CCRN Endocrine, Hematology, GI, Renal and Integumentary Practice Test

25 practice questions

Choose an answer, then check it under Show answer.

1. Question 1 of 25Easy

   In a patient with systemic lupus erythematosus who has new edema and a rising creatinine, which urinalysis finding most strongly suggests lupus nephritis?

   1. AA. Bacteria with positive nitrites
   2. BB. Hyaline casts with a high specific gravity
   3. CC. Red blood cell casts with proteinuria
   4. DD. Calcium oxalate crystals
   Show answer to question 1

   Answer: C. Red blood cell casts with proteinuria

   Lupus nephritis is an immune-complex glomerulonephritis, and red cell casts with proteinuria are hallmarks of glomerular inflammation. Low complement levels and a rising anti-dsDNA titer support the diagnosis, which is confirmed by kidney biopsy.

   Why the other options are wrong

   • ABacteria and nitrites indicate a urinary tract infection rather than glomerular inflammation.
   • BHyaline casts in concentrated urine are a nonspecific finding of dehydration, not of glomerular inflammation.
   • DCalcium oxalate crystals suggest stones or certain toxic ingestions rather than lupus-related glomerular disease.

2. Question 2 of 25Hard

   A 48-year-old man with acute pancreatitis has received lactated Ringer's solution at 250 mL/h for 14 hours. His heart rate has fallen from 118 to 92/min, his urine output is 70 mL/h and his BUN is falling. He now has new crackles in both lung bases, a respiratory rate of 28/min and an SpO2 that has dropped from 96% to 89% on 2 L/min of oxygen. What should the nurse do?

   1. AA. Increase the infusion rate to meet the goal for severe disease
   2. BB. Ask the provider for a fluid bolus to protect kidney perfusion
   3. CC. Ask the provider to reassess the fluid rate given signs of overload
   4. DD. Keep the current rate until his lipase level returns to normal
   Show answer to question 2

   Answer: C. Ask the provider to reassess the fluid rate given signs of overload

   His perfusion has improved, shown by a lower heart rate, good urine output and a falling BUN, while new crackles, tachypnea and falling SpO2 suggest fluid overload. Current guidance favors moderate, goal-directed fluids with frequent reassessment, because aggressive fluid loading increases overload without improving outcomes.

   Why the other options are wrong

   • ALarge fixed fluid volumes increase fluid overload in pancreatitis without improving outcomes.
   • BHis perfusion targets are already met, so a bolus would worsen the pulmonary congestion.
   • DLipase does not guide fluid therapy, and its level does not track severity or recovery.

3. Question 3 of 25Medium

   A critically ill patient with traumatic brain injury is receiving intravenous desmopressin for post-traumatic diabetes insipidus. Twenty-four hours into therapy, the patient becomes increasingly lethargic and complains of a severe headache. Which laboratory result is the most likely cause of these symptoms?

   1. AA. Serum glucose of 220 mg/dL
   2. BB. Serum calcium of 7.8 mg/dL
   3. CC. Serum potassium of 5.6 mEq/L
   4. DD. Serum sodium of 124 mEq/L
   Show answer to question 3

   Answer: D. Serum sodium of 124 mEq/L

   A major complication of desmopressin therapy combined with ongoing hypotonic fluid administration is water intoxication and dilutional hyponatremia, leading to cerebral edema, headache, and altered mental status. Although hyperkalemia can occur with kidney injury, it does not typically present acutely with headache and cerebral signs in the context of desmopressin titration.

4. Question 4 of 25Easy

   A 24-year-old man with type 1 diabetes is admitted to the ICU with diabetic ketoacidosis. He has dry mucous membranes, heart rate 128/min, blood pressure 86/52 mm Hg, glucose 612 mg/dL and serum potassium 4.6 mEq/L. Which intervention should the nurse anticipate first?

   1. AA. Continuous infusion of IV regular insulin
   2. BB. Rapid infusion of isotonic crystalloid
   3. CC. Infusion of IV sodium bicarbonate
   4. DD. Replacement with IV potassium chloride
   Show answer to question 4

   Answer: B. Rapid infusion of isotonic crystalloid

   This hypotensive patient has a large water and sodium deficit from osmotic diuresis, so isotonic crystalloid comes first to restore perfusion. Fluids also lower the glucose, and insulin is started once fluid resuscitation is under way and the potassium level is known.

   Why the other options are wrong

   • AInsulin is essential but follows the start of fluids, because shifting glucose and water into cells before volume is restored can worsen hypotension.
   • CBicarbonate is not routine in DKA and is considered only for very severe acidemia.
   • DWith a potassium of 4.6 mEq/L, potassium is added to the fluids once urine output is confirmed, but restoring volume comes first.

5. Question 5 of 25Medium

   An 82-year-old resident of a skilled nursing facility is transferred to the intensive care unit with lethargy, temperature 35.6 degrees C (96.1 degrees F), heart rate 114 beats/min, respiratory rate 26 breaths/min, and blood pressure 80/42 mm Hg. The urine is dark, cloudy, and malodorous. Following the initial recognition of septic shock from a presumed urinary tract focus, which action is recommended within the first hour of resuscitation?

   1. AA. Collect blood and urine cultures and initiate broad-spectrum intravenous antimicrobials
   2. BB. Perform continuous bladder irrigation with antifungal and antibacterial solutions
   3. CC. Initiate an infusion of 5% albumin boluses before taking any blood cultures
   4. DD. Withhold intravenous fluid boluses until a bedside echocardiogram assesses cardiac ejection fraction
   Show answer to question 5

   Answer: A. Collect blood and urine cultures and initiate broad-spectrum intravenous antimicrobials

   Current Surviving Sepsis Campaign guidelines recommend obtaining appropriate cultures (blood and urine) and administering broad-spectrum intravenous antimicrobials within 1 hour of recognizing septic shock, accompanied by crystalloid fluid resuscitation. Fluid resuscitation should not be delayed for cardiac imaging in the setting of frank hypotension. Bladder irrigation with antimicrobial solutions is ineffective for systemic urosepsis and is not standard management.

6. Question 6 of 25Medium

   A 62-year-old patient with severe septic shock develops bleeding from intravenous puncture sites, hematuria, and petechiae. Coagulation studies reveal a platelet count of 45,000/mcL, a prothrombin time of 28 seconds, and a fibrinogen level of 65 mg/dL. Which blood component should the nurse anticipate administering to target this patient's critical hypofibrinogenemia?

   1. AA. Prothrombin complex concentrate
   2. BB. Cryoprecipitate
   3. CC. Fresh frozen plasma
   4. DD. Packed red blood cells
   Show answer to question 6

   Answer: B. Cryoprecipitate

   Cryoprecipitate contains concentrated amounts of fibrinogen, factor VIII, and von Willebrand factor, making it the preferred therapy to rapidly raise fibrinogen when levels drop below 100 mg/dL in disseminated intravascular coagulation. Fresh frozen plasma contains fibrinogen along with other clotting factors, but large volumes are necessary to correct profound hypofibrinogenemia, increasing the risk of volume overload. Prothrombin complex concentrate replaces vitamin K-dependent factors rather than fibrinogen.

7. Question 7 of 25Medium

   A 66-year-old man with septic shock and acute kidney injury is receiving CRRT under the unit protocol with an ordered net fluid removal of 150 mL/hr. Over 2 hours, his norepinephrine dose has doubled, his MAP has fallen from 72 to 61 mm Hg, and his lactate has risen from 2.1 to 3.4 mmol/L. He remains 6 L positive since admission. Which action should the nurse take?

   1. AA. Reduce or pause the removal and report the change now
   2. BB. Continue the removal rate, since he is still 6 L positive
   3. CC. Stop CRRT and return the blood until his MAP recovers
   4. DD. Keep the removal rate and report the MAP at the next update
   Show answer to question 7

   Answer: A. Reduce or pause the removal and report the change now

   Net fluid removal must match what the circulation can tolerate, and a falling MAP with a rising vasopressor dose and lactate shows that removal is outpacing refill from the tissues. Net removal is reduced or paused and the provider is informed, even though total body fluid remains high.

   Why the other options are wrong

   • BTotal body overload does not make it safe to remove intravascular volume faster than it can refill from the tissues.
   • CStopping the circuit ends solute and acid-base clearance and wastes the filter, while setting net removal to zero keeps therapy running.
   • DContinuing the same removal rate and delaying the report lets the hypoperfusion worsen.

8. Question 8 of 25Medium

   A patient on postoperative day 3 following a minimally invasive esophagectomy with cervical anastomosis suddenly develops a heart rate of 132/min, temperature of 101.8°F (38.8°C), and respiratory rate of 28/min. Physical assessment reveals erythema along the left neck incision with palpable crepitus extending to the upper chest. Which postoperative complication is the patient most likely experiencing?

   1. AA. Tracheobronchial fistulization from endotracheal cuff pressure
   2. BB. Gastric conduit ischemia without perforation
   3. CC. Recurrent laryngeal nerve injury
   4. DD. Cervical anastomotic leak
   Show answer to question 8

   Answer: D. Cervical anastomotic leak

   Tachycardia, fever, tachypnea, cervical wound erythema, and subcutaneous emphysema (crepitus) after an esophagectomy are hallmark signs of an anastomotic leak from the cervical reconstruction. Recurrent laryngeal nerve injury typically manifests with hoarseness and vocal cord paresis rather than local soft-tissue crepitus and systemic inflammatory signs. Isolated conduit ischemia without perforation would not typically cause cervical crepitus.

9. Question 9 of 25Easy

   Which condition must be ruled out before the first dose of rasburicase is given to prevent tumor lysis syndrome?

   1. AA. Sulfonamide antibiotic allergy
   2. BB. A history of gout
   3. CC. Well-controlled hypertension
   4. DD. G6PD deficiency
   Show answer to question 9

   Answer: D. G6PD deficiency

   Rasburicase breaks down uric acid and generates hydrogen peroxide, which can cause severe hemolysis and methemoglobinemia in patients with G6PD deficiency, so it is contraindicated in them. Patients at higher risk are screened before the first dose, and allopurinol is used instead when the deficiency is present.

   Why the other options are wrong

   • ARasburicase is not a sulfonamide, so a sulfonamide allergy is not a reason to withhold it.
   • BA history of gout does not interfere with rasburicase, which lowers uric acid regardless of its cause.
   • CHypertension does not interact with rasburicase or increase its risk of hemolysis.

10. Question 10 of 25Medium

    Ten minutes after a unit of packed red blood cells is started, a 45-year-old woman reports lower back pain and says she feels that something is wrong. Her temperature has risen from 37.0°C to 38.4°C (98.6°F to 101.1°F), her blood pressure has fallen from 124/76 to 92/54 mm Hg, and her urine has turned dark red. The nurse stops the transfusion. Which action should the nurse take next?

    1. AA. Keep the vein open with 0.9% sodium chloride through new tubing
    2. BB. Flush the blood tubing with saline to keep the line open
    3. CC. Discard the bag and tubing in a biohazard container
    4. DD. Remove the IV catheter to stop any further reaction
    Show answer to question 10

    Answer: A. Keep the vein open with 0.9% sodium chloride through new tubing

    Back pain, fever, hypotension, dark urine and a sense of doom soon after starting red cells suggest an acute hemolytic reaction, usually from ABO incompatibility. After stopping the unit, the nurse keeps IV access open with 0.9% sodium chloride through new tubing so that no more blood from the old line enters, then notifies the provider and blood bank and sends the bag and tubing for testing.

    Why the other options are wrong

    • BFlushing the original blood tubing pushes the incompatible red cells left in it into the patient.
    • CThe bag and tubing must go back to the blood bank so the cause of the reaction can be investigated.
    • DIV access is needed to give fluids and drugs for hypotension and kidney protection, so the catheter stays in place.

11. Question 11 of 25Medium

    A 59-year-old man with cirrhosis and ascites who was admitted from home this morning has a temperature of 100.6°F (38.1°C), mild diffuse abdominal tenderness and new confusion. A diagnostic paracentesis shows an ascitic fluid neutrophil count of 620 cells/mm3, and the culture is pending. Which action should the nurse anticipate?

    1. AA. Wait for the culture result before starting antibiotics
    2. BB. Start an empiric IV third-generation cephalosporin now
    3. CC. Remove a large volume of fluid to clear the infection
    4. DD. Prepare for emergency laparotomy to find a perforation
    Show answer to question 11

    Answer: B. Start an empiric IV third-generation cephalosporin now

    An ascitic neutrophil count of 250 cells/mm3 or more establishes spontaneous bacterial peritonitis. For this community-acquired infection, an empiric IV third-generation cephalosporin such as ceftriaxone starts right away without waiting for culture results, and IV albumin is often added to lower the risk of kidney failure. Hospital-acquired infection or recent antibiotic exposure may call for broader coverage.

    Why the other options are wrong

    • ADelaying antibiotics for culture results increases mortality, and cultures are often negative even when infection is present.
    • CDraining the fluid does not treat the infection; antibiotics do.
    • DSpontaneous bacterial peritonitis is treated medically; surgery is for secondary peritonitis from a perforation or abscess.

12. Question 12 of 25Hard

    A 66-year-old man receives 2 units of plasma before a procedure. Ninety minutes after the second unit, he develops acute dyspnea, a temperature of 38.3°C (100.9°F), an SpO2 of 82% on 6 L/min of oxygen and a blood pressure of 88/50 mm Hg. A chest x-ray shows new bilateral infiltrates. His CVP is 4 mm Hg, his neck veins are flat, and an echocardiogram shows normal left ventricular function. Which condition is most likely?

    1. AA. Transfusion-associated circulatory overload
    2. BB. Acute hemolytic transfusion reaction
    3. CC. Anaphylactic transfusion reaction
    4. DD. Transfusion-related acute lung injury
    Show answer to question 12

    Answer: D. Transfusion-related acute lung injury

    New hypoxemia and bilateral infiltrates within 6 hours of transfusion, with fever, hypotension, a low CVP and normal left ventricular function, fit transfusion-related acute lung injury, a noncardiogenic pulmonary edema often caused by donor antibodies in plasma-rich products. Care is supportive with oxygen and ventilation, and diuretics are avoided.

    Why the other options are wrong

    • ACirculatory overload typically causes hypertension, distended neck veins and a high CVP, not hypotension with a CVP of 4 mm Hg.
    • BAcute hemolysis usually follows red cell transfusion and causes back pain, dark urine and bleeding rather than isolated lung injury.
    • CAnaphylaxis begins within minutes with bronchospasm, angioedema and hypotension, not 90 minutes later with fever and bilateral infiltrates.

13. Question 13 of 25Easy

    Dopamine has extravasated from a peripheral IV. Which medication should the nurse anticipate the provider ordering for injection into the affected area?

    1. AA. Hyaluronidase
    2. BB. Dexrazoxane
    3. CC. Sodium thiosulfate
    4. DD. Phentolamine
    Show answer to question 13

    Answer: D. Phentolamine

    Phentolamine is an alpha-adrenergic blocker that reverses the local vasoconstriction caused by extravasated vasopressors such as dopamine and norepinephrine, limiting ischemic tissue necrosis.

    Why the other options are wrong

    • AHyaluronidase helps disperse extravasated hyperosmolar solutions and some other agents, but it does not reverse vasoconstriction.
    • BDexrazoxane is an IV antidote for extravasation of anthracycline chemotherapy.
    • CSodium thiosulfate is used for extravasation of certain alkylating chemotherapy agents, such as mechlorethamine.

14. Question 14 of 25Easy

    Which measure is most effective in preventing infection in a patient with profound neutropenia after chemotherapy?

    1. AA. A diet that excludes fresh fruit and vegetables
    2. BB. Placement in a negative-pressure isolation room
    3. CC. Strict hand hygiene by everyone who enters the room
    4. DD. Rectal temperature checks every 4 hours
    Show answer to question 14

    Answer: C. Strict hand hygiene by everyone who enters the room

    Hand hygiene is the single most effective measure for preventing infection in patients with neutropenia, together with careful central line and skin care. Many traditional restrictions have little supporting evidence.

    Why the other options are wrong

    • ARestrictive neutropenic diets have not been shown to reduce infections compared with standard safe food handling.
    • BNegative pressure draws hallway air into the room and is meant for airborne infections, not for protecting immunocompromised patients.
    • DRectal thermometers can injure the mucosa and introduce bacteria, so rectal temperatures are avoided in neutropenia.

15. Question 15 of 25Medium

    A 72-year-old woman with hypertension and heart failure is admitted with dehydration from gastroenteritis and a creatinine of 2.3 mg/dL (baseline 1.1 mg/dL). Her home medications are lisinopril, furosemide, metoprolol and atorvastatin, and she has been taking ibuprofen several times a day for knee pain. Which combination most likely contributed to her kidney injury?

    1. AA. Metoprolol, atorvastatin and lisinopril
    2. BB. Atorvastatin, metoprolol and furosemide
    3. CC. Ibuprofen, lisinopril and furosemide
    4. DD. Ibuprofen, metoprolol and atorvastatin
    Show answer to question 15

    Answer: C. Ibuprofen, lisinopril and furosemide

    NSAIDs block prostaglandin dilation of the afferent arteriole, ACE inhibitors remove angiotensin II constriction of the efferent arteriole, and diuretics reduce volume, so together they sharply lower glomerular filtration, especially during dehydration. This combination, often called the triple whammy, is a common and preventable cause of acute kidney injury.

    Why the other options are wrong

    • AMetoprolol and atorvastatin do not impair glomerular filtration, and lisinopril alone is far less harmful without an NSAID and a diuretic.
    • BThis combination lacks both the NSAID and the ACE inhibitor whose effects on the glomerular arterioles cause the injury.
    • DIbuprofen contributes, but metoprolol and atorvastatin do not, and the main risk comes from an NSAID combined with an ACE inhibitor and a diuretic.

16. Question 16 of 25Easy

    Which pattern of laboratory changes is characteristic of tumor lysis syndrome?

    1. AA. High potassium, high phosphorus, low calcium, high uric acid
    2. BB. High potassium, low phosphorus, high calcium, high uric acid
    3. CC. Low potassium, high phosphorus, high calcium, high uric acid
    4. DD. Low potassium, low phosphorus, low calcium, high uric acid
    Show answer to question 16

    Answer: A. High potassium, high phosphorus, low calcium, high uric acid

    Rapid breakdown of tumor cells releases potassium, phosphate and nucleic acids that are metabolized to uric acid, and the excess phosphate binds calcium and lowers the serum level. Uric acid and calcium phosphate deposits can cause acute kidney injury, which worsens the imbalances.

    Why the other options are wrong

    • BPhosphorus rises in tumor lysis, and the excess phosphate binds calcium, so calcium falls rather than rises.
    • CPotassium released from lysed cells rises, and calcium falls as it binds the released phosphate.
    • DPotassium and phosphorus are released from dying cells, so both rise rather than fall.

17. Question 17 of 25Easy

    A sacral pressure injury has full-thickness tissue loss with bone visible at the base. A small amount of yellow slough lines one edge but does not obscure the base. How should the nurse classify this injury?

    1. AA. Stage 2
    2. BB. Stage 3
    3. CC. Stage 4
    4. DD. Unstageable
    Show answer to question 17

    Answer: C. Stage 4

    Full-thickness skin and tissue loss with exposed or directly palpable bone, tendon, ligament, fascia, muscle or cartilage is a stage 4 pressure injury. Slough may be present, and the injury can still be staged when it does not obscure the wound base.

    Why the other options are wrong

    • AStage 2 is partial-thickness loss with exposed dermis and no fat, slough or deeper tissue.
    • BStage 3 is full-thickness skin loss in which fat may show, but bone, tendon or muscle is not exposed.
    • DUnstageable applies when slough or eschar obscures the base so the depth cannot be seen.

18. Question 18 of 25Medium

    A 52-year-old woman who took prednisone daily for 3 years stopped it abruptly a week ago. She is admitted with vomiting, confusion and a blood pressure of 76/40 mm Hg that does not improve after 2 L of 0.9% sodium chloride. Her glucose is 58 mg/dL. Which treatment should the nurse anticipate?

    1. AA. Oral prednisone at her home dose once the vomiting stops
    2. BB. Fludrocortisone with a slower saline infusion
    3. CC. IV hydrocortisone with continued isotonic fluids and dextrose
    4. DD. Norepinephrine infusion while awaiting a morning cortisol level
    Show answer to question 18

    Answer: C. IV hydrocortisone with continued isotonic fluids and dextrose

    Long-term glucocorticoid therapy suppresses the adrenal axis, and abrupt withdrawal can cause adrenal crisis with refractory hypotension and hypoglycemia. Treatment is immediate stress-dose IV hydrocortisone with isotonic fluids and dextrose, without waiting for test results.

    Why the other options are wrong

    • AA maintenance oral dose is inadequate and unreliable in a vomiting, hypotensive patient in crisis.
    • BFludrocortisone does not replace cortisol, and slowing fluids would worsen her hypovolemia.
    • DWithout cortisol the shock persists despite vasopressors, and treatment must not wait for a laboratory result.

19. Question 19 of 25Medium

    A 67-year-old man has received a continuous heparin infusion for 7 days for a pulmonary embolism. His platelet count has fallen from 240,000 to 92,000/mm3, and his right calf has become swollen and painful. He has no bleeding. The provider suspects heparin-induced thrombocytopenia (HIT). Which plan should the nurse anticipate?

    1. AA. Stop all heparin, including flushes, and start argatroban
    2. BB. Change the heparin infusion to enoxaparin injections
    3. CC. Stop the heparin and transfuse platelets to prevent bleeding
    4. DD. Stop the heparin and start warfarin the same day
    Show answer to question 19

    Answer: A. Stop all heparin, including flushes, and start argatroban

    A platelet fall of more than 50% 5 to 10 days after heparin was started, with a new thrombosis, strongly suggests HIT, a prothrombotic antibody reaction. All heparin exposure, including flushes and heparin-coated catheters, is stopped, and a non-heparin anticoagulant such as argatroban is started without waiting for test results.

    Why the other options are wrong

    • BLow-molecular-weight heparin cross-reacts with HIT antibodies and must also be avoided.
    • CPlatelet transfusion can fuel thrombosis in HIT and is reserved for serious bleeding, which he does not have.
    • DStarting warfarin during acute HIT can cause venous limb gangrene, so it waits until platelets recover and overlaps a non-heparin anticoagulant.

20. Question 20 of 25Hard

    A patient with severe myxedema coma presents with profound hypothermia and hypotension. When planning warming interventions, which strategy should the nurse use to prevent cardiovascular collapse?

    1. AA. Active internal rewarming with heated peritoneal lavage
    2. BB. Active core rewarming using heated intravascular catheters
    3. CC. Rapid surface rewarming using forced-air warming blankets set to high
    4. DD. Passive external rewarming with warm blankets
    Show answer to question 20

    Answer: D. Passive external rewarming with warm blankets

    In myxedema coma, passive external rewarming with standard blankets is preferred because rapid active rewarming causes sudden peripheral vasodilation, precipitating profound hypotension and circulatory collapse. Active core or aggressive surface rewarming is indicated for severe accidental hypothermia, but in myxedema coma, slow correction allows vascular tone to adapt as thyroid replacement takes effect.

21. Question 21 of 25Medium

    Three days after a prolonged episode of septic shock, a 61-year-old woman's creatinine has risen from 0.9 to 3.6 mg/dL, although her blood pressure and volume status are now normal. Which urine findings are most consistent with ischemic acute tubular necrosis?

    1. AA. Bland hyaline casts, urine sodium 8 mEq/L, FENa 0.3%
    2. BB. Muddy brown granular casts, urine sodium 58 mEq/L, FENa 3.1%
    3. CC. White cell casts with bacteria and positive nitrites
    4. DD. Bland sediment with a specific gravity of 1.030 or higher
    Show answer to question 21

    Answer: B. Muddy brown granular casts, urine sodium 58 mEq/L, FENa 3.1%

    Ischemic tubular necrosis damages tubular cells so that they can no longer reabsorb sodium or concentrate urine: the urine sodium is high, often above 40 mEq/L, the FENa is above 2%, and sloughed tubular cells form muddy brown granular casts.

    Why the other options are wrong

    • AA low urine sodium and FENa with bland hyaline casts show intact tubules conserving sodium, the prerenal pattern.
    • CWhite cell casts with bacteria and nitrites suggest pyelonephritis rather than ischemic tubular injury.
    • DHighly concentrated urine shows preserved tubular concentrating ability, which is lost in tubular necrosis.

22. Question 22 of 25Hard

    A patient with prolonged neutropenia has received fourth-generation cephalosporin monotherapy for five days for persistent fever. Surveillance blood and urine cultures remain negative, but temperatures continue to peak above 38.5 degrees Celsius daily. What is the recommended next step in management?

    1. AA. Switching the cephalosporin to oral trimethoprim-sulfamethoxazole
    2. BB. Initiating empiric antifungal therapy covering Candida and Aspergillus species
    3. CC. Doubling the dose of the existing cephalosporin and adding filgrastim
    4. DD. Discontinuing all antibiotics because noninfectious drug fever is the most likely cause
    Show answer to question 22

    Answer: B. Initiating empiric antifungal therapy covering Candida and Aspergillus species

    In patients with prolonged neutropenia and persistent or recurrent fever after 4 to 7 days of broad-spectrum antibacterial therapy, invasive fungal infections caused by Candida or Aspergillus species are a leading cause of mortality and warrant empiric antifungal therapy. Discontinuing antimicrobial therapy in a persistently febrile neutropenic host is unsafe. Step-down to oral antibiotics or simply increasing the cephalosporin dose fails to address opportunistic fungal pathogens.

23. Question 23 of 25Hard

    A critically ill patient receiving high-dose intravenous amphotericin B deoxycholate for a systemic fungal infection requires close laboratory monitoring. Which combination of electrolyte and acid-base abnormalities is most characteristic of amphotericin B-induced renal tubular toxicity?

    1. AA. Hypokalemia, hypomagnesemia, and normal anion gap metabolic acidosis
    2. BB. Hypocalcemia, hyperphosphatemia, and respiratory alkalosis
    3. CC. Hyperkalemia, hypermagnesemia, and metabolic alkalosis
    4. DD. Hyperkalemia, hypocalcemia, and high anion gap metabolic acidosis
    Show answer to question 23

    Answer: A. Hypokalemia, hypomagnesemia, and normal anion gap metabolic acidosis

    Amphotericin B causes distal renal tubular cell membrane permeability defects (distal type 1 renal tubular acidosis), leading to tubular potassium and magnesium wasting alongside impaired hydrogen ion excretion resulting in a normal anion gap metabolic acidosis. Hyperkalemia and hypermagnesemia are incorrect because amphotericin B promotes direct renal wasting rather than retention of these divalent and monovalent cations.

24. Question 24 of 25Hard

    A 58-year-old man with known peptic ulcer disease has vomited about 1,000 mL of bright red blood in the past 30 minutes and is still actively vomiting blood. He now opens his eyes only to a loud voice. His blood pressure is 88/52 mm Hg and heart rate 128/min, two large-bore IV catheters are in place, and urgent endoscopy is planned. Which intervention should the nurse anticipate before the endoscopy begins?

    1. AA. Moderate sedation with IV midazolam during the endoscopy
    2. BB. Endotracheal intubation to protect the airway
    3. CC. Nasogastric lavage with iced saline until the return is clear
    4. DD. Placement of a balloon tamponade tube to slow the bleeding
    Show answer to question 24

    Answer: B. Endotracheal intubation to protect the airway

    Ongoing massive hematemesis with a depressed level of consciousness puts this patient at high risk of aspirating blood, so the airway should be secured with endotracheal intubation before endoscopy. Resuscitation with blood products continues at the same time.

    Why the other options are wrong

    • ASedation without a secured airway further depresses protective reflexes and can worsen his hypotension.
    • CIced saline lavage does not stop bleeding, can cause hypothermia and is not recommended.
    • DBalloon tamponade is a temporary bridge for uncontrolled variceal bleeding, not a treatment for a bleeding ulcer.

25. Question 25 of 25Hard

    A critically ill patient with severe paralytic ileus and pancreatitis has progressive abdominal distension. Over the past 3 hours, urine output has decreased to 10 mL/hr and peak inspiratory pressures on the mechanical ventilator have risen from 24 to 38 cm H2O. The nurse measures a transvesical intra-abdominal pressure of 23 mm Hg. Which clinical target is most appropriate when managing this patient?

    1. AA. Instill 150 mL of sterile saline into the bladder prior to pressure transducing
    2. BB. Position the patient in steep reverse Trendelenburg to lower airway pressures
    3. CC. Initiate severe fluid restriction to minimize retroperitoneal third-spacing
    4. DD. Maintain an abdominal perfusion pressure of at least 60 mm Hg
    Show answer to question 25

    Answer: D. Maintain an abdominal perfusion pressure of at least 60 mm Hg

    An intra-abdominal pressure greater than 20 mm Hg associated with new organ dysfunction (oliguria, decreased lung compliance) defines abdominal compartment syndrome, where a primary hemodynamic goal is maintaining an abdominal perfusion pressure (mean arterial pressure minus intra-abdominal pressure) of at least 60 mm Hg. Instilling 150 mL of fluid into the bladder will falsely elevate measured pressure, as standard guidelines recommend instilling no more than 20 to 25 mL of saline.

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