PCCN Questions And Answer
1. Two days following a near-drowning accident, a pt is dyspneic, using
accessory muscles, expectorating large amounts of secretions and
reporting feeling of impending death. Changes to the assessment data
include RR- 24 TO 36
CXR clear to bilateral diffuse infiltrates
ABG 40% face mask or 100% non-rebreather mask
pO2 120 mm Hg to 56 mm Hg
pCO2 33 mmHg to 56 mmHg
pH 7.42 to 7.35
HCO3 24 meq/L to 27 mEq/L
Which of the ff do these changes most likely represent
A. aspiration pneumonia
B. pulmonary embolism
C. interstitial pneumonitis
D. ARDS: D. The onset of symptoms occured within 48 hours of the incident. THe
bilateral diffuse infiltrates and ABG results indicating hypoxemia and CO2
retention are all consistent with ARDS.
Aspiration pneumonia should include hypoxxemia, respiratory alkalosis. The CXR
results would reveal an area of opacity with aspiration pneumonia rather than
diffuse infiltrates.
Interstitial lung disease invlolves an inflammation of supportive tissue between the
air sacs rather than inflammation in the air sacs themselves. Symptoms would be
SOB and a dry cough.
2. A pt reports chest pain that is sharp, constant, worse when lying down
and alleviated with sitting up and leaning forward. The most likely cause of
these findings is
A. ACS
B. Pericarditis
C. C. PE
D. AAA: B Pericarditis is inflammation of the pericardial sac. The damaged
epicardium becomes rough and inflamed and irritates the pericardium lying
adjacent to it, precipitating pericarditis. Pain is the most common symptom of
pericarditis. THe pain is sharp, constant and is alleviated when sitting up and
leaning forward.
, PCCN Questions And Answer
3. A pt tells a nurse, "I don't know how I'm going to pay for this
hospitalization."
The nurse should
A. arrange a meeting with hospital social services staff
B. Notify the business office so a payment plan can be designed
C. redirect the pt toward meeting psychologic needs
D. give the pt applications for public assistance medical coverage: A.
Collaboration with a social worker is indicated in this case the social worker can
assist the pt in identifying ways to address the financial implications of this
hospitalization and help identify methods of payments.
4. A cardiac pt with with DNR status is being managed medically. The nurse
notes a new cough, thick yellow sputum and a temperature of 101.4 (38.4)
Coarse crackles are present in the right upper field. The nurse should most
immediately anticipate
A. blood and sputum cultures followed by a broad spectrum abx
B. mucolytics and judicious IV fluid administration
C. an antyipyretic and conservative management
D. NPO status and encouragement of frequent activity: A. This pt symptoms
are consistent with pneumonia. Management should include abx therapy,
oxygen therapy for hypoxemia, mechanical ventilation if acute respiratory
failure develops, fluid management for hydration, nutritional support, and
treatment of associated medical problems and complications.
5. Which of the ff findings is most indicative of a ruptured aortic aneurysm
A. Back pain
B. bounding peripheral pulses
C. intermittent claudication
D. warm, flushed skin: A. An aneurysm is the localized dilation of an artery.
Should an aneurysm rupture, blood will build up under pressure in the tissues
surrounding the aorta, which can result in acute pain and tenderness in theses
areas. This is particularly the case if the aneurysm leaks from the back of the
aorta. Ruptured AAA presents with a classic triad of pain in the flank or back,
hypotension and a pulsatile abdominal mass; however, only about half of the
full triad. The pt will complain of the pain and may feel cold, sweaty and faint on
standing. The pt may also report abdominal pain. A small percentage may have
vomiting
, PCCN Questions And Answer
6. According to recommendations based on research findings, pain
assessment should occur
A. based on changes in vital signs
B. only when the pt movements indicate the pt is seeking attention
C. routinely, regardless of physical findings
D. only when the presence of pain can be validated: C. Pain is considered the
fifth vital sign and must be assessed regularly. Presence of physical findings
may be part of the comprehensive assessment of pain. However, physical
findings may not be present in all patients with pain
7. A pt with a tracheostomy requires frequent suctioning for thick sputum,
A nurse finds a colleague instilling saline in the endotracheal tube prior to
suctioning. The most appropriate response by the nurse would be to
A. report the colleague to the charge nurse or manager
B. noted the practice on the pt chart to ensure consistency of suctioning
techniques
C. ask the attending physician to review the suctioning policy.
D. collaborate with the colleague to review the evidence about this practice.:
D. In addition to an unappreciable increase in sputum recovery, use of NS
adversely affects arterial and global tissue oxygenation and dislodges bacterial
colonies, thus contributing to lower airway contamination. Other harmful pt
outcomes have been reported in the nursing literature, including delays in
return to baseline vital signs, Spo2 and intracranial pressure. Because no solid
scientifically based benefits for routine use of normal saline have been shown,
it is highly recommended that this potentially harmful practice be abandoned.
Instead, treatment considerations should center on ways to prevent the
development of thick tenacious secretions. A review of these data should take
place with the colleague to help mitigate continuation of this dangerous practice
8. Upon admission to the PCU, you screen a pt to determine whether to
administer an influenza vaccine. Which of the following is a contraindication
to the vaccine?
A. Guillian-Barre syndrome
B. chronic renal failure
C. COPD
, PCCN Questions And Answer
D. cirrhosis: A. Persons who developed Guillain-Barre syndrome after receiving
an influenza vaccine should not receive the influenza vaccine without checking
with their provider
9. Emergency treatment of ventricular dysrhythmias for the pt who has an
ICD pacemaker includes which of the following
A. If a pt develops vfib, the nurse should not defibrillate with external
paddles B. if the ICD is firing correctly and the pt does not have pulse, CPR
is not indicated
C. when preparing for external defibrillation, avoid placing the paddle
directly over the ICD pulse generator
D. when you need to turn off all functions of the ICD or pacemaker, apply
a magnet: C. Defibrillation has been known to cause malfunction of an ICD or
pacemaker. Care should be taken to ensure the defibrillation paddle/ pads are
applied at least 4-finger breaths away from the device. The anterior-lateral and
anterior-posterior positions for paddle/pad placement are acceptable in a pt with a
permanent ICD or pacemaker. The pads may also be placed safely away from the
ICD with 1 pad at the apex left mid-axillary, 5th ICS., and the other pad right of the
sternum just below the clavicle.
Based on the device implanted and the manufacturer, application of a magnet may
turn device off or reset to the default settings.
10. A pt is admitted following mitral valve replacement. Which of the
following
should most likely be included in the patent's plan of care
A. positive inotropic agent
B. anticoagulant
C. prophylactic antibiotic
D. ACE inhibitor: B. Anticoagulatn therapy recommendations are based on the
valve apparatus and the pt risk factors (afib, LV dyfunction, previous
thromboembolism, and hypercoagulable condition). Mechanical valve
replacement require lifelong anticoagulant therapy, while most pt with
bioprosthetic valve replacement require short term anti-coagulation (3 months).
In pt with NSR and no risk factors for thrombus, only aspirin therapy is
recommended after bioprosthetic valve replacement.
11. A pt with multiple rib fractures sustained in a motor vehicle collision 4
days ago reports sudden chest pain and difficulty breathing. Chest xray
1. Two days following a near-drowning accident, a pt is dyspneic, using
accessory muscles, expectorating large amounts of secretions and
reporting feeling of impending death. Changes to the assessment data
include RR- 24 TO 36
CXR clear to bilateral diffuse infiltrates
ABG 40% face mask or 100% non-rebreather mask
pO2 120 mm Hg to 56 mm Hg
pCO2 33 mmHg to 56 mmHg
pH 7.42 to 7.35
HCO3 24 meq/L to 27 mEq/L
Which of the ff do these changes most likely represent
A. aspiration pneumonia
B. pulmonary embolism
C. interstitial pneumonitis
D. ARDS: D. The onset of symptoms occured within 48 hours of the incident. THe
bilateral diffuse infiltrates and ABG results indicating hypoxemia and CO2
retention are all consistent with ARDS.
Aspiration pneumonia should include hypoxxemia, respiratory alkalosis. The CXR
results would reveal an area of opacity with aspiration pneumonia rather than
diffuse infiltrates.
Interstitial lung disease invlolves an inflammation of supportive tissue between the
air sacs rather than inflammation in the air sacs themselves. Symptoms would be
SOB and a dry cough.
2. A pt reports chest pain that is sharp, constant, worse when lying down
and alleviated with sitting up and leaning forward. The most likely cause of
these findings is
A. ACS
B. Pericarditis
C. C. PE
D. AAA: B Pericarditis is inflammation of the pericardial sac. The damaged
epicardium becomes rough and inflamed and irritates the pericardium lying
adjacent to it, precipitating pericarditis. Pain is the most common symptom of
pericarditis. THe pain is sharp, constant and is alleviated when sitting up and
leaning forward.
, PCCN Questions And Answer
3. A pt tells a nurse, "I don't know how I'm going to pay for this
hospitalization."
The nurse should
A. arrange a meeting with hospital social services staff
B. Notify the business office so a payment plan can be designed
C. redirect the pt toward meeting psychologic needs
D. give the pt applications for public assistance medical coverage: A.
Collaboration with a social worker is indicated in this case the social worker can
assist the pt in identifying ways to address the financial implications of this
hospitalization and help identify methods of payments.
4. A cardiac pt with with DNR status is being managed medically. The nurse
notes a new cough, thick yellow sputum and a temperature of 101.4 (38.4)
Coarse crackles are present in the right upper field. The nurse should most
immediately anticipate
A. blood and sputum cultures followed by a broad spectrum abx
B. mucolytics and judicious IV fluid administration
C. an antyipyretic and conservative management
D. NPO status and encouragement of frequent activity: A. This pt symptoms
are consistent with pneumonia. Management should include abx therapy,
oxygen therapy for hypoxemia, mechanical ventilation if acute respiratory
failure develops, fluid management for hydration, nutritional support, and
treatment of associated medical problems and complications.
5. Which of the ff findings is most indicative of a ruptured aortic aneurysm
A. Back pain
B. bounding peripheral pulses
C. intermittent claudication
D. warm, flushed skin: A. An aneurysm is the localized dilation of an artery.
Should an aneurysm rupture, blood will build up under pressure in the tissues
surrounding the aorta, which can result in acute pain and tenderness in theses
areas. This is particularly the case if the aneurysm leaks from the back of the
aorta. Ruptured AAA presents with a classic triad of pain in the flank or back,
hypotension and a pulsatile abdominal mass; however, only about half of the
full triad. The pt will complain of the pain and may feel cold, sweaty and faint on
standing. The pt may also report abdominal pain. A small percentage may have
vomiting
, PCCN Questions And Answer
6. According to recommendations based on research findings, pain
assessment should occur
A. based on changes in vital signs
B. only when the pt movements indicate the pt is seeking attention
C. routinely, regardless of physical findings
D. only when the presence of pain can be validated: C. Pain is considered the
fifth vital sign and must be assessed regularly. Presence of physical findings
may be part of the comprehensive assessment of pain. However, physical
findings may not be present in all patients with pain
7. A pt with a tracheostomy requires frequent suctioning for thick sputum,
A nurse finds a colleague instilling saline in the endotracheal tube prior to
suctioning. The most appropriate response by the nurse would be to
A. report the colleague to the charge nurse or manager
B. noted the practice on the pt chart to ensure consistency of suctioning
techniques
C. ask the attending physician to review the suctioning policy.
D. collaborate with the colleague to review the evidence about this practice.:
D. In addition to an unappreciable increase in sputum recovery, use of NS
adversely affects arterial and global tissue oxygenation and dislodges bacterial
colonies, thus contributing to lower airway contamination. Other harmful pt
outcomes have been reported in the nursing literature, including delays in
return to baseline vital signs, Spo2 and intracranial pressure. Because no solid
scientifically based benefits for routine use of normal saline have been shown,
it is highly recommended that this potentially harmful practice be abandoned.
Instead, treatment considerations should center on ways to prevent the
development of thick tenacious secretions. A review of these data should take
place with the colleague to help mitigate continuation of this dangerous practice
8. Upon admission to the PCU, you screen a pt to determine whether to
administer an influenza vaccine. Which of the following is a contraindication
to the vaccine?
A. Guillian-Barre syndrome
B. chronic renal failure
C. COPD
, PCCN Questions And Answer
D. cirrhosis: A. Persons who developed Guillain-Barre syndrome after receiving
an influenza vaccine should not receive the influenza vaccine without checking
with their provider
9. Emergency treatment of ventricular dysrhythmias for the pt who has an
ICD pacemaker includes which of the following
A. If a pt develops vfib, the nurse should not defibrillate with external
paddles B. if the ICD is firing correctly and the pt does not have pulse, CPR
is not indicated
C. when preparing for external defibrillation, avoid placing the paddle
directly over the ICD pulse generator
D. when you need to turn off all functions of the ICD or pacemaker, apply
a magnet: C. Defibrillation has been known to cause malfunction of an ICD or
pacemaker. Care should be taken to ensure the defibrillation paddle/ pads are
applied at least 4-finger breaths away from the device. The anterior-lateral and
anterior-posterior positions for paddle/pad placement are acceptable in a pt with a
permanent ICD or pacemaker. The pads may also be placed safely away from the
ICD with 1 pad at the apex left mid-axillary, 5th ICS., and the other pad right of the
sternum just below the clavicle.
Based on the device implanted and the manufacturer, application of a magnet may
turn device off or reset to the default settings.
10. A pt is admitted following mitral valve replacement. Which of the
following
should most likely be included in the patent's plan of care
A. positive inotropic agent
B. anticoagulant
C. prophylactic antibiotic
D. ACE inhibitor: B. Anticoagulatn therapy recommendations are based on the
valve apparatus and the pt risk factors (afib, LV dyfunction, previous
thromboembolism, and hypercoagulable condition). Mechanical valve
replacement require lifelong anticoagulant therapy, while most pt with
bioprosthetic valve replacement require short term anti-coagulation (3 months).
In pt with NSR and no risk factors for thrombus, only aspirin therapy is
recommended after bioprosthetic valve replacement.
11. A pt with multiple rib fractures sustained in a motor vehicle collision 4
days ago reports sudden chest pain and difficulty breathing. Chest xray
