CCRN Musculoskeletal, Neurological and Behavioral Practice Test

25 practice questions

Choose an answer, then check it under Show answer.

1. Question 1 of 25Hard

   A 42-year-old patient admitted with necrotizing soft-tissue infection is receiving linezolid and fentanyl. The patient has a history of major depressive disorder treated with fluoxetine. The nurse notes new agitation, profuse diaphoresis, shivering, ocular clonus, and hyperreflexia in the lower extremities with a core temperature of 38.9 degrees C (102.0 degrees F). Which clinical feature best differentiates this condition from neuroleptic malignant syndrome?

   1. AA. Severe generalized lead-pipe muscular rigidity
   2. BB. Marked elevation of serum creatine kinase levels
   3. CC. Spontaneous neuromuscular clonus and hyperreflexia
   4. DD. Autonomic instability with labile blood pressure
   Show answer to question 1

   Answer: C. Spontaneous neuromuscular clonus and hyperreflexia

   Hunter criteria for serotonin toxicity emphasize neuromuscular excitation, specifically spontaneous, inducible, or ocular clonus along with hyperreflexia. In contrast, neuroleptic malignant syndrome is characterized by hyporeflexia and generalized lead-pipe muscle rigidity. Autonomic instability and elevated creatine kinase can occur in both syndromes and do not reliably differentiate them.

2. Question 2 of 25Medium

   A patient in the intensive care unit was placed in physical restraints after violently assaulting staff and trying to extubate the endotracheal tube. Two hours later, the patient is calm, follows commands, and cooperates with respiratory therapy. What is the most appropriate nursing action regarding the restraints?

   1. AA. Wait for a continuous 24-hour period of calm behavior before removal
   2. BB. Discontinue the restraints promptly based on the behavioral improvement
   3. CC. Keep the restraints in place until the patient is completely extubated
   4. DD. Maintain the restraints until the original time-limited medical order expires
   Show answer to question 2

   Answer: B. Discontinue the restraints promptly based on the behavioral improvement

   Physical restraints should be discontinued at the earliest possible time, as soon as the patient demonstrates behavioral control and the immediate threat to safety has resolved. Keeping restraints in place until an order expires or requiring arbitrary delays, such as waiting for extubation or 24 hours of calm, unnecessarily prolongs restraint use and violates ethical and regulatory care standards.

3. Question 3 of 25Medium

   A patient presents with an acute spontaneous intracerebral hemorrhage. The baseline blood pressure is 195/105 mm Hg, and the Glasgow Coma Scale score is 13. According to current AHA/ASA guidelines, what is the most appropriate systolic blood pressure target to minimize hematoma expansion while avoiding hypoperfusion?

   1. AA. Maintain systolic pressure between 130 and 150 mm Hg
   2. BB. Maintain systolic pressure between 160 and 180 mm Hg
   3. CC. Maintain systolic pressure between 180 and 200 mm Hg
   4. DD. Maintain systolic pressure between 100 and 120 mm Hg
   Show answer to question 3

   Answer: A. Maintain systolic pressure between 130 and 150 mm Hg

   Current guidelines recommend acute lowering of systolic blood pressure to a target range of 130 to 150 mm Hg in patients presenting with mild-to-moderate spontaneous intracerebral hemorrhage and systolic blood pressure between 150 and 220 mm Hg. Maintaining a systolic pressure of 160 to 180 mm Hg is associated with higher rates of hematoma expansion. Lowering systolic pressure below 130 mm Hg can compromise cerebral perfusion and worsen renal outcomes.

4. Question 4 of 25Hard

   A 45-year-old kidney transplant recipient who takes tacrolimus has a blood pressure of 204/116 mm Hg, a severe headache, blurred vision and a generalized seizure. MRI shows bilateral posterior white matter edema. Which plan should the nurse anticipate?

   1. AA. IV thrombolysis for a posterior circulation stroke
   2. BB. Controlled BP lowering and review of the immunosuppressant
   3. CC. High-dose methylprednisolone for kidney transplant rejection
   4. DD. Hypertonic saline to shrink the cerebral edema
   Show answer to question 4

   Answer: B. Controlled BP lowering and review of the immunosuppressant

   Severe hypertension, headache, visual change and seizures with posterior white matter edema fit posterior reversible encephalopathy syndrome, which calcineurin inhibitors such as tacrolimus can trigger. Management is controlled blood pressure reduction, seizure treatment and reducing or changing the offending drug.

   Why the other options are wrong

   • AThe imaging shows edema rather than an arterial occlusion, and uncontrolled severe hypertension also contraindicates thrombolysis.
   • CNothing here suggests rejection, and high-dose steroids do not address the cause of this encephalopathy.
   • DThis vasogenic edema comes from failed autoregulation and resolves with blood pressure control, not osmotic therapy.

5. Question 5 of 25Hard

   A 58-year-old man with a complete T2 spinal cord injury develops a severe headache, nasal stuffiness and a blood pressure of 188/102 mm Hg. The nurse has already taken the first steps for this emergency, and his blood pressure is now 180/98 mm Hg. He has an indwelling urinary catheter, and no urine has drained into the bag for 2 hours. Which action should the nurse take next?

   1. AA. Perform a rectal check for stool with lidocaine jelly
   2. BB. Recheck his blood pressure in 15 minutes before acting
   3. CC. Inspect the catheter and tubing for kinks or a blockage
   4. DD. Irrigate the catheter forcefully with 60 mL of cold saline
   Show answer to question 5

   Answer: C. Inspect the catheter and tubing for kinks or a blockage

   The bladder is the most common trigger of autonomic dysreflexia, and an empty drainage bag for 2 hours suggests an obstructed catheter. The nurse checks the whole system for kinks, clamps or blockage and corrects it; if it still does not drain, the catheter is replaced, with the blood pressure checked every few minutes.

   Why the other options are wrong

   • AThe bowel is checked after the urinary system has been ruled out as the trigger.
   • BWaiting 15 minutes leaves dangerous hypertension and its cause untreated; pressure is checked every few minutes.
   • DOnly gentle irrigation with a small volume of body-temperature fluid is used, because forceful cold irrigation can worsen the episode.

6. Question 6 of 25Easy

   Which history is most typical of an acute epidural hematoma?

   1. AA. Gradual confusion over 3 weeks after a minor fall in an older adult
   2. BB. Immediate, prolonged coma after a high-speed rotational injury
   3. CC. Brief loss of consciousness, a lucid interval, then rapid decline
   4. DD. Headache and brief confusion after a blow that resolve within days
   Show answer to question 6

   Answer: C. Brief loss of consciousness, a lucid interval, then rapid decline

   An epidural hematoma usually follows a temporal blow that tears the middle meningeal artery. Arterial bleeding between the skull and dura often allows a lucid interval before rapid decline with an ipsilateral dilated pupil, which requires emergent surgical evacuation.

   Why the other options are wrong

   • ASlow decline weeks after minor trauma in an older adult is typical of a chronic subdural hematoma from torn bridging veins.
   • BImmediate, lasting coma after rotational acceleration suggests diffuse axonal injury.
   • DSymptoms that resolve within days without structural injury describe a concussion.

7. Question 7 of 25Medium

   A patient with an external ventricular drain has a new fever and suspected ventriculitis. The critical care nurse prepares to obtain a cerebrospinal fluid sample from the drain for culture and analysis. Which technique must the nurse use?

   1. AA. Draw the specimen directly from the distal drainage collection bag
   2. BB. Aspirate cerebrospinal fluid with a sterile syringe using slow, passive flow without force
   3. CC. Aspirate rapidly using a high-pressure syringe to clear any intraventricular debris
   4. DD. Instill sterile normal saline through the line to loosen adherence before withdrawal
   Show answer to question 7

   Answer: B. Aspirate cerebrospinal fluid with a sterile syringe using slow, passive flow without force

   Cerebrospinal fluid samples from an external ventricular drain should be obtained using strict aseptic technique from the sampling port closest to the patient, allowing fluid to fill the syringe slowly or drip passively without forceful aspiration to avoid parenchymal collapse or choroid plexus suction. Samples must never be retrieved from the distal collection bag because prolonged stagnation renders specimens inaccurate for culture and cell counts.

8. Question 8 of 25Hard

   A 22-year-old man with closed fractures of both femurs is in skeletal traction awaiting surgery. Thirty-six hours after the crash he becomes confused and restless, with a respiratory rate of 32/min, an SpO2 of 86% on 4 L/min by nasal cannula, a temperature of 38.4°C (101.1°F) and pinpoint red spots on his upper chest, axillae and conjunctivae. Which condition is most likely?

   1. AA. Alcohol withdrawal delirium
   2. BB. Pulmonary embolism from a leg DVT
   3. CC. Hospital-acquired pneumonia
   4. DD. Fat embolism syndrome
   Show answer to question 8

   Answer: D. Fat embolism syndrome

   Respiratory distress with hypoxemia, new confusion and a petechial rash on the upper body, axillae and conjunctivae 24 to 72 hours after long-bone fractures is the classic picture of fat embolism syndrome. Treatment is supportive, with oxygen and ventilation as needed.

   Why the other options are wrong

   • AWithdrawal can cause confusion, fever and tachycardia but does not cause hypoxemia with a petechial rash.
   • BPulmonary embolism causes hypoxemia but not petechiae on the chest, axillae and conjunctivae.
   • CPneumonia can cause fever and hypoxemia but not this petechial rash or the typical timing after fractures.

9. Question 9 of 25Easy

   A pelvic binder is being applied to a patient with an unstable pelvic ring fracture and hypotension. Where should the binder be centered?

   1. AA. Over the iliac crests
   2. BB. At the level of the umbilicus
   3. CC. Over the greater trochanters
   4. DD. Over the upper thighs below the groin
   Show answer to question 9

   Answer: C. Over the greater trochanters

   A binder centered over the greater trochanters, roughly at the level of the pubic symphysis, closes the pelvic ring most effectively and reduces pelvic volume and bleeding.

   Why the other options are wrong

   • AA binder over the iliac crests sits too high to close the pelvic ring effectively.
   • BAt the umbilicus the binder squeezes the abdomen and does not stabilize the pelvic ring.
   • DBelow the groin the binder compresses the thighs and cannot reduce the pelvic ring.

10. Question 10 of 25Easy

    Which statement about endovascular coiling of a ruptured cerebral aneurysm is accurate?

    1. AA. It requires a craniotomy to place a clip across the aneurysm neck
    2. BB. It removes the later risk of delayed cerebral ischemia
    3. CC. It is put off until the vasospasm period has passed
    4. DD. It uses an arterial catheter, so care includes the access site
    Show answer to question 10

    Answer: D. It uses an arterial catheter, so care includes the access site

    Coiling fills the aneurysm with detachable coils delivered through a catheter, usually from the femoral or radial artery, without opening the skull. Afterward, the nurse monitors the access site and distal pulses along with neurologic status.

    Why the other options are wrong

    • AThis describes surgical clipping, an open procedure, rather than the endovascular approach.
    • BSecuring the aneurysm prevents rebleeding, but vasospasm and delayed cerebral ischemia can still develop afterward.
    • CRuptured aneurysms are secured as early as feasible, because the risk of rebleeding is highest soon after rupture.

11. Question 11 of 25Medium

    A patient in the neuro intensive care unit experiences recurrent, prolonged episodes of sympathetic storming. The nurse monitors closely for which systemic complication associated with this persistent hyperadrenergic state?

    1. AA. Hypercatabolism and profound weight loss
    2. BB. Persistent hypothermia and shivering
    3. CC. Suppression of the cerebral metabolic rate of oxygen
    4. DD. Hyponatremia secondary to cerebral salt wasting
    Show answer to question 11

    Answer: A. Hypercatabolism and profound weight loss

    The extreme catecholamine excess and dystonia during paroxysmal sympathetic hyperactivity cause severe hypermetabolism and hypercatabolism, which can triple baseline caloric needs and cause rapid, dramatic weight loss and muscle breakdown. Sympathetic storming leads to core hyperthermia rather than hypothermia and markedly increases the cerebral metabolic rate of oxygen, which exacerbates secondary brain injury risk.

12. Question 12 of 25Easy

    Which presentation is typical of hypoactive delirium in an ICU patient?

    1. AA. Restlessness, pulling at tubes and visible hallucinations
    2. BB. Sad mood and hopelessness with normal attention
    3. CC. Acute onset of lethargy, slowed responses and inattention
    4. DD. Memory loss over years with a normal level of alertness
    Show answer to question 12

    Answer: C. Acute onset of lethargy, slowed responses and inattention

    Hypoactive delirium is an acute disturbance of attention with reduced activity, drowsiness and slowed responses. Because it is easily mistaken for fatigue or depression, routine screening with a validated tool is needed to detect it.

    Why the other options are wrong

    • AAgitation, tube pulling and hallucinations describe hyperactive delirium.
    • BDepression affects mood, while attention and alertness are generally preserved.
    • DA slow decline over years with normal alertness describes dementia, not an acute confusional state.

13. Question 13 of 25Medium

    A 33-year-old man with a C7 spinal cord injury is breathing on his own. Each time he is moved from lying flat to sitting upright in a chair, he becomes short of breath and his vital capacity falls. What should the nurse do before he next sits up?

    1. AA. Fit an abdominal binder while he is supine
    2. BB. Keep him in bed until his breathing improves
    3. CC. Teach him pursed-lip breathing for sitting
    4. DD. Raise his legs on a footstool in the chair
    Show answer to question 13

    Answer: A. Fit an abdominal binder while he is supine

    Paralyzed abdominal muscles let the abdominal contents sag when he sits up, which lowers and flattens the diaphragm and reduces vital capacity. A binder applied while he is supine supports the diaphragm's position and improves breathing upright; it also helps prevent orthostatic hypotension.

    Why the other options are wrong

    • BProlonged bed rest worsens deconditioning and lung complications, and his problem when upright is mechanical.
    • CPursed-lip breathing helps air trapping in COPD, not weak breathing from abdominal muscle paralysis.
    • DRaising the legs does not support the diaphragm or improve vital capacity when he is upright.

14. Question 14 of 25Easy

    Which cerebrospinal fluid pattern is most consistent with acute bacterial meningitis?

    1. AA. Cloudy fluid, many neutrophils, low glucose and high protein
    2. BB. Clear fluid, mostly lymphocytes, normal glucose and mildly high protein
    3. CC. Clear fluid, a normal cell count and a high protein level
    4. DD. Bloody fluid that clears from the first tube to the last tube
    Show answer to question 14

    Answer: A. Cloudy fluid, many neutrophils, low glucose and high protein

    Bacterial meningitis typically produces turbid fluid with a high white cell count dominated by neutrophils, a low glucose and a high protein. The opening pressure is often elevated.

    Why the other options are wrong

    • BThis pattern is typical of viral (aseptic) meningitis.
    • CHigh protein without a rise in cells suggests a condition such as Guillain-Barre syndrome rather than infection.
    • DBlood that clears across the tubes suggests a traumatic tap rather than infection or hemorrhage.

15. Question 15 of 25Medium

    After a fall from a ladder, a 49-year-old man has bruising around both eyes and clear fluid dripping from his nose. Which order should the nurse question?

    1. AA. Keep the head of the bed raised to 30 degrees
    2. BB. Insert a nasogastric tube for decompression
    3. CC. Place a loose gauze pad under the nose
    4. DD. Instruct the patient not to blow his nose
    Show answer to question 15

    Answer: B. Insert a nasogastric tube for decompression

    Periorbital bruising with clear nasal drainage suggests a basilar skull fracture with a cerebrospinal fluid leak. A nasal tube can pass through the fracture into the cranial vault, so gastric tubes are placed orally until the fracture is excluded.

    Why the other options are wrong

    • AHead elevation is appropriate and may reduce both the leak and ICP.
    • CA loose drip pad lets fluid drain freely; packing the nose would trap fluid and raise the risk of infection.
    • DAvoiding nose blowing limits pressure changes that can worsen the leak or draw bacteria inward.

16. Question 16 of 25Medium

    A 77-year-old woman who takes warfarin for atrial fibrillation is admitted with an acute intracerebral hemorrhage. Her INR is 3.2. Which reversal therapy should the nurse anticipate?

    1. AA. Fresh frozen plasma, with a repeat INR checked the next morning
    2. BB. Oral vitamin K, with the next warfarin dose held
    3. CC. IV protamine sulfate given slowly over 10 minutes
    4. DD. Four-factor prothrombin complex concentrate and IV vitamin K
    Show answer to question 16

    Answer: D. Four-factor prothrombin complex concentrate and IV vitamin K

    For warfarin-associated intracerebral hemorrhage with an elevated INR, four-factor prothrombin complex concentrate corrects the INR faster and with less volume than plasma. IV vitamin K is given as well, because the concentrate's effect wears off before warfarin is cleared.

    Why the other options are wrong

    • APlasma corrects the INR slowly and needs a large volume, and waiting until morning misses ongoing hematoma growth.
    • BOral vitamin K takes many hours to act and is not adequate by itself for an active intracranial bleed.
    • CProtamine reverses heparin, not warfarin, and does not lower the INR.

17. Question 17 of 25Easy

    A ventilated patient has a RASS score of -4. When the nurse attempts the CAM-ICU delirium assessment, what is the correct conclusion?

    1. AA. Delirium is present, because the patient cannot follow commands
    2. BB. Delirium is absent, because the patient shows no agitation
    3. CC. The screen is completed using eye blinks instead of hand squeezes
    4. DD. The screen cannot be done; it is repeated when arousal improves
    Show answer to question 17

    Answer: D. The screen cannot be done; it is repeated when arousal improves

    The CAM-ICU is completed only when the patient responds to voice, a RASS of -3 or lighter. At -4 or -5 the patient is recorded as unable to be assessed, and the screen is repeated when sedation lightens.

    Why the other options are wrong

    • ANot following commands at this depth reflects sedation or coma, not a positive delirium screen.
    • BLack of agitation does not rule out delirium, and the screen cannot be completed at this depth.
    • CChanging the response method does not help, because attention testing requires a patient who responds to voice.

18. Question 18 of 25Medium

    Which positioning plan best supports cerebral venous outflow in an intubated patient with increased intracranial pressure?

    1. AA. Flat and supine, with a towel roll under the neck
    2. BB. Head of bed at 30 degrees, with the head turned to one side
    3. CC. Head of bed at 30 degrees, with the head midline and neck neutral
    4. DD. Head of bed at 30 degrees, with the hips flexed past 90 degrees
    Show answer to question 18

    Answer: C. Head of bed at 30 degrees, with the head midline and neck neutral

    Raising the head of the bed with the head midline and the neck neutral promotes jugular venous drainage and lowers ICP while preserving cerebral perfusion. Tight endotracheal tube ties and cervical collars that compress the neck veins are also avoided.

    Why the other options are wrong

    • ALying flat and extending the neck over a roll impede venous drainage and raise ICP.
    • BTurning the head to the side can kink or compress the jugular veins and impair venous outflow.
    • DSharp hip flexion raises intra-abdominal and intrathoracic pressure, which can raise ICP.

19. Question 19 of 25Easy

    A 68-year-old man arrives in the emergency department at 07:10. His wife found him with right arm weakness and slurred speech when he woke at 06:30. He went to bed at 23:00 feeling well, and nobody saw him awake during the night. Which time should the nurse record as the last known well?

    1. AA. 06:30, when his wife found the symptoms after he woke
    2. BB. 23:00, when he went to bed without symptoms
    3. CC. 07:10, when he arrived in the emergency department
    4. DD. 02:45, halfway between bedtime and waking
    Show answer to question 19

    Answer: B. 23:00, when he went to bed without symptoms

    When onset is not witnessed, the last known well is the last time the patient was known to be at his neurologic baseline; for deficits found on waking, that is when he went to sleep. This time, not the time of discovery, is used for treatment-window decisions.

    Why the other options are wrong

    • AThe time of discovery shows when the deficits were noticed, not when he was last normal, and could wrongly place him inside a treatment window.
    • CArrival time reflects transport, not symptom onset, and plays no part in defining the last known well.
    • DA calculated midpoint is not an accepted way to set onset, because nothing places him at baseline at that time.

20. Question 20 of 25Medium

    Before a ruptured cerebral aneurysm is secured, which nursing goal has the highest priority?

    1. AA. Prevent vasospasm by raising blood pressure above baseline
    2. BB. Prevent cerebral edema by restricting IV fluid intake
    3. CC. Prevent deconditioning by getting the patient up to a chair
    4. DD. Prevent rebleeding by controlling pain and blood pressure
    Show answer to question 20

    Answer: D. Prevent rebleeding by controlling pain and blood pressure

    Rebleeding is most likely in the first hours after rupture and carries a high mortality, so before the aneurysm is secured the priority is avoiding hypertension, treating pain and limiting stimulation. Early coiling or clipping is the definitive protection.

    Why the other options are wrong

    • AVasospasm develops days later, and raising blood pressure before the aneurysm is secured increases the risk of rebleeding.
    • BRestricting fluids promotes hypovolemia, which raises the risk of delayed cerebral ischemia after subarachnoid hemorrhage.
    • CExertion raises blood pressure, so mobilization waits until the aneurysm is secured and the patient is stable.

21. Question 21 of 25Hard

    A patient enrolled in an outpatient methadone maintenance program (100 mg daily) is admitted to the ICU with severe septic shock and requires amiodarone for new-onset atrial fibrillation with rapid ventricular response. Which diagnostic assessment should the nurse prioritize related to this medication combination?

    1. AA. Serial arterial blood gases to assess for metabolic alkalosis
    2. BB. Serial 12-lead electrocardiograms to measure the QTc interval
    3. CC. Continuous pulse pressure variation to evaluate fluid responsiveness
    4. DD. Daily serum trough levels to detect acute nephrotoxicity
    Show answer to question 21

    Answer: B. Serial 12-lead electrocardiograms to measure the QTc interval

    Both methadone and amiodarone prolong the cardiac QTc interval by blocking cardiac potassium channels (hERG channels). Co-administration significantly amplifies the risk of excessive QTc prolongation and malignant polymorphic ventricular tachycardia (Torsades de Pointes), necessitating close serial electrocardiographic monitoring. Methadone is not directly nephrotoxic, does not induce metabolic alkalosis, and pulse pressure variation monitors volume status rather than methadone-related cardiotoxicity.

22. Question 22 of 25Medium

    A 40-year-old woman with a crush injury of the forearm has a tense forearm and severe pain that increases when her fingers are passively extended. The surgeon has been called. In which position should the nurse keep the limb?

    1. AA. At the level of the heart
    2. BB. Elevated well above the heart
    3. CC. Hanging below the level of the heart
    4. DD. Elevated, with ice packs over the forearm
    Show answer to question 22

    Answer: A. At the level of the heart

    These findings suggest acute compartment syndrome. Keeping the limb at heart level avoids lowering arterial inflow, as elevation does, without adding venous congestion. The nurse also loosens or removes circumferential dressings and splints.

    Why the other options are wrong

    • BElevation lowers arterial pressure in the limb and further reduces perfusion when compartment pressure is high.
    • CA dependent position adds venous congestion and swelling within the compartment.
    • DElevation reduces perfusion, and ice causes vasoconstriction that can worsen ischemia.

23. Question 23 of 25Medium

    A critically ill patient with a documented history of severe psychological trauma requires an urgent arterial catheter insertion. When the clinical team gathers at the bedside, the patient becomes visibly tremulous, guarded, and diaphoretic. Applying trauma-informed care principles, which action should the nurse take first?

    1. AA. Administer an unrequested dose of intravenous midazolam to blunt procedural recall
    2. BB. Ask bedside family members to step out into the waiting area to reduce stimulation
    3. CC. Proceed rapidly with the insertion while firmly reassuring the patient that the procedure is necessary
    4. DD. Explain the procedural steps, seek permission before touching, and offer appropriate choices
    Show answer to question 23

    Answer: D. Explain the procedural steps, seek permission before touching, and offer appropriate choices

    Trauma-informed care prioritizes safety, transparency, collaboration, and empowerment; transparent communication and asking permission before touching restore personal agency and reduce the risk of triggering traumatic memories. Administering sedatives without consent or rushing through the intervention disregards patient autonomy and can lead to psychological re-traumatization. Eliminating family presence often removes a key emotional support system unless the patient explicitly requests their departure.

24. Question 24 of 25Hard

    During apnea testing for brain death determination, a 52-year-old woman is disconnected from the ventilator with oxygen flowing into her endotracheal tube. Her baseline PaCO2 was 40 mm Hg. Over 9 minutes the nurse sees no chest or abdominal movement, her SpO2 stays at 96%, and her blood pressure is stable. An arterial blood gas then shows pH 7.18 and PaCO2 66 mm Hg. How should this result be interpreted?

    1. AA. It is positive, as no breaths occurred at the target values
    2. BB. It is inconclusive, as the PaCO2 must reach at least 80 mm Hg
    3. CC. It must be stopped, as the pH has fallen below a safe limit
    4. DD. It is invalid, as oxygen was given during the apnea period
    Show answer to question 24

    Answer: A. It is positive, as no breaths occurred at the target values

    No breathing effort while the PaCO2 rose from 40 to 66 mm Hg and the arterial pH fell to 7.18 is a positive apnea test, which supports brain death. A PaCO2 of 66 mm Hg exceeds the 60 mm Hg threshold and is more than 20 mm Hg above her baseline, and a pH of 7.18 is acidemic. Oxygen given through the tube prevents hypoxemia during the test.

    Why the other options are wrong

    • BCurrent criteria call for a PaCO2 of at least 60 mm Hg with an acidemic pH, and this result clearly meets them; 80 mm Hg is not required.
    • CA falling pH is the intended stimulus to breathe and part of the target; the test is stopped for hypotension, hypoxemia or dysrhythmias, none of which occurred.
    • DOxygen is routinely given through the tube during apnea testing to prevent hypoxemia.

25. Question 25 of 25Hard

    A 67-year-old woman 1 day after abdominal surgery suddenly becomes restless, pulls at her nasal cannula and tries to climb out of bed. She has an as-needed order for IV haloperidol. Her heart rate is 118/min, respiratory rate 30/min and SpO2 84%. Which action should the nurse take first?

    1. AA. Give the ordered haloperidol to calm her
    2. BB. Apply soft wrist restraints to protect her
    3. CC. Call her daughter to come sit with her
    4. DD. Give oxygen and assess her breathing
    Show answer to question 25

    Answer: D. Give oxygen and assess her breathing

    Agitation can be the first sign of a physiologic problem such as hypoxemia, pain, hypoglycemia or a full bladder. With an SpO2 of 84% and tachypnea, she needs oxygen and a breathing assessment before any sedative or restraint is considered.

    Why the other options are wrong

    • AA sedative could mask the cause and further depress her breathing while she is hypoxemic.
    • BRestraint does not treat the cause and increases distress; the cause and less restrictive measures come first.
    • CFamily presence can calm patients, but it does not correct her hypoxemia.

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