CCRN (Adult) - Direct Care Eligibility Pathway v1.0

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Exam contains 146 questions

A patient is admitted with a traumatic brain injury after being thrown from a horse. Despite numerous interventions, the patient is declared brain dead. The parents have consented for organ donation, and the patient's mother requests to lay next to her daughter before being taken to the operating room. Which of the following is the nurse's most appropriate response?

  • A. "Please sit at the side of the bed, hold her hand, and talk to her."
  • B. "I will need a few minutes to prepare and organize this for you."
  • C. "It would be too risky to move all of the machines and wires."
  • D. "We must obtain permission from the organ donation team first."


Answer : B

The nurse is caring for a patient with an unstable pelvic fracture related to a crush injury. The patient suddenly develops a fever, hypotension, tachycardia, respiratory distress, and petechiae is noted on the face and chest. The nurse should suspect

  • A. compartment syndrome.
  • B. sepsis.
  • C. hypovolemic shock.
  • D. a fat embolus.


Answer : D

A patient who had a liver resection now has a copious amount of serous drainage from the surgical incision. Which of the following should a nurse anticipate when caring for this patient?

  • A. preparing for an incision and debridement of the wound
  • B. administering antibiotics
  • C. applying several abdominal dressings
  • D. applying a drainage pouch to the site


Answer : D

A patient with acute salicylate overdose will most likely have which of the following acid-base disturbances?

  • A. respiratory alkalosis
  • B. metabolic alkalosis
  • C. metabolic acidosis
  • D. respiratory acidosis


Answer : A

On evaluation of an infected pressure injury in a patient admitted with pneumonia, the nurse discovers bone exposed at the base of the wound. The nurse should be concerned with

  • A. malnutrition.
  • B. osteomyelitis.
  • C. necrotizing fasciitis.
  • D. gas gangrene.


Answer : B

A family nurse is caring for a patient who is actively dying and has several family members present. According to the unit policy, two visitors are allowed at the bedside for 15 minute intervals. The family requests that all members be able to visit together and have extended time with the patient. Which of the following is the nurse's best response?

  • A. "Two visitors can come in the room at any time."
  • B. "One extra person can visit the patient at a time."
  • C. "You can all visit your loved one as needed."
  • D. "You need to follow our unit's visiting policy."


Answer : C

An older adult patient is admitted with acute exacerbation of congestive heart failure. An echocardiogram indicates that EF is unchanged at 50%. The patient is most likely experiencing

  • A. heart failure with preserved EF.
  • B. left ventricular failure.
  • C. heart failure with reduced EF.
  • D. advanced heart failure.


Answer : A

A patient with a history of mastoiditis presents with fever, malaise, vomiting, altered level of consciousness, muscle hypotonia, and new-onset seizures. These symptoms are most indicative of

  • A. Guillain-Barré syndrome.
  • B. CVA.
  • C. meningitis.
  • D. a transient ischemic attack.


Answer : C

An intra-aortic balloon pump (IABP) is used in a patient with heart failure to

  • A. increase preload.
  • B. decrease afterload.
  • C. increase afterload.
  • D. decrease preload.


Answer : B

Assessment of a patient with a head injury reveals increased muscle tone and contractures positioning of the upper extremities. A nurse should

  • A. consult a physical therapist regarding appropriate positioning.
  • B. recognize that contractures are an expected response after a head injury.
  • C. obtain an order for a muscle relaxer.
  • D. use wrist restraints to maintain upper extremity extension.


Answer : A

A patient with pneumonia is mechanically ventilated. A nursing student asks why the nurse is performing in-line and oral suction when subglottic responds that in-line, oral, and subglottic suction are performed suction is also being used. The nurse

  • A. to stimulate the cough reflex and mobilize secretions.
  • B. together as part of the nursing process.
  • C. along with saline lavage to loosen secretions.
  • D. to prevent pathogens from migrating into the lungs.


Answer : D

A patient has visitors whose loud talking and laughing disrupts other patients and visitors in the ICU. Which of the following is the most effective way for a nurse to address this situation?

  • A. Initiate discussions about a visiting plan that includes behavioral limits.
  • B. Discuss the developmental needs of the patient with the family.
  • C. Create a visiting contract that includes behavioral limits and present it to the family.
  • D. Consult the social worker to create a visiting contract.


Answer : A

Which of the following intubated patients is most at risk for developing ventilator-associated pneumonia (VAP)?

  • A. 91-year-old patient, 54 kg, from home with osteoporosis and hypothyroidism
  • B. 84-year-old patient, 38 kg, from a skilled nursing facility receiving chemotherapy for colorectal cancer
  • C. 68-year-old patient, 142 kg, from an assisted living facility with COPD and dialysis-dependent renal disease
  • D. 72-year-old patient, 81 kg, from a nursing home with heart failure and chronic bronchitis


Answer : B

Which of the following should a nurse anticipate in a patient with alcohol dependence after abrupt cessation of alcohol?

  • A. asterixis
  • B. coagulopathy
  • C. seizure
  • D. hypermagnesium


Answer : C

A patient who has a Sengstaken-Blakemore tube must be monitored for proper tube position and balloon inflation to reduce the risk of

  • A. complete airway obstruction.
  • B. hepatic congestion.
  • C. gastric tamponade.
  • D. duodenal perforation.


Answer : A

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Exam contains 146 questions

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