Certification Test Prep

Certification Test Prep Top 10 Review Tips

T

he television show Late Night With David Letterman may not have invented the top 10 list, but the show certainly made it more popular. Here is a top 10 list for preparing to take an acute or critical care certification examination. 10. Read an acute or critical care textbook. 9. Talk to a colleague who has passed the examination. 8. Take an Advanced Cardiovascular Life Support (ACLS) class. 7. Retake a basic critical care course or an American Association of Critical-Care Nurses Essentials of Critical Care Orientation (AACN-ECCO) program. 6. Form a study group and review together. 5. Review the test blueprint and create a study plan for the areas of weakness. 4. Make (or buy) and review flash cards with questions. 3. Attend a certification review course live or webinar. 2. Take practice questions from a book, website, or the AACN Self-Assessment Exam (AACN-SAE). 1. Take the review questions in each issue of Critical Care Nurse.

CCRN Practice Questions 1. A patient with end-stage liver failure, ascites, and bleeding esophageal varices is treated with a Sengstaken-Blakemore tube, a vasopressin infusion at 0.5 U/min, and normal saline at 150 mL/h.The patient is agitated, restless, and appears cyanotic. The nurse’s priority is to A. Call for the respiratory therapist to intubate B. Apply oxygen via nonrebreather and get a sample for arterial blood gas (ABG) analysis C. Cut the balloon lumens with scissors D. Begin cardiopulmonary resuscitation (CPR) and administer 1mg intravenous (IV) epinephrine Test plan topic: Gastrointestinal, 6% of the CCRN questions

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Contributors Carol Rauen, RN, MS, CCNS, CCRN, PCCN, CEN, RN-BC, the department editor, is an independent clinical nurse specialist in The Outer Banks of North Carolina. Carol welcomes feedback from readers and practice questions from potential contributors at [email protected]. Mary Beth Flynn Makic, RN, PhD, CNS, CCNS, is a research nurse scientist in critical care at University of Colorado Hospital and an associate professor adjoint at the University of Colorado College of Nursing. She contributed the PCCN-specific questions. Lisa M. Soltis, MSN, APRN, PCCN, CCRN-CSC, CCNS, is a cardiovascular/ critical care clinical nurse specialist for Wake Med Health & Hospital in Raleigh, North Carolina. She contributed the CCRN questions. ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014547

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2. In addition to hypocalcemia, which of the following laboratory findings are expected for a patient with pancreatitis? A. Elevated serum level of amylase and decreased serum level of lipase B. Elevated serum level of lipase and hypoglycemia C. Decreased serum level of amylase and lipase D. Elevated serum level of amylase and hyperglycemia Test plan topic: Gastrointestinal, 6% of the CCRN questions

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3. What would be the most common laboratory finding for a patient with a history and symptoms consistent with the syndrome of inappropriate antidiuretic hormone (SIADH)? A. Hyponatremia B. Hyperkalemia C. Hyperosmolality D. Hypocalcemia Test plan topic: Endocrine, 5% of the CCRN questions 4. A patient complaining of shortness of breath and feelings of extreme anxiety is tachypneic, tachycardic, and using accessory muscles. What type of ventilation/perfusion (V/Q ) mismatch is occurring? A. Intrapulmonary shunt B. Silent unit C. Increased ratio of PaO2 to fraction of inspired oxygen (FIO2) D. Physiologic dead space Test plan topic: Pulmonary, 18% of the CCRN questions 5. A trauma victim has sustained right rib fractures and pulmonary contusions. Auscultation reveals decreased breath sounds on the right side. Blood pressure (BP) was 85/40 mm Hg, heart rate (HR) was 130/min, respiratory rate (RR) was 32/min, and breathing was slightly labored. In addition to oxygen administration, the nurse should prepare for A. Thoracentesis and IV administration of fluid B. Chest tube insertion and fluid bolus C. Emergent intubation and thoracotomy D. Pericardiocentesis and administration of a bolus of IV fluid Test plan topic: Pulmonary, 18% of the CCRN questions

Correct Answers and Rationales for CCRN Questions 1. Correct Answer: C Rationale

Asphyxiation or aspiration can occur if the tube migrates and occludes the airway. A pair of scissors must be at the bedside so that the 3 balloon lumens can be cut if needed. Calling a respiratory therapist (A) or giving supplemental oxygen (B) will not treat the acute emergency, and a delay

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in treatment could worsen the situation and cause irreversible damage. The situation does not involve a patient who is coding, so beginning CPR (D) would not be required. Source

Chulay M, Burns SM. AACN Essentials of Critical Care Nursing. 2nd ed. New York, NY: McGraw Hill; 2010:335.

2. Correct Answer: D Rationale

Pancreatitis is commonly diagnosed on the basis of laboratory values. The most classic findings are elevated levels of 2 of the enzymes made in the pancreas: serum amylase and lipase. Two other common findings are hypocalcemia and hyperglycemia. Source


3. Correct Answer: A Rationale

The increased production of ADH causes decreased urinary output and fluid overload resulting in a serum hyponatremia and low osmolality. The fluid overload state would cause hypokalemia and low osmolality. Source



Physiologic dead space will occur when there is poor perfusion but adequate ventilation with a pulmonary embolism. Intrapulmonary shunt (A) occurs when there is poor ventilation but adequate perfusion (acute respiratory distress syndrome [ARDS], pneumonia). A silent unit (B) is when there is no perfusion and no ventilation (cardiac arrest), and a PaO2:FIO2 ratio (C) is used to predict shunting and hypoxemia. Source

Chulay M, Burns SM. AACN Essentials of Critical Care Nursing. 2nd ed. New York, NY: McGraw Hill; 2010:272-273.

5. Correct Answer: B Rationale

The patient has rib fractures with decreased breath sounds and signs of respiratory distress. Chest tube



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placement can help with potential hemo/pneumothorax, oxygen would be indicated, and a fluid bolus would be the first-line treatment for hypotension. The chest tube placement will essentially provide a thoracentesis (A) and allow for continuous draining. Although intubation (C) and pericardiocentesis (D) might be required in a person with blunt chest trauma, the immediate priority will be the insertion of the chest tube. Source


Progressive Care Nursing (PCCN) Practice Questions 1. The nurse notes the following when analyzing a patient’s telemetry strip: HR, 65/min and regular; PR interval, 0.22 seconds; QRS complex, 0.10 seconds; QTc, 0.52 seconds. Which of the following dysrhythmias is the patient at risk for? A. Atrial fibrillation because the PR interval is wide B. Sinus arrhythmia because the QRS complex is narrow C. Torsades de pointes because the QTc is wide D. Third-degree heart block because the PR interval is narrow Test plan topic: Cardiovascular, 32% of the PCCN questions 2. A patient with chronic obstructive pulmonary disease (COPD) is admitted for worsening dyspnea and possible pneumonia. The current ABG results are pH, 7.19; PaO2, 52 mm Hg; PaCO2, 68 mm Hg; HCO3-, 32 mmol/L. The nurse would interpret these results as A. Metabolic acidosis with hypoxemia B. Respiratory acidosis with hypoxemia C. Respiratory alkalosis with typical oxygenation for a COPD patient D. Metabolic alkalosis with typical oxygenation for a COPD patient Test plan topic: Pulmonary, 14% of the PCCN questions 3. A 76-year-old patient is receiving gentamicin and linezolid for an infection. Which of the following potential complications is the most important for the nurse to monitor this patient for?

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A. Acute delirium B. Acute kidney injury C. Acute hepatic failure D. Sepsis Test plan topic: Renal, 6% of the PCCN questions 4. An older patient is experiencing delirium 24 hours following hip replacement. Which intervention might worsen the patient’s condition? A. Removing any unnecessary tubes and equipment from the room B. Assessing and treating the patient’s pain every 2 hours C. Ensuring that the patient has a means to call for help D. Loosely applying soft restraints Test plan topic: Behavioral, 4% of the PCCN questions 5. A patient shows a new slight facial droop and the patient’s right arm is weaker than the left. A priority intervention would be to A. Obtain a serum glucose level B. Obtain a full set of vital signs C. Initiate the stroke protocol D. Initiate the code response team Test plan topic: Neurological, 5% of the PCCN questions

Correct Answers and Rationales for PCCN Questions 1. Correct Answer: C Rationale

QT measurements reflect the duration of ventricular repolarization. Lengthening of QT interval is associated with arrhythmias, adverse cardiac events, and increased mortality because a longer QT duration places the vulnerable ventricular repolarization phase close to the next depolarization, increasing the likelihood of R-on-T. The most common arrhythmia that occurs with prolonged QTc is torsades de pointes. Atrial fibrillation, sinus bradycardia, and third-degree heart block are not typically associated with prolonged ventricular repolarization (QTc >0.50 seconds).

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Sources

Pickham D. Understanding and documenting QT intervals. Crit Care Nurse. 2013;33:73-75. Webner C. Applying evidence at the bedside: a journey to excellence in bedside cardiac monitoring. Dimens Crit Care Nurs. 2011;30(1):8-18.


Based on the ABG analysis, the patient is experiencing a respiratory acidosis with hypoxemia most likely due to the pneumonia. A pH of 7.19 indicates acidosis; a PaCO2 of 68 mm Hg is elevated and a cause of acidosis; an HCO3- of 32 mmol/L indicates renal compensation; a PaO2 of 52 mm Hg indicates hypoxemia. Source

Lian XJ. Using ABGs to optimize mechanical ventilation. Nursing. 2013;43(6): 46-52.


Gentamicin is a nephrotoxic agent that places patients at risk for acute kidney injury, and this risk is increased in older patients. Acute delirium (A), liver failure (C), and sepsis (D) are all complications that could occur in an older adult with an infection but would not be caused by the administration of an antibiotic.

5. Correct Answer: C Rationale

The stroke protocol should be activated as soon as signs of stroke are identified in a patient. Initial signs of stroke include facial droop, arm down drift, and garbled speech. For best outcomes, the time elapsed between initials signs of stroke and treatment must be as short as possible. Sources

National Stroke Association. Warning Signs of Stroke: FAST. http://www.stroke .org/site/PageServer?pagename=symp&s_subsrc=SEM_google_grant _Keyword%20Correlation_Symptoms%20Of%20Stroke_stroke%20symptoms _b_17770654790&utm_source=google&utm_medium=grant&utm _campaign=Keyword%20Correlation. Accessed January 14, 2014. 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke. http://my.americanheart.org/professional/ScienceNews/2013 -Guidelines-for-the-Early-Management-of-Patients-with-Acute-Ischemic -Stroke_UCM_448778_Article.jsp. Accessed January 14, 2014.

AACN Certcorp publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN Certification exam handbook. The contributor of each question written for this column has listed the source used in developing each item. CCN

Sources

Dirkes S. Acute kidney injury: not just acute renal failure anymore. Crit Care Nurse. 2011;31:37-50. Dugdale D. Basic metabolic panel. MedlinePlus. http://www.nlm.nih.gov /medlineplus/ency/article/003462.htm. Accessed January 16, 2014.


Older patients are at increased risk for delirium during acute hospitalization. Interventions to manage acute delirium include removing or camouflaging tubes, removing unnecessary equipment, frequently reorienting the patient, and ensuring that the call bell is consistently within reach, assessing and treating pain effectively, and encouraging mobility and involvement in activities of daily living. Restraining the patient is contraindicated in the care of patients with delirium. Sources

Balas MC, Rice M, Chaperon C, et al. Management of delirium in critically ill older adults. Crit Care Nurse. 2012;32:15-26. doi: 10.4037/ccn2012480. Bell L. AACN practice alert: delirium assessment and management. http://www .aacn.org/wd/practice/content/practicealerts/delirium-practice-alert .pcms?menu=practice. Accessed January 16, 2014.

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Top 10 Review Tips Carol Rauen, Mary Beth Flynn Makic and Lisa M. Soltis Crit Care Nurse 2014;34 69-72 10.4037/ccn2014547 ©2014 American Association of Critical-Care Nurses Published online http://ccn.aacnjournals.org/ Personal use only. For copyright permission information: http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

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Critical Care Nurse is an official peer-reviewed journal of the American Association of Critical-Care Nurses (AACN) published bimonthly by AACN, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright ©2016 by AACN. All rights reserved.
