リアルCCRN-Adult問題集でAACN正確な解答2024年最新版を試そう
AACN CCRN CCRN-Adult試験練習問題集
質問 # 68
A patient is admitted with Gl bleeding. During the assessment, the nurse notes the patient to be tremulous, anxious, and startles every time he is touched by the nurse. Which of the following is the most pertinent part of the patient's history to obtain?
- A. medication history
- B. last alcohol intake
- C. psychiatric history
- D. time of last meal
正解：B
解説：
Alcohol withdrawal syndrome
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answer: A
The patient's symptoms of tremulousness, anxiety, and startle response suggest that he may be experiencing alcohol withdrawal, which can occur within hours to days after the last drink. Alcohol withdrawal can cause severe complications, such as seizures, delirium tremens, and death, if not treated promptly and appropriately.
Alcohol withdrawal can also worsen GI bleeding by increasing gastric acid secretion, impairing clotting factors, and causing hypertension and tachycardia. Therefore, the most pertinent part of the patient's history to obtain is the last alcohol intake, which can help determine the risk and severity of withdrawal and guide the management of the patient.
References:
* Management of moderate and severe alcohol withdrawal syndromes: This article states that "Symptoms of alcohol withdrawal occur because alcohol is a central nervous system depressant. When a person drinks frequently, the brain compensates for alcohol's depressant effects by increasing the activity of excitatory neurotransmitters, such as norepinephrine, serotonin, dopamine, and glutamate, and reducing the activity of inhibitory neurotransmitters, such as gamma-aminobutyric acid (GABA). When alcohol intake is abruptly discontinued or reduced, this neuroadaptation is unmasked, resulting in a hyperexcitable state that is responsible for the characteristic withdrawal symptoms."
* Alcoholic Gastritis: Causes, Symptoms and Treatment: This article states that "Alcohol Gastritis is a type of acute gastritis and is caused by excessive alcohol consumption. The sudden inflammation of the stomach lining can be very painful and cause severe stomach cramping, irritability and vomiting. While consuming too much alcohol is the main cause of Alcohol Gastritis, it often develops in connection with some sort of infection, direct irritation or localized tissue damage. It can be caused by: Taking non-steroidal, anti-inflammatory medications like aspirin or ibuprofen (i.e., NSAIDs). Certain bacterial infections. Bile reflux from proximal small intestine. Autoimmune disorders."
* Can You Get Internal Bleeding from Alcohol Abuse: This article states that "Over time, alcohol abuse
* starts to eat away at the stomach lining. Continued drinking sets the stage for alcoholic gastritis to develop. Under these conditions, internal bleeding from alcohol abuse takes the form of blood oozing from stomach lines on an ongoing basis."
質問 # 69
A patient with a history of six cardiac catheterizations relates that he has received differing instructions about the duration of required bedrest after the procedure. To further investigate this issue, which of the following is a nurse's most appropriate action?
- A. Review recent published research about bedrest protocols.
- B. Ask the nursing supervisor to request standardized physician orders for patients who have undergone catheterization.
- C. Conduct an informal chart review and outcome evaluation of patients treated with different bedrest protocols.
- D. Ask about obtaining an independent evaluation of unit outcomes.
正解：A
解説：
The nurse's most appropriate action is to review recent published research about bedrest protocols, as this would provide the nurse with the most current and reliable evidence to guide clinical practice and improve patient outcomes. Bedrest protocols after cardiac catheterization may vary depending on the type of access site, the use of closure devices, the patient's risk factors, and the clinician's preference. However, there is a growing body of research that supports early ambulation and shorter bedrest duration to reduce the risk of complications, such as bleeding, hematoma, back pain, and venous thromboembolism, and to enhance patient comfort and satisfaction123. Asking about obtaining an independent evaluation of unit outcomes, conducting an informal chart review and outcome evaluation of patients treated with different bedrest protocols, or asking the nursing supervisor to request standardized physician orders for patients who have undergone catheterization are not the most appropriate actions, as they may not reflect the best available evidence, may be biased or incomplete, or may not address the patient's concern.
References:
* 1: Bedrest After Cardiac Catheterization: A Systematic Review and Meta-analysis4, p. 1-2.
* 2: Early Ambulation After Cardiac Catheterization: A Literature Review, p. 1-2.
* 3: Bed Rest After Cardiac Catheterization: A Review of the Evidence, p. 1-2.
質問 # 70
A patient who had a liver resection now has a copious amount of serous drainage from the surgical incision.
Which of the following should a nurse anticipate when caring for this patient?
- A. preparing for an incision and debridement of the wound
- B. applying a drainage pouch to the site
- C. administering antibiotics
- D. applying several abdominal dressings
正解：D
解説：
A copious amount of serous drainage from a liver resection incision may indicate a bile leak, which can cause pain, infection, and delayed healing. The nurse should anticipate applying several abdominal dressings to absorb the fluid and protect the wound. The nurse should also monitor the patient for signs of infection, such as fever, increased white blood cell count, and foul-smelling drainage. The nurse should notify the surgeon of the excessive drainage and follow the orders for further interventions, such as imaging studies, drainage catheter placement, or surgical repair. Antibiotics may be prescribed, but they are not the first-line treatment for a bile leak. Incision and debridement of the wound may be necessary if there is necrotic tissue or infection, but it is not the initial action. Applying a drainage pouch to the site may not be sufficient to contain the large amount of fluid and may increase the risk of skin breakdown.
References:
* Problems after cancer surgery to remove part of your liver: This article states that "The bile ducts connect the liver and gallbladder to the small bowel. There is a risk of bile leaking from the ducts on the cut surface of the liver. This may cause pain, sickness and a high temperature. Rarely, you might need another operation to repair the leak."
* Understanding Liver Abscess Treatment - Saint Luke's Health System: This article states that "The provider uses CT scan or ultrasound to help place the wire in the right spot. A thin, flexible tube (catheter) is then placed over the wire and into the abscess. The tube is left in place for 5 to 7 days to drain the fluid. In some cases, surgery may be done to cut into the liver abscess and drain it."
* How Much Time Does it Take to Recover from Liver Surgery?: This article states that "If you have any drainage from your incision or if the area around your incision is puffy or red, visit your surgeon. Take a shower every day with warm water. When you are ready to take solid foods, make sure to eat 4 to 6 small meals every day. Do not lift heavy weights for 8 weeks after your surgery."
質問 # 71
After the administration of haloperidol (Haldol), a nurse should monitor closely for
- A. respiratory failure and cardiac failure.
- B. widened QRS complex.
- C. prolonged QT interval and cardiac dysrhythmias.
- D. increased agitation.
正解：C
解説：
Haloperidol
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Haloperidol has a known side effect of prolonging the QT interval, which can lead to cardiac dysrhythmias123. Therefore, after the administration of haloperidol, it is important for a nurse to monitor for a prolonged QT interval and cardiac dysrhythmias123. This is why continuous cardiac monitoring is recommended if repeated doses are given1.
質問 # 72
A patient presents with the following hemodynamics:
MAP 40 mm Hg
PAD6 mm Hg
PAOP5 mm Hg
CI1.8 L/min/m2
SVR875 dynes/sec/cm-5
Which of the following is essential in the plan of care?
- A. fluid resuscitation
- B. whole blood
- C. loop diuretic
- D. vasopressors
正解：A
解説：
The patient has signs of hypovolemic shock, which is characterized by low MAP, low PAOP, low CI, and high SVR. The patient needs fluid resuscitation to restore intravascular volume and improve tissue perfusion. Loop diuretic, vasopressors, and whole blood are not indicated in this case.
References:
* Reference Guide for CCRN (Adult), page 14.
* Adult CCRN/CCRN-E/CCRN-K Certification Review Course Online - Individual Purchase, Module 1:
Cardiovascular, Part 1: Shock.
質問 # 73
While recording hourly ventilator checks on a patient who is being mechanically ventilated, the nurse notes that the PIP has gradually increased by 5 cm H2O over the past 4 hours. This increase indicates
- A. a decrease in airway resistance.
- B. a leak in the ET tube cuff.
- C. an improvement in pulmonary function.
- D. a decrease in lung compliance.
正解：D
解説：
An increase in peak inspiratory pressure (PIP) over time in a mechanically ventilated patient indicates a decrease in lung compliance. This means the lungs are becoming stiffer and less able to expand, which can be caused by conditions such as pulmonary edema, ARDS, or pneumothorax. It is important to address the underlying cause of decreased lung compliance to prevent further respiratory complications. References: = CCRN Exam Handbook, AACN Adult CCRN Certification Review Course
質問 # 74
A patient is admitted for acute benzodiazepine overdose. Nursing interventions should include administration of
- A. osmotic diuretics.
- B. sodium bicarbonate.
- C. naloxone (Narcan).
- D. flumazenil (Romazicon).
正解：D
解説：
Flumazenil is a benzodiazepine antagonist that can reverse the effects of benzodiazepine overdose. It acts by competitively inhibiting the activity at the benzodiazepine receptor, thus reversing sedation and other effects caused by benzodiazepines. Sodium bicarbonate, naloxone, and osmotic diuretics are not appropriate treatments for benzodiazepine overdose. References: AACN Adult CCRN Certification Review Course, AACN CCRN Exam Handbook.
質問 # 75
The rationale for initiating early enteral feeding in a patient with sepsis is to
- A. minimize translocation of GI bacteria.
- B. minimize electrolyte imbalances and fluid shifts.
- C. increase GI motility.
- D. prevent pulmonary aspiration.
正解：A
解説：
Early enteral feeding in patients with sepsis is crucial as it helps maintain gut integrity, thereby minimizing the translocation of gastrointestinal (GI) bacteria. The presence of nutrients in the gut lumen supports the mucosal barrier function and reduces bacterial translocation, which can lead to secondary infections and further complications in septic patients. References: = CCRN Exam Handbook and AACN's Certification Review Course materials.
質問 # 76
The underlying pathophysiology of disseminated intravascular coagulation (DIC) is best explained as
- A. inactivation of tissue thromboplastin.
- B. depletion of clotting factors.
- C. depression of platelet aggregation.
- D. fragmentation of erythrocytes.
正解：B
解説：
Disseminated intravascular coagulation (DIC) is a condition where blood clots form excessively and block blood vessels, leading to organ damage and bleeding. The pathophysiology of DIC involves excess and unregulated thrombin generation, which consumes coagulation factors and platelets, and activates fibrinolysis1. Thus, in severe DIC there is paradoxically simultaneous thrombosis and spontaneous bleeding2.
This is due to the depletion of clotting factors, which is a key aspect of the underlying pathophysiology of DIC12.
質問 # 77
A patient post-surgical externalized ventricular drain placement has treatment orders that include continuous cerebrospinal fluid (CSF) drainage at 10 mm Hg. Which of the following should the nurse anticipate with an increase in the ICP above 25 mm Hg?
- A. a decrease in the pulse pressure
- B. an increase in the cerebral perfusion pressure from 65 to 70
- C. a change in CSF drainage from clear to pink
- D. the amplitude of P2 greater than P1 on the waveform morphology
正解：D
解説：
An increase in intracranial pressure (ICP) above 25 mm Hg often results in changes in the waveform morphology observed in the monitoring of intracranial pressure. Specifically, the amplitude of P2 becomes greater than P1, which is indicative of decreased intracranial compliance. This pattern is known as the
"pathological waveform," suggesting increased intracranial pressure and decreased ability of the brain to accommodate the pressure changes. References: CCRN Exam Handbook, AACN, page 23, section on Neurological.
質問 # 78
A patient who underwent bowel resection surgery due to small bowel rupture is tachycardic and hypotensive.
A nurse calls the on-call surgical resident and reports the findings. No new orders are received. The nurse should continue to monitor the patient and
- A. consult the nearest nursing colleague.
- B. inform the clinical manager in the morning.
- C. notify the charge nurse during nightly rounds.
- D. initiate the rapid response team.
正解：D
解説：
The patient's tachycardia and hypotension following bowel resection surgery indicate potential severe complications such as hemorrhage or septic shock, which require immediate intervention. If the on-call surgical resident does not provide new orders, the nurse must act promptly to prevent further deterioration by initiating the rapid response team (RRT). The RRT can provide critical interventions and facilitate timely transfer to a higher level of care if needed. References: = CCRN Exam Handbook, AACN Adult CCRN Certification Review Course
質問 # 79
The nurse is caring for a patient with neutropenia secondary to chemotherapy. When communicating dietary needs to the provider, the nurse should request which of the following to improve the patient's immune function?
- A. low protein diet
- B. high carbohydrate diet
- C. nutritional supplements
- D. total parental nutrition
正解：C
解説：
Nutritional supplements are beneficial for patients with neutropenia secondary to chemotherapy, as they can help provide adequate calories, protein, vitamins, and minerals that are essential for immune function and tissue repair. Chemotherapy can cause side effects such as nausea, vomiting, loss of appetite, taste changes, and mouth sores, which can make it difficult for patients to eat enough food and meet their nutritional needs.
Nutritional supplements can be in the form of oral drinks, shakes, bars, or powders, or they can be administered through a feeding tube or intravenously. The nurse should request nutritional supplements that are appropriate for the patient's condition, preferences, and tolerance, and that are compatible with the neutropenic diet and food safety guidelines. The nurse should also monitor the patient's weight, hydration, and laboratory values, and report any signs of malnutrition, infection, or intolerance to the provider.
References:
* Nutrition for the Person With Cancer During Treatment: A Guide for Patients and Families: This article states that "Nutritional supplements are products that can be used to add nutrients to your diet or to lower your risk of health problems. They can be in pill, capsule, tablet, or liquid form. They might have vitamins, minerals, amino acids, herbs, or other substances. Some examples of common supplements are calcium, iron, omega-3 fatty acids, vitamin C, and vitamin D. You might need supplements if you cannot get enough nutrients from foods or if you have certain health conditions that might cause a deficiency, such as cancer, diabetes, or chronic diarrhea."
* Nutrition in Cancer Care (PDQ)-Patient Version: This article states that "Nutritional support is therapy for people who do not get enough nourishment by eating or drinking. You may need nutritional support if you have trouble swallowing, have lost your appetite, or are losing weight. Nutritional support can be given in different ways: Enteral nutrition is liquid food given through a tube (called a feeding tube) into the stomach or small intestine. Parenteral nutrition is a liquid mixture of nutrients given through a vein (intravenous or IV). Oral nutrition is food or liquid taken by mouth. This includes nutritional supplements, such as drinks, shakes, bars, or powders that have protein, carbohydrates, fat, vitamins, and minerals."
* Nutrition and Cancer: What You Need to Know: This article states that "Nutritional supplements can help you meet your calorie and protein needs when you are not able to eat enough food. They can also provide extra vitamins and minerals. There are many types of nutritional supplements, such as drinks, shakes, puddings, bars, and powders. Some are designed for people with cancer and have extra calories and protein. Your doctor, nurse, or dietitian can help you choose the best supplement for you. You can buy some supplements at the grocery store or pharmacy, but others may need a prescription."
質問 # 80
A patient is admitted for sepsis secondary to pneumonia. The patient has received 2000 mL of plasmalyte and their BP remains 80/50. What should the nurse anticipate next for the patient?
- A. norepinephrine
- B. 1L of plasmalyte
- C. dopamine
- D. vasopressin
正解：A
質問 # 81
Appropriate outcomes for a patient with status asthmaticus include
- A. increased PaCO2 and decreased FEV1.
- B. decreased peak flow rates and decreased wheezing.
- C. paradoxical breathing and increased FEV1.
- D. normal PaCO2 and increased FEV1.
正解：D
解説：
The appropriate outcomes for a patient with status asthmaticus are normal PaCO2 and increased FEV1. Status asthmaticus is a severe and life-threatening asthma exacerbation that does not respond to conventional treatment. It causes severe bronchoconstriction, air trapping, and mucus plugging, leading to hypoxemia, hypercapnia, and respiratory failure. The goals of treatment are to reverse the airway obstruction, improve gas exchange, and prevent complications. PaCO2 is the partial pressure of carbon dioxide in the blood, which reflects the adequacy of ventilation. FEV1 is the forced expiratory volume in one second, which measures the amount of air that can be forcefully exhaled in the first second of a breath. It reflects the degree of bronchoconstriction and airflow limitation. A patient with status asthmaticus typically has elevated PaCO2 and reduced FEV1 due to poor ventilation and severe obstruction. Therefore, normalizing PaCO2 and increasing FEV1 indicate improvement in the patient's condition and response to treatment.
References:
* Status Asthmaticus: Symptoms, Causes, Diagnosis, and Treatment - Healthline: This article states that
"Status asthmaticus is a severe form of asthma with symptoms similar to a typical asthma attack. But for status asthmaticus, symptoms may worsen as the asthma attack continues. Status asthmaticus is an older, less precise term for what's now more commonly known as acute severe asthma or a severe asthma exacerbation. It refers to an asthma attack that doesn't improve with traditional treatments, such as inhaled bronchodilators. These attacks can last for several minutes or even hours."
* Status Asthmaticus (Severe Acute Asthma) - WebMD: This article states that "Status asthmaticus is a severe asthma attack that doesn't get better with your usual treatments. It can be life-threatening and needs urgent medical attention. If you have a bad asthma attack and your rescue inhaler or your nebulizer doesn't help, you need medical care right away. If an attack comes on quickly and it doesn't respond to regular treatment, it can lead to status asthmaticus."
* Management of Status Asthmaticus | SpringerLink: This article states that "Status asthmaticus is a life-threatening condition characterized by progressive respiratory failure despite aggressive treatment.
It is defined as an acute exacerbation of asthma that remains unresponsive to initial treatment with bronchodilators. Status asthmaticus can vary in severity from mild to fatal. The pathophysiology of status asthmaticus is complex and involves airway inflammation, bronchospasm, airway edema, mucus plugging, and increased airway resistance. The clinical manifestations of status asthmaticus include dyspnea, wheezing, cough, chest tightness, tachypnea, tachycardia, hypoxemia, and hypercapnia. The diagnosis of status asthmaticus is based on history, physical examination, and laboratory tests, such as arterial blood gas analysis, spirometry, and chest radiography. The management of status asthmaticus consists of oxygen therapy, inhaled beta-2 agonists, systemic corticosteroids, and adjunctive therapies, such as anticholinergics, magnesium sulfate, ketamine, and noninvasive or invasive mechanical ventilation. The goals of treatment are to relieve bronchoconstriction, reduce airway inflammation, correct hypoxemia, normalize or reduce carbon dioxide levels, and avoid or treat complications."
質問 # 82
The nurse who is caring for a patient following an esophagectomy notes new subcutaneous emphysema in the upper chest and neck. The nurse should expect an order for
- A. gastric decompression.
- B. chest tube insertion.
- C. IV antibiotics.
- D. a CT scan.
正解：D
解説：
Subcutaneous emphysema (SE) is a condition where gas or air accumulates in the subcutaneous tissue layer of the skin, causing swelling and a crackling sensation when touched. SE can occur after esophagectomy, a surgical procedure to remove part or all of the esophagus, due to air leakage from the anastomosis site or the lung. SE can also be a sign of a more serious complication, such as anastomotic leakage, mediastinitis, or tracheal injury12. Therefore, the nurse should expect an order for a CT scan, which is a diagnostic imaging test that can detect the source and extent of the air leakage and any associated complications. A CT scan can also guide the appropriate management of SE, which may include conservative measures, such as increasing the suction of the chest tube, or more invasive interventions, such as surgical repair or drainage123. Chest tube insertion, IV antibiotics, and gastric decompression are not likely to be ordered for SE after esophagectomy, as they do not address the underlying cause of the air leakage or the potential complications. Chest tube insertion may be indicated for pneumothorax, but not for SE alone. IV antibiotics may be indicated for infection, but not for SE alone. Gastric decompression may be indicated for gastric distension, but not for SE alone.
質問 # 83
After consultation with the interdisciplinary team, a nurse implements progressive mobility by having the patient sit at the side of the bed. The patient's HR increases by 10, RR increases by 6, SpO2 remains at 94%, and BP remains stable. The patient states he is tired. Which of the following should be the nurse's next action?
- A. Return the patient to a supine position and notify the physician.
- B. Progress to sitting in a chair during the next activity.
- C. Wait for assistance from physical therapy to resume mobility.
- D. Discontinue the attempts to mobilize the patient.
正解：A
解説：
The patient's increased heart rate and respiratory rate, along with the patient's statement of feeling tired, may indicate that the activity was too strenuous123. It's important to ensure patient safety and comfort, so the nurse should return the patient to a supine position123. The physician should be notified about the patient's response to the activity for further evaluation and to adjust the care plan if necessary123.
質問 # 84
The water retention associated with SIADH is characterized by
- A. UO greater than fluid intake, extreme weight gain, and mild (2+) pitting edema.
- B. fluid intake greater than UO, weight gain, and increased urine osmolality and sodium.
- C. fluid intake greater than UO, increased serum osmolality and sodium, and severe (4+) pitting edema.
- D. UO greater than fluid intake and severe (4+) pitting edema.
正解：B
解説：
The syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention. This results in fluid intake being greater than urine output (UO), weight gain due to fluid retention, and concentrated urine with increased osmolality and sodium levels. SIADH does not typically present with severe pitting edema or increased serum osmolality and sodium.
References: =
* CCRN (Adult) Certification Review Course Online: Endocrine Emergencies.
* American Association of Critical-Care Nurses (AACN). (2024). CCRN Exam Handbook. Retrieved from AACN CCRN Exam Handbook
* Adult CCRN/CCRN-E/CCRN-K Certification Review Course Online. AACN
質問 # 85
Which of the following is most indicative of successful treatment for salicylate poisoning?
- A. decrease in CPK
- B. decrease in gastric pH
- C. alkalinization of urine
- D. osmotic diuresis
正解：C
解説：
Salicylate poisoning
Alkalinization of urine is one of the main goals of treatment for salicylate poisoning, as it enhances the renal excretion of salicylate and reduces its reabsorption. Alkalinization of urine can be achieved by administering intravenous sodium bicarbonate and maintaining adequate hydration and urine output. Alkalinization of urine can be monitored by measuring the urine pH, which should be above 7.5. Osmotic diuresis, decrease in gastric pH, and decrease in CPK are not indicative of successful treatment for salicylate poisoning. Osmotic diuresis may occur as a result of salicylate toxicity, but it does not improve the elimination of salicylate. Decrease in gastric pH may impair the absorption of salicylate, but it does not affect the elimination of salicylate. Decrease in CPK may reflect the resolution of rhabdomyolysis, which is a possible complication of salicylate poisoning, but it does not reflect the clearance of salicylate.
References:
* Salicylate (aspirin) poisoning: Management - UpToDate1, p. 1-2.
* Salicylate poisoning - Symptoms, diagnosis and treatment | BMJ Best Practice US2, p. 4-5.
質問 # 86
A nurse has responded to a rapid response call on a medical-surgical floor in the hospital. The nurse finds the patient with the following data:
BP72/30
HR132
RR24
T102.3° F (39.0° C)
SpO295%
Ph7.13
PaCO234 mm Hg
PaO288 mm Hg
HCO3 14 mEq/L
Na+ 142 mEq/L
The nurse should anticipate an order to administer which of the following?
- A. 8.4% sodium bicarbonate
- B. phenylephrine (Neo-Synephrine)
- C. amiodarone (Cordarone)
- D. 0.9% sodium chloride
正解：B
解説：
The patient's data indicate that the patient is in shock, which is a life-threatening condition characterized by inadequate tissue perfusion and organ dysfunction. The patient has a low blood pressure, a high heart rate, a fever, and a metabolic acidosis, which suggest that the patient may have septic shock, which is caused by a severe infection that triggers a systemic inflammatory response. The nurse should anticipate an order to administer phenylephrine (Neo-Synephrine), which is a vasopressor agent that constricts the blood vessels and increases the blood pressure and tissue perfusion. Phenylephrine is recommended as a first-line agent for septic shock by the Surviving Sepsis Campaign guidelines1. 8.4% sodium bicarbonate is not indicated for the treatment of septic shock, as it may worsen the acid-base balance and increase the risk of complications2.
0.9% sodium chloride is a normal saline solution that may be used for fluid resuscitation, but it may not be sufficient to restore the blood pressure and may cause fluid overload, hyperchloremia, and kidney injury3.
Amiodarone (Cordarone) is an antiarrhythmic drug that is used to treat ventricular tachycardia or fibrillation, but it is not effective for septic shock and may cause hypotension, bradycardia, and other adverse effects4.
References:
* Surviving Sepsis Campaign. (2020). Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Retrieved from 1, p. 16.
* Marik, P. E., & Bellomo, R. (2013). A rational approach to fluid therapy in sepsis. British Journal of Anaesthesia, 110(3), 323-329. Retrieved from 2, p. 327.
* Semler, M. W., & Rice, T. W. (2019). Saline versus balanced crystalloids for intravenous fluid therapy in the emergency department: study protocol for a cluster-randomized, multiple-crossover trial. Trials,
20(1), 1-10. Retrieved from 3, p. 2-3.
* Lexicomp Online. (2021). Amiodarone. Retrieved from 4, p. 1-2.
質問 # 87
A patient is admitted with hypotension, tachycardia, and intermittent confusion. Upon arrival, the patient asks to walk to the bathroom. Which of the following is a nurse's best action?
- A. Assess the patient's vital signs and ask the physician for an order for activity.
- B. Encourage the patient to walk independently to the bathroom to enhance early mobility.
- C. Conduct a fall risk assessment and institute appropriate interventions.
- D. Situate the patient in bed and provide a bed pan.
正解：D
解説：
Given the patient's symptoms of hypotension, tachycardia, and intermittent confusion, the safest course of action is to keep the patient in bed to prevent falls and further injury. The patient is at high risk for falls due to their hemodynamic instability and altered mental status. Using a bed pan minimizes the risk of injury compared to allowing the patient to walk, which could lead to falls and worsen their condition. References: = CCRN Exam Handbook, AACN Adult CCRN Certification Review Course
質問 # 88
Which of the following is the most common prerenal cause of acute tubular necrosis?
- A. shock
- B. crush injury
- C. beta-hemolytic streptococcal infection
- D. blood transfusion reaction
正解：A
解説：
Shock is the most common prerenal cause of acute tubular necrosis (ATN). In the context of prerenal conditions, shock leads to decreased renal perfusion and subsequent ischemia, which can cause damage to the renal tubules. Other options such as blood transfusion reaction, crush injury, and beta-hemolytic streptococcal infection can lead to renal damage but are not the most common prerenal causes of ATN. References: CCRN Exam Handbook, AACN, page 28, section on Renal/GU.
質問 # 89
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