyspnea and air hunger, and benzodiazepines may be used for associated anxiety or distress. These medications should be titrated to comfort. Neuromuscular blockers are inappropriate because they only prevent movement while leaving the patient potentially aware of dyspnea. Re-intubation would conflict with the comfort-focused plan of care.

Category: Multisystem

100. Question

A critically ill patient with a massive upper gastrointestinal hemorrhage receives 8 units of packed red blood cells and 6 units of fresh frozen plasma through a rapid infuser. The nurse then observes facial twitching, muscle tremors, a prolonged QT interval, and a decrease in blood pressure to 85/45 mm Hg. Which electrolyte imbalance is most likely responsible?

  1. Hyponatremia
  2. Hypocalcemia
  3. Hyperkalemia
  4. Hypomagnesemia
Show Answer & Rationale

Correct Answer: B.

Large-volume transfusion can deliver a significant citrate load from stored blood products. Citrate binds ionized calcium, which can cause acute hypocalcemia during massive transfusion. Neuromuscular irritability, such as twitching and tremors, along with QT prolongation and hypotension, are consistent with clinically significant hypocalcemia. The hypotension results in part from impaired myocardial contractility.

Category: Multisystem

Professional Caring & Ethical Practice

101. Question

An alert and oriented adult admitted with decompensated heart failure gives the nurse a copy of their advance directive. Which statement best explains the main purpose of this document?

  1. It guides medical decision-making if the patient loses the capacity to do so.
  2. It legally overrides the clinical judgment of the attending physician.
  3. It prevents the patient’s family from visiting or receiving medical updates.
  4. It automatically initiates a do-not-resuscitate (DNR) order upon admission.
Show Answer & Rationale

Correct Answer: A.

An advance directive communicates the patient’s healthcare preferences or identifies a decision-maker for situations in which the patient can no longer make decisions. It does not replace the choices of a currently competent patient, automatically create a DNR order, or block appropriate family involvement. It also does not override sound clinical judgment in routine care.

Category: Professional Caring & Ethical Practice

102. Question

A nurse has cared for a patient with severe anoxic brain injury for the past two weeks. Although the healthcare team views additional interventions as medically futile, the family continues to request aggressive resuscitative treatment. The nurse is unable to sleep well, feels guilty, and has begun dreading work. Which organizational response is the most appropriate next step for addressing the nurse’s situation?

  1. Refuse to administer any further life-sustaining medications to the patient.
  2. Request a transfer to a different unit to avoid caring for the patient.
  3. Initiate a formal ethics committee consultation to review the case.
  4. Confront the family about the suffering they are causing the patient.
Show Answer & Rationale

Correct Answer: C.

The nurse’s symptoms are consistent with moral distress caused by conflict between the care being provided and the team’s view of what is medically appropriate. An ethics consultation offers a formal process for addressing disagreements about goals of care and medical futility. Avoiding the patient, confronting the family, or refusing ordered care would be inappropriate and could harm the patient-family relationship or constitute abandonment.

Category: Professional Caring & Ethical Practice

103. Question

The family of a patient with refractory cardiogenic shock has chosen to stop vasopressor therapy and focus on comfort care. One family member asks the nurse, “Does turning off this medicine mean we are killing him?” Which response by the nurse best reflects ethical principles?

  1. “No, withdrawing the medication simply allows his underlying disease to take its natural course.”
  2. “The decision is ultimately up to the physician, so you should not feel guilty about it.”
  3. “He is already functionally deceased, so the medication isn’t truly keeping him alive.”
  4. “Yes, but it is the most humane thing to do because his quality of life is gone.”
Show Answer & Rationale

Correct Answer: A.

Stopping life-sustaining treatment is ethically and legally distinct from causing death. When vasopressors are withdrawn, the patient’s underlying disease process is allowed to progress naturally while comfort is maintained. The nurse should provide accurate reassurance without shifting responsibility to the physician, labeling the action as killing, or making inaccurate statements about the patient already being deceased.

Category: Professional Caring & Ethical Practice

104. Question

A heavily sedated patient on mechanical ventilation suddenly becomes hemodynamically unstable and requires emergent central venous catheter placement. No family members are available, and there is no designated healthcare proxy documented. How should consent be handled for this procedure?

  1. The bedside nurse should sign the consent form on behalf of the patient.
  2. The procedure can proceed under the doctrine of implied consent for emergencies.
  3. The procedure should be delayed until a family member can be reached by phone.
  4. A court order must be obtained before the central line can be placed.
Show Answer & Rationale

Correct Answer: B.

When an immediate intervention is necessary to prevent serious harm or death, and the patient lacks capacity with no surrogate available, emergency implied consent permits treatment to proceed. Waiting for a family member or court order could dangerously delay care. The nurse cannot provide consent on the patient’s behalf.

Category: Professional Caring & Ethical Practice

105. Question

A patient with traumatic brain injury has a Glasgow Coma Scale score of 3 and no remaining brainstem reflexes. What is the critical care nurse’s professional responsibility related to possible organ donation?

  1. Notify the local organ procurement organization (OPO) of the patient’s clinical status.
  2. Determine the patient’s medical suitability for solid organ donation.
  3. Approach the family to request consent for organ donation.
  4. Inform the attending physician that care should be withdrawn to preserve organs.
Show Answer & Rationale

Correct Answer: A.

The nurse should recognize clinical triggers for potential organ donation and promptly notify the organ procurement organization according to policy. The OPO determines suitability and coordinates the donation process, including family discussions by trained personnel. It is not within the bedside nurse’s scope of practice to obtain consent or suggest withdrawing care for the purpose of organ preservation.

Category: Professional Caring & Ethical Practice

106. Question

An 82-year-old patient with end-stage chronic obstructive pulmonary disease and multiorgan failure remains on maximal mechanical ventilatory support. The patient’s spouse tearfully says to the nurse, “I don’t know what to do. I want him to live, but I don’t want him to suffer.” Which nursing action best supports patient advocacy and helps clarify goals of care?

  1. Request a multidisciplinary care conference to discuss the patient’s prognosis and options.
  2. Reassure the spouse that the healthcare team is doing everything possible to cure the patient.
  3. Advise the spouse that withdrawing life support is the most humane option.
  4. Inform the attending physician that the spouse wants to transition to comfort measures.
Show Answer & Rationale

Correct Answer: A.

A multidisciplinary meeting allows the family to hear consistent information about prognosis, treatment choices, and supportive resources from the full care team. Providing reassurance that the team is trying to cure the patient may be misleading when the patient has end-stage disease and multiorgan failure. The nurse should not direct the spouse toward withdrawing treatment or assume that the spouse has chosen comfort care.

Category: Professional Caring & Ethical Practice

107. Question (Challenging)

A devout Jehovah’s Witness is admitted with severe gastrointestinal bleeding and a hemoglobin level of 4.2 g/dL. The patient is alert, oriented, and strongly refuses blood transfusions. The surgical resident orders two units of packed red blood cells and says, “We have to give it, or he’ll die.” What is the nurse’s priority action?

  1. Withhold the transfusion and advocate for the patient’s autonomous decision.
  2. Administer the blood as ordered, as preserving life is the primary ethical duty.
  3. Wait until the patient falls asleep or loses consciousness to administer the blood.
  4. Ask the hospital chaplain to convince the patient to accept the transfusion.
Show Answer & Rationale

Correct Answer: A.

A competent adult has the right to refuse treatment, even when refusal may result in death. The nurse must not administer blood against the patient’s clearly stated wishes and should advocate for respect of the patient’s religious beliefs and autonomy. Waiting until the patient cannot object or trying to pressure the patient through a chaplain would violate ethical and legal standards.

Category: Professional Caring & Ethical Practice

108. Question

An older adult hospitalized with sepsis develops hyperactive delirium. The patient is agitated, attempting to remove intravenous lines, and reporting auditory hallucinations. Which nursing intervention best demonstrates a caring practice that promotes a healing environment?

  1. Applying bilateral wrist restraints to prevent line removal.
  2. Turning on the television in the room to provide a distraction.
  3. Administering scheduled doses of haloperidol every 4 hours.
  4. Clustering nursing care at night to promote uninterrupted sleep.
Show Answer & Rationale

Correct Answer: D.

Supporting sleep and reducing nighttime disruptions are key nonpharmacologic strategies for delirium care. Clustering care helps promote a calmer environment and supports the patient’s sleep-wake cycle. Restraints and routine antipsychotic use are not preferred first-line approaches, and television may worsen confusion or hallucinations.

Category: Professional Caring & Ethical Practice

109. Question

A newly assigned critical care resident writes an order to begin an epinephrine infusion at a starting dose that appears unusually high for a patient with septic shock. The bedside nurse questions the order, but the resident dismisses the concern and demands that the infusion be started immediately. What should the nurse do next?

  1. Escalate the concern to the attending physician or nursing chain of command.
  2. Administer the medication as ordered and document the resident’s insistence.
  3. Refuse to care for the patient and request a different assignment.
  4. Start the infusion at a lower, safer dose and notify the resident later.
Show Answer & Rationale

Correct Answer: A.

When a potential medication safety issue is not resolved after questioning the order, the nurse must escalate the concern through the appropriate chain of command. This protects the patient while keeping the nurse within professional scope. Giving a potentially unsafe dose or independently changing the dose could result in a medication error, and refusing the assignment does not address the immediate risk.

Category: Professional Caring & Ethical Practice

110. Question

A nursing unit has had substantial staff turnover, and nurses leaving the unit report burnout and moral distress related to providing aggressive treatment in situations they believe are futile. Which leadership action would best address this issue at the systems level?

  1. Offer financial bonuses to nurses who agree to work extra shifts.
  2. Limit the number of complex, long-term patients admitted to the ICU.
  3. Implement a mandatory resilience and stress-reduction seminar for all staff.
  4. Establish regular, structured interdisciplinary debriefings and ethics rounds.
Show Answer & Rationale

Correct Answer: D.

Moral distress related to perceived futile care is best addressed through structured opportunities for communication, ethical discussion, and team reflection. Interdisciplinary debriefings and ethics rounds help staff process difficult cases and improve shared decision-making. Resilience training or financial incentives focus on individual endurance rather than correcting the unit-level contributors to distress.

Category: Professional Caring & Ethical Practice

111. Question

A critical care nurse is giving report before transferring a patient to a medical-surgical unit at the end of the shift. Which communication approach best supports collaboration and patient safety during this handoff?

  1. Leaving a detailed voicemail for the receiving nurse summarizing the shift.
  2. Using a standardized communication tool, such as SBAR, during bedside handoff.
  3. Relaying the most critical information to the transport technician to pass along.
  4. Printing the electronic health record and sending it with the patient transport team.
Show Answer & Rationale

Correct Answer: B.

A structured bedside handoff using SBAR promotes clear, consistent communication and gives both nurses an opportunity to ask questions and verify important information. This reduces omissions and misunderstandings during transitions of care. Voicemail, printed records alone, or secondhand communication through transport staff do not provide the same interactive safety check.

Category: Professional Caring & Ethical Practice

112. Question

During administration of an intravenous antibiotic, the nurse observes that the IV pump display repeatedly freezes and must be manually restarted. Which action best reflects systems thinking and a commitment to patient safety?

  1. Borrow a pump from the adjacent patient room to finish the infusion.
  2. Continue to use the pump, but monitor the infusion rate very closely.
  3. Remove the pump from use, tag it as defective, and notify clinical engineering.
  4. Tape a note to the pump warning other nurses that the screen freezes.
Show Answer & Rationale

Correct Answer: C.

A malfunctioning pump should be removed from service so it cannot harm the current patient or be used again by another clinician. Tagging the pump and notifying clinical engineering ensures the equipment problem is addressed through the proper safety process. Monitoring closely, leave a note, or borrowing equipment from another room are workarounds that do not correct the hazard.

Category: Professional Caring & Ethical Practice

113. Question

A unit-based council has identified an increase in ventilator-associated pneumonia (VAP) rates. The nursing staff wants to examine current evidence to guide improvements in practice. Which action should the nurses take first in the evidence-based practice process?

  1. Conduct an audit of current VAP bundle compliance on the unit.
  2. Implement a new oral care protocol on a trial basis.
  3. Formulate a clear, searchable clinical question using the PICO format.
  4. Develop a new unit policy based on a recent journal article.
Show Answer & Rationale

Correct Answer: C.

Before searching and appraising evidence, the clinical issue should be translated into a focused, answerable question. PICO helps define the patient population, intervention, comparison, and desired outcome, so the literature search is targeted. Changing policy or trialing an intervention before completing the evidence-based practice process would be premature.

Category: Professional Caring & Ethical Practice

114. Question

A patient receiving palliative care is expected to die within several hours, and the family is gathered at the bedside. Which nursing action is the priority for demonstrating caring practice in this situation?

  1. Restrict visitors to two at a time to keep the room quiet and orderly.
  2. Ensure proactive administration of medications for pain and dyspnea.
  3. Encourage the family to leave the room so the patient can rest peacefully.
  4. Obtain routine vital signs every two hours to track the dying process.
Show Answer & Rationale

Correct Answer: B.

Near the end of life, nursing care should focus primarily on comfort and relief of distressing symptoms such as pain and shortness of breath. Proactive medication administration helps prevent unnecessary suffering. Routine vital signs, unnecessary visitor restrictions, or asking the family to leave may interfere with comfort-focused, family-centered care.

Category: Professional Caring & Ethical Practice

115. Question

Staff in the intensive care unit have recently experienced frequent false physiologic monitor alarms, and responses to alarms have become delayed. Which systems-based intervention would be most effective in improving alarm management and protecting patient safety?

  1. Assign a single nursing assistant to monitor the central telemetry station at all times.
  2. Customize individual patient alarm parameters based on their baseline and clinical condition.
  3. Lower the volume on all central station monitors to reduce noise pollution.
  4. Instruct nurses to permanently disable alarms for patients who are hemodynamically stable.
Show Answer & Rationale

Correct Answer: B.

Adjusting alarm limits to reflect each patient’s condition helps reduce unnecessary alarms while preserving clinically meaningful alerts. This addresses a root contributor to alarm fatigue rather than creating unsafe workarounds. Lowering alarm volume, disabling alarms, or relying on only one person to watch monitors does not adequately resolve the systems problem.

Category: Professional Caring & Ethical Practice

116. Question

A patient suffers a cardiac arrest in the ICU while the spouse is present in the room. The spouse asks to remain during the resuscitation. Which nursing action best reflects professional caring practice?

  1. Ask the physician running the code if they are comfortable with family presence.
  2. Allow the spouse to remain in the room with a designated staff member to explain events.
  3. Escort the spouse to the waiting room to protect them from emotional trauma.
  4. Tell the spouse they can stay only if they promise not to cry or interfere with the team.
Show Answer & Rationale

Correct Answer: B.

Family presence during resuscitation is supported when it can be managed safely, especially when a staff member is assigned to support the family and explain what is happening. This approach respects family-centered care while minimizing disruption to the resuscitation team. Automatically removing the spouse, placing inappropriate emotional conditions on the spouse, or making family presence solely dependent on physician preference is not the best standard of caring practice.

Category: Professional Caring & Ethical Practice

117. Question

A patient who communicates only in Mandarin is admitted to the ICU with acute respiratory failure. The patient’s adult daughter is bilingual and offers to interpret medical information between the patient and the healthcare team. What action should the nurse take?

  1. Utilize the daughter as the primary translator to ensure the patient feels comfortable.
  2. Speak slowly and clearly in English while using hand gestures to explain procedures.
  3. Obtain an objective professional medical interpreter to facilitate communication.
  4. Use a generic internet translation tool on a mobile device for basic assessments.
Show Answer & Rationale

Correct Answer: C.

A trained medical interpreter provides accurate, neutral communication and helps ensure the patient can participate meaningfully in care decisions. Family members may not know medical terminology, may unintentionally miscommunicate information, or may filter distressing details. Internet translation tools and gestures are not reliable for critical medical communication.

Category: Professional Caring & Ethical Practice

118. Question

An unconscious patient arrives after a major motor vehicle collision and needs emergency surgery. The patient has no advance directive or named healthcare proxy, but has a spouse and two adult children. Under standard ethical practice for surrogate decision-making, whose consent should the team seek first?

  1. The hospital’s ethics committee.
  2. The primary care physician.
  3. The patient’s spouse.
  4. The adult children, acting by consensus.
Show Answer & Rationale

Correct Answer: C.

When a patient lacks decision-making capacity and has not named a healthcare proxy, surrogate decision-making generally follows a legal hierarchy. In most situations, the spouse is the first appropriate surrogate before adult children. The ethics committee or primary care physician may assist with guidance, but does not replace an available legal next of kin.

Category: Professional Caring & Ethical Practice

119. Question

A critically ill Muslim patient has died in the intensive care unit. The family asks whether they may wash and prepare the body before transport to the morgue. Which response by the nurse best reflects culturally sensitive care and respect for diversity?

  1. Inform the family that the funeral home will handle the ritual washing and preparation of the body.
  2. Explain that hospital policy requires nursing staff to perform postmortem care for infection control.
  3. Allow the family to wash the patient only after the nurse has removed all invasive lines and tubes.
  4. Provide the family with the necessary supplies, ensure their privacy, and offer assistance if needed.
Show Answer & Rationale

Correct Answer: D.

Respectful postmortem care includes supporting religious and cultural practices when they can be safely accommodated. Offering supplies, privacy, and help allows the family to carry out the ritual while maintaining patient dignity. Denying the request or prioritizing routine hospital practice without a valid safety or legal reason would not reflect culturally responsive care.

Category: Professional Caring & Ethical Practice

120. Question

A 45-year-old patient with amyotrophic lateral sclerosis (ALS) is ventilator-dependent but fully alert and oriented. The patient clearly and consistently states a desire to be extubated and receive comfort-focused care. The spouse strongly objects and pleads with the team to continue ventilation. What is the nurse’s primary ethical responsibility?

  1. Continue ventilator support until the patient and spouse reach a consensus.
  2. Support the spouse’s wishes to preserve the patient’s life at all costs.
  3. Request a psychiatric evaluation to determine if the patient is depressed.
  4. Advocate for the patient’s autonomous right to refuse life-sustaining treatment.
Show Answer & Rationale

Correct Answer: D.

A competent adult patient has the legal and ethical authority to decline any medical treatment, including mechanical ventilation. The spouse’s distress should be acknowledged and supported, but it does not override the patient’s informed decision. A psychiatric evaluation is not required solely because the patient wishes to stop life-sustaining treatment, and waiting for family agreement would fail to honor the patient’s autonomy.

Category: Professional Caring & Ethical Practice

121. Question

A critical care nurse gives an intravenous medication meant for Patient A to Patient B after confusing two patients with similar last names in neighboring rooms. Neither patient is harmed. Which systems-level response is most appropriate to reduce the risk of a similar event?

  1. Conduct a root cause analysis to identify contributing environmental and systemic factors.
  2. Issue a formal written warning to the nurse who committed the error.
  3. Reassign patients with similar names to different nurses without altering unit processes.
  4. Require the nurse to complete mandatory remediation on medication administration.
Show Answer & Rationale

Correct Answer: A.

A root cause analysis examines how system factors such as patient placement, identification processes, workflow, interruptions, staffing, or technology contributed to the error. This approach supports safer processes rather than focusing only on individual blame. Punitive responses or isolated reassignment strategies are unlikely to correct the underlying conditions that allowed the error to occur.

Category: Professional Caring & Ethical Practice

122. Question

A patient recovering from diabetic ketoacidosis is being prepared for transfer to a step-down unit. The nurse plans to teach the patient about insulin administration. What should the nurse do first?

  1. Demonstrate the proper technique for subcutaneous injection.
  2. Inform the patient about the potential complications of hypoglycemia.
  3. Provide the patient with printed materials about insulin types.
  4. Assess the patient’s baseline knowledge and readiness to learn.
Show Answer & Rationale

Correct Answer: D.

Effective teaching begins with determining what the patient already understands, how ready the patient is to learn, and whether any barriers to learning are present. This assessment allows the nurse to tailor education to the patient’s needs. Providing written information, demonstrating skills, or teaching complications before this assessment may not meet the patient’s learning needs.

Category: Professional Caring & Ethical Practice

123. Question

A critical care nurse believes the charge nurse is repeatedly assigning them the most acutely ill patients. The nurse is becoming increasingly frustrated and fatigued. What is the most appropriate collaborative approach to addressing this conflict?

  1. File a formal grievance with the human resources department immediately.
  2. Request a private meeting with the charge nurse to discuss assignment concerns.
  3. Discuss the unfair assignments with other staff nurses at the nurses’ station.
  4. Refuse to accept the next high-acuity patient assigned by the charge nurse.
Show Answer & Rationale

Correct Answer: B.

The most professional first step is to speak directly and privately with the charge nurse to clarify concerns and seek a solution. This supports respectful collaboration and appropriate conflict resolution. Discussing the issue with coworkers, refusing assignments, or immediately escalating to human resources bypasses the usual first step and may worsen the conflict.

Category: Professional Caring & Ethical Practice

124. Question (Challenging)

A patient with a devastating subarachnoid hemorrhage has met criteria for clinical brain death, confirmed by two independent physician examinations. The family does not accept the diagnosis, says spinal reflexes show the patient is still alive, and threatens legal action if mechanical ventilation is discontinued. What is the most appropriate response by the nurse?

  1. Explain to the family that spinal reflexes do not originate in the brain and indicate death.
  2. Continue all supportive care indefinitely until the family is ready to accept the diagnosis.
  3. Extubate the patient immediately, as brain death is equivalent to legal death.
  4. Request an urgent interdisciplinary meeting with providers, risk management, and the family.
Show Answer & Rationale

Correct Answer: D.

Disputed brain death requires careful communication, emotional support, and adherence to institutional and legal processes. An interdisciplinary meeting allows providers, risk management, ethics, and supportive services to address the family’s concerns and explain the diagnosis clearly. Immediate extubation could escalate conflict, while indefinite continuation of support is not appropriate once death has been legally determined.

Category: Professional Caring & Ethical Practice

125. Question

The nurse is teaching a family member how to safely perform tracheostomy suctioning for a patient who will be discharged home. After giving verbal directions and demonstrating the procedure, how should the nurse best evaluate the family member’s learning?

  1. Ask the family member if they feel comfortable performing the procedure.
  2. Administer a short written quiz on the steps of sterile suctioning.
  3. Observe the family member performing a return demonstration on the patient.
  4. Have the family member independently explain the procedure to another nurse.
Show Answer & Rationale

Correct Answer: C.

Tracheostomy suctioning is a hands-on skill, so the best evaluation is direct observation of the learner performing the procedure. A return demonstration confirms whether the family member can safely apply the steps in practice. Verbal explanations, written quizzes, or self-reported comfort do not adequately verify procedural competence.

Category: Professional Caring & Ethical Practice

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