Certification Test Prep Becoming Certified Is Wicked Good
T
he words of 2 characters from the musical “Wicked” represent the 2 sides of the “self-talk” many of us engage in when we are thinking about stepping up professionally. These lyrics offer 2 divergent philosophies. The male lead, Flyero, in his song “Dancing Through Life,” says “Why invite stress in? Stop studying strife and learn to live the unexamined life. Life is more painless for the brainless. Life is fraught less when you are thoughtless. Those who don’t try—never look foolish.” The female lead, Elphaba, in her song “Defying Gravity,” says “I’m through accepting limits because someone says they’re so. But till I try, I’ll never know! Too late for second-guessing. Too late to go back to sleep. It’s time to trust my instincts. Close my eyes and leap! I think I’ll try defying gravity and you cannot bring me down. Everyone deserves a chance to fly.” Obviously the more challenging route has the potential burdens of stress, strife, and risk of failure. Most nurses do not choose the path toward certification because it is easy, they choose it because it is wicked good. Good for patients, practice, and professionally. Trust your instincts and go defy gravity, fly, and get certified.
RAUEN
STANCZAK
BIRCHMEIER
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]. Donna Stanczak, RN, MSN, CCRN, clinical educator in the surgical intensive care unit at MedStar Georgetown University Hospital, Washington, DC, contributed the CCRN questions. Tammy Birchmeier, MSN, CCRN, CCNS, assistant professor at Sentara College of Health Sciences, Chesapeake, Virginia, contributed the progressive care nursing (PCCN) questions. ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014162
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CCRN Practice Questions 1. Measurement of an anion gap is most helpful in determining the cause of which acid-base imbalance? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis Test plan topic: Pulmonary, 18% of the CCRN questions 2. A patient has just arrived from the emergency department (ED) complaining of shortness of breath. A sample for arterial blood gas analysis (ABG) was collected and the results are pH 7.54, PaCO2 30 mm Hg, HCO324 mm Hg, PaO2 100 mm Hg. In addition to ventricular ectopy, the nurse would expect the patient to exhibit circumoral A. Tingling and hyperreflexia B. Cyanosis and decreased deep tendon reflexes C. Tingling and decreased deep tendon reflexes D. Cyanosis and hyperreflexia Test plan topic: Pulmonary, 18% of the CCRN questions 3. A patient with upper gastrointestinal (GI) bleeding from esophageal varices is receiving vasopressin therapy. Which of
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the following new assessment findings should receive the highest priority? A. Nausea B. Abdominal pain C. Melena D. Increased urine output Test plan topic: Gastrointestinal, 6% of the CCRN questions. 4. In addition to serum blood glucose monitoring, what interventions would a critical care nurse anticipate for a patient with hepatic encephalopathy? A. High-protein diet, Kayexalate (sodium polystyrene), sedation B. Low-protein diet, Kayexalate, sedation C. Low-protein diet, lactulose, no sedatives D. High-protein diet, lactulose, no sedatives Test plan topic: Gastrointestinal, 6% of the CCRN questions. 5. The nurse receives a critical value call for a potassium level of 8 mEq/L for a patient with acute kidney injury. Which of the treatment orders helps to remove potassium from the body? A. Intravenous (IV) insulin and 50% dextrose B. Kayexalate C. IV sodium bicarbonate D. IV calcium chloride Test plan topic: Renal, 6% of the CCRN questions
Correct Answers and Rationales for CCRN Practice Questions 1. Correct Answer: D Rationale
The anion gap is used to evaluate patients in metabolic acidosis to determine if the problem is an accumulation of hydrogen ions or a loss of bicarbonate. The normal anion gap is 12 (±2) mEq/L. A metabolic acidosis with a anion gap greater than 14 mEq/L is most likely caused by an accumulation of organic acid (eg, lactic acid or ketoacids). A metabolic acidosis with a normal anion gap indicates a decrease in bicarbonate concentration (eg, diarrhea, fluid resuscitation with normal saline). Source
Burns SM. AACN Essentials of Critical Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014:122.
www.ccnonline.org
2. Correct Answer: A Rationale
Respiratory alkalosis is a condition where the pH is greater than 7.45 and the PaCO2 is less than 35 mm Hg. A state of alkalosis results in increased calcium binding to albumin, resulting in a decrease in ionized calcium. Hypocalcemia is accompanied by circumoral tingling, hyperreflexia, and ventricular ectopy. Circumoral cyanosis would indicate a decrease in oxygen level, and decreased deep tendon reflexes would indicate elevated calcium levels. Source
Burns SM. AACN Essentials of Critical Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014:390.
3. Correct Answer: B Rationale
Vasopressin is a potent vasoconstrictor that can lead to the development of acute mesenteric ischemia. Patients with variceal bleeding frequently have nausea (A) and melena (C). Vasopressin is an antidiuretic (D) hormone, so urine output would be decreased. Source
Burns SM. AACN Essentials of Critical Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014:206.
4. Correct Answer: C Rationale
Low blood sugar can potentially aggravate preexistent encephalopathy. A low-protein diet decreases the production of urea, which produces bacteria. Lactulose traps ammonia and facilitates elimination by the GI tract. The accumulation of sedatives not cleared by the liver can worsen encephalopathy. Kayexalate facilitates the elimination of potassium by the GI tract but has no effect on encephalopathy. Source
Burns SM. AACN Essentials of Critical Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014:363.
5. Correct Answer: B Rationale
All of these medications are used to manage a patient with a critically high potassium level. IV insulin and dextrose (A) or IV sodium bicarbonate (C) transfer potassium into the cell. Calcium chloride (D) directly antagonizes the membrane actions of potassium on the heart.
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Of all choices presented, Kayexalate is the only one that actually removes potassium from the body. Source
Burns SM. AACN Essentials of Critical Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014:392.
PCCN Practice Questions 1. Which clinical finding most alerts the nurse to the possibility of the most serious complication in a patient with atrial fibrillation? A. Speech alterations B. Increased fatigue C. Increased heart rate D. Dyspnea with activity Test plan topic: Cardiovascular, 33% of the PCCN questions
Test plan topic: Pulmonary, 14% of the PCCN questions 5. Which of the following clinical situations correlates with arterial blood gas results of pH 7.22, HCO3- 23 mEq/L, PaCO2 65 mm Hg, PaO2 56 mm Hg? A. Acute tracheal obstruction B. Anxiety-induced hyperventilation C. Chronic obstructive pulmonary disease (COPD) D. Diarrhea for 36 hours in a debilitated patient Test plan topic: Pulmonary, 14% of the PCCN questions
Correct Answers and Rationales for PCCN Practice Questions 1. Correct Answer: A Rationale
2. A patient receiving oxygen via Venturi mask at 40% is cyanotic with labored respirations. Which action should be performed first? A. Call respiratory therapy to check the oxygen saturation B. Listen to lung sounds and obtain a respiratory rate C. Remove bedding from around the adaptor opening D. Call the Rapid Response Team immediately
Atrial fibrillation increases the risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Atrial fibrillation often has a rapid ventricular response as a result (C). Fatigue (B) is a nonspecific complaint and dyspnea (D) may result from the decreased cardiac output that may occur with rhythm disturbance.
Test plan topic: Pulmonary, 14% of the PCCN questions
Source
3. The nurse observes a prominent U wave on an electrocardiograph (ECG) tracing. Which action is most appropriate for the nurse to take? A. Document the finding as a normal variant B. Review the patient’s daily electrolyte results C. Move the code cart outside the patient’s room D. Perform a 12-lead electrocardiogram immediately Test plan topic: Renal, GI, Heme, and Endocrine together make up 18% of the PCCN questions 4. A patient has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar. Which assessment finding requires immediate action by the nurse? A. Blood-tinged sputum B. Rhonchi in upper lobes bilaterally C. Dry mucous membranes D. Frequent nonproductive cough
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American Heart Association. Advanced Cardiovascular Life Support Provider Manual. Dallas, TX: American Heart Association; 2011.
2. Correct Answer: C Rationale
The Venturi mask works by drawing in a specific amount of air to mix with the oxygen through holes in an adaptor fitted at the bottom of the mask. Holes of different sizes allow different amounts of room air to be entrained, changing the amount of oxygen delivered. Bedding (or clothing) wrapped around those holes would effectively change the fraction of inspired oxygen (FIO2). The nurse should ensure that the holes remain unobstructed. Other options are appropriate but are not the first choice, because this simple step may solve the problem. Source
St. John R, Seckel M. Airway and ventilator management. In: Burns S. AACN Essentials of Progressive Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014:107-109.
www.ccnonline.org
3. Correct Answer: B Rationale
Prominent U waves may be the result of hypokalemia. The nurse should review the patient’s electrolyte results. Although documentation (A) is important, this is not a normal variant. Moving the crash cart (C) closer to the room may or may not be warranted. Although this finding may warrant a 12-lead ECG (D), it is not the nurse’s immediate priority and may be delegated.
Source
St. John R, Seckel A. Airway and ventilatory management. In: Burns S, ed. AACN Essentials of Progressive Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014: 93-131.
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
Source
Riera AR. The enigmatic sixth wave of the electrocardiogram: the U wave. Cardiol J. 2008;15(5):408-421.
4. Correct Answer: D Rationale
Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough, substernal chest pain, GI upset, and dyspnea. Pulmonary toxicity symptoms result from an inflammation that starts in the airways leading to the lungs and then spreads into the lungs. The symptoms appear in the upper chest region (substernal and carnal regions). This begins as a mild tickle on inhalation and progresses to frequent coughing. Blood-tinged sputum (A) is expected in patients with new tracheostomies. Rhonchi (B) in upper lobes indicate sputum that can be expectorated and are not an emergent problem. Dry mucous membranes (C) should be lubricated, and the client’s hydration status can be checked. Source
Mach WJ, Thimmesch AR, Pierce JT, Pierce JD. Consequences of hyperoxia and the toxcity of oxygen in the lung. Nurs Res Pract. 2011:260482. doi:10.1155/2011/260482.
5. Correct Answer: A Rationale
The ABG values indicate a respiratory acidosis with normal levels of bicarbonate, suggesting that the problem is not metabolic. The low oxygen and high carbon dioxide levels are consistent with respiratory acidosis from hypoventilation. The lack of metabolic compensation demonstrates an acute event. Hyperventilation (B) commonly manifests as a respiratory alkalosis, COPD (C) with respiratory acidosis with hypoxia and partial or attempted metabolic compensation, and diarrhea (D) with metabolic acidosis.
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CriticalCareNurse
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67
Copyright of Critical Care Nurse is the property of American Association of Critical-Care Nurses and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
T
he words of 2 characters from the musical “Wicked” represent the 2 sides of the “self-talk” many of us engage in when we are thinking about stepping up professionally. These lyrics offer 2 divergent philosophies. The male lead, Flyero, in his song “Dancing Through Life,” says “Why invite stress in? Stop studying strife and learn to live the unexamined life. Life is more painless for the brainless. Life is fraught less when you are thoughtless. Those who don’t try—never look foolish.” The female lead, Elphaba, in her song “Defying Gravity,” says “I’m through accepting limits because someone says they’re so. But till I try, I’ll never know! Too late for second-guessing. Too late to go back to sleep. It’s time to trust my instincts. Close my eyes and leap! I think I’ll try defying gravity and you cannot bring me down. Everyone deserves a chance to fly.” Obviously the more challenging route has the potential burdens of stress, strife, and risk of failure. Most nurses do not choose the path toward certification because it is easy, they choose it because it is wicked good. Good for patients, practice, and professionally. Trust your instincts and go defy gravity, fly, and get certified.
RAUEN
STANCZAK
BIRCHMEIER
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]. Donna Stanczak, RN, MSN, CCRN, clinical educator in the surgical intensive care unit at MedStar Georgetown University Hospital, Washington, DC, contributed the CCRN questions. Tammy Birchmeier, MSN, CCRN, CCNS, assistant professor at Sentara College of Health Sciences, Chesapeake, Virginia, contributed the progressive care nursing (PCCN) questions. ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014162
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CCRN Practice Questions 1. Measurement of an anion gap is most helpful in determining the cause of which acid-base imbalance? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis Test plan topic: Pulmonary, 18% of the CCRN questions 2. A patient has just arrived from the emergency department (ED) complaining of shortness of breath. A sample for arterial blood gas analysis (ABG) was collected and the results are pH 7.54, PaCO2 30 mm Hg, HCO324 mm Hg, PaO2 100 mm Hg. In addition to ventricular ectopy, the nurse would expect the patient to exhibit circumoral A. Tingling and hyperreflexia B. Cyanosis and decreased deep tendon reflexes C. Tingling and decreased deep tendon reflexes D. Cyanosis and hyperreflexia Test plan topic: Pulmonary, 18% of the CCRN questions 3. A patient with upper gastrointestinal (GI) bleeding from esophageal varices is receiving vasopressin therapy. Which of
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the following new assessment findings should receive the highest priority? A. Nausea B. Abdominal pain C. Melena D. Increased urine output Test plan topic: Gastrointestinal, 6% of the CCRN questions. 4. In addition to serum blood glucose monitoring, what interventions would a critical care nurse anticipate for a patient with hepatic encephalopathy? A. High-protein diet, Kayexalate (sodium polystyrene), sedation B. Low-protein diet, Kayexalate, sedation C. Low-protein diet, lactulose, no sedatives D. High-protein diet, lactulose, no sedatives Test plan topic: Gastrointestinal, 6% of the CCRN questions. 5. The nurse receives a critical value call for a potassium level of 8 mEq/L for a patient with acute kidney injury. Which of the treatment orders helps to remove potassium from the body? A. Intravenous (IV) insulin and 50% dextrose B. Kayexalate C. IV sodium bicarbonate D. IV calcium chloride Test plan topic: Renal, 6% of the CCRN questions
Correct Answers and Rationales for CCRN Practice Questions 1. Correct Answer: D Rationale
The anion gap is used to evaluate patients in metabolic acidosis to determine if the problem is an accumulation of hydrogen ions or a loss of bicarbonate. The normal anion gap is 12 (±2) mEq/L. A metabolic acidosis with a anion gap greater than 14 mEq/L is most likely caused by an accumulation of organic acid (eg, lactic acid or ketoacids). A metabolic acidosis with a normal anion gap indicates a decrease in bicarbonate concentration (eg, diarrhea, fluid resuscitation with normal saline). Source
Burns SM. AACN Essentials of Critical Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014:122.
www.ccnonline.org
2. Correct Answer: A Rationale
Respiratory alkalosis is a condition where the pH is greater than 7.45 and the PaCO2 is less than 35 mm Hg. A state of alkalosis results in increased calcium binding to albumin, resulting in a decrease in ionized calcium. Hypocalcemia is accompanied by circumoral tingling, hyperreflexia, and ventricular ectopy. Circumoral cyanosis would indicate a decrease in oxygen level, and decreased deep tendon reflexes would indicate elevated calcium levels. Source
Burns SM. AACN Essentials of Critical Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014:390.
3. Correct Answer: B Rationale
Vasopressin is a potent vasoconstrictor that can lead to the development of acute mesenteric ischemia. Patients with variceal bleeding frequently have nausea (A) and melena (C). Vasopressin is an antidiuretic (D) hormone, so urine output would be decreased. Source
Burns SM. AACN Essentials of Critical Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014:206.
4. Correct Answer: C Rationale
Low blood sugar can potentially aggravate preexistent encephalopathy. A low-protein diet decreases the production of urea, which produces bacteria. Lactulose traps ammonia and facilitates elimination by the GI tract. The accumulation of sedatives not cleared by the liver can worsen encephalopathy. Kayexalate facilitates the elimination of potassium by the GI tract but has no effect on encephalopathy. Source
Burns SM. AACN Essentials of Critical Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014:363.
5. Correct Answer: B Rationale
All of these medications are used to manage a patient with a critically high potassium level. IV insulin and dextrose (A) or IV sodium bicarbonate (C) transfer potassium into the cell. Calcium chloride (D) directly antagonizes the membrane actions of potassium on the heart.
CriticalCareNurse
Vol 34, No. 6, DECEMBER 2014
65
Of all choices presented, Kayexalate is the only one that actually removes potassium from the body. Source
Burns SM. AACN Essentials of Critical Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014:392.
PCCN Practice Questions 1. Which clinical finding most alerts the nurse to the possibility of the most serious complication in a patient with atrial fibrillation? A. Speech alterations B. Increased fatigue C. Increased heart rate D. Dyspnea with activity Test plan topic: Cardiovascular, 33% of the PCCN questions
Test plan topic: Pulmonary, 14% of the PCCN questions 5. Which of the following clinical situations correlates with arterial blood gas results of pH 7.22, HCO3- 23 mEq/L, PaCO2 65 mm Hg, PaO2 56 mm Hg? A. Acute tracheal obstruction B. Anxiety-induced hyperventilation C. Chronic obstructive pulmonary disease (COPD) D. Diarrhea for 36 hours in a debilitated patient Test plan topic: Pulmonary, 14% of the PCCN questions
Correct Answers and Rationales for PCCN Practice Questions 1. Correct Answer: A Rationale
2. A patient receiving oxygen via Venturi mask at 40% is cyanotic with labored respirations. Which action should be performed first? A. Call respiratory therapy to check the oxygen saturation B. Listen to lung sounds and obtain a respiratory rate C. Remove bedding from around the adaptor opening D. Call the Rapid Response Team immediately
Atrial fibrillation increases the risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Atrial fibrillation often has a rapid ventricular response as a result (C). Fatigue (B) is a nonspecific complaint and dyspnea (D) may result from the decreased cardiac output that may occur with rhythm disturbance.
Test plan topic: Pulmonary, 14% of the PCCN questions
Source
3. The nurse observes a prominent U wave on an electrocardiograph (ECG) tracing. Which action is most appropriate for the nurse to take? A. Document the finding as a normal variant B. Review the patient’s daily electrolyte results C. Move the code cart outside the patient’s room D. Perform a 12-lead electrocardiogram immediately Test plan topic: Renal, GI, Heme, and Endocrine together make up 18% of the PCCN questions 4. A patient has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar. Which assessment finding requires immediate action by the nurse? A. Blood-tinged sputum B. Rhonchi in upper lobes bilaterally C. Dry mucous membranes D. Frequent nonproductive cough
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CriticalCareNurse
Vol 34, No. 6, DECEMBER 2014
American Heart Association. Advanced Cardiovascular Life Support Provider Manual. Dallas, TX: American Heart Association; 2011.
2. Correct Answer: C Rationale
The Venturi mask works by drawing in a specific amount of air to mix with the oxygen through holes in an adaptor fitted at the bottom of the mask. Holes of different sizes allow different amounts of room air to be entrained, changing the amount of oxygen delivered. Bedding (or clothing) wrapped around those holes would effectively change the fraction of inspired oxygen (FIO2). The nurse should ensure that the holes remain unobstructed. Other options are appropriate but are not the first choice, because this simple step may solve the problem. Source
St. John R, Seckel M. Airway and ventilator management. In: Burns S. AACN Essentials of Progressive Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014:107-109.
www.ccnonline.org
3. Correct Answer: B Rationale
Prominent U waves may be the result of hypokalemia. The nurse should review the patient’s electrolyte results. Although documentation (A) is important, this is not a normal variant. Moving the crash cart (C) closer to the room may or may not be warranted. Although this finding may warrant a 12-lead ECG (D), it is not the nurse’s immediate priority and may be delegated.
Source
St. John R, Seckel A. Airway and ventilatory management. In: Burns S, ed. AACN Essentials of Progressive Care Nursing. 3rd ed. New York, NY: McGraw Hill; 2014: 93-131.
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
Source
Riera AR. The enigmatic sixth wave of the electrocardiogram: the U wave. Cardiol J. 2008;15(5):408-421.
4. Correct Answer: D Rationale
Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough, substernal chest pain, GI upset, and dyspnea. Pulmonary toxicity symptoms result from an inflammation that starts in the airways leading to the lungs and then spreads into the lungs. The symptoms appear in the upper chest region (substernal and carnal regions). This begins as a mild tickle on inhalation and progresses to frequent coughing. Blood-tinged sputum (A) is expected in patients with new tracheostomies. Rhonchi (B) in upper lobes indicate sputum that can be expectorated and are not an emergent problem. Dry mucous membranes (C) should be lubricated, and the client’s hydration status can be checked. Source
Mach WJ, Thimmesch AR, Pierce JT, Pierce JD. Consequences of hyperoxia and the toxcity of oxygen in the lung. Nurs Res Pract. 2011:260482. doi:10.1155/2011/260482.
5. Correct Answer: A Rationale
The ABG values indicate a respiratory acidosis with normal levels of bicarbonate, suggesting that the problem is not metabolic. The low oxygen and high carbon dioxide levels are consistent with respiratory acidosis from hypoventilation. The lack of metabolic compensation demonstrates an acute event. Hyperventilation (B) commonly manifests as a respiratory alkalosis, COPD (C) with respiratory acidosis with hypoxia and partial or attempted metabolic compensation, and diarrhea (D) with metabolic acidosis.
www.ccnonline.org
CriticalCareNurse
Vol 34, No. 6, DECEMBER 2014
67
Copyright of Critical Care Nurse is the property of American Association of Critical-Care Nurses and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
