CCRN-Adult CCRN (Adult) - Direct Care Eligibility Pathway Questions and Answers

In the context of cardiogenic shock managed with vasopressor and inotrope therapies, organ dysfunction from hypoperfusion can manifest as elevated creatinine and abdominal pain. Elevated creatinine indicates renal impairment, a common result of poor perfusion to the kidneys. Abdominal pain can indicate hypoperfusion to the gastrointestinal tract, leading to ischemic bowel or other GI complications. These symptoms are direct indicators of hypoperfusion and organ dysfunction. References : = CCRN Exam Handbook, AACN Adult CCRN Certification Review Course

Crush injuries can lead to significant muscle damage and rhabdomyolysis, resulting in the release of intracellular potassium into the bloodstream, causing hyperkalemia. Tall peaked T waves are a classic sign of hyperkalemia, which needs to be closely monitored in these patients. References : = CCRN Exam Handbook and AACN ' s Certification Review Course materials.

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

When seeking to make changes to a documentation screen in the electronic health record (EHR), it is crucial to involve all relevant stakeholders to ensure their buy-in and support. This includes discussing the proposed changes with those who will be directly impacted by it and obtaining their feedback. This collaborative approach can help in identifying potential issues and garnering the necessary support for the proposal, increasing the likelihood of it being accepted by the EHR committee in the future. References : = CCRN Exam Handbook, page 58

Pulmonary hypertension leads to increased pressure in the pulmonary circulation, which can cause right ventricular hypertrophy and failure. This results in systemic venous congestion, presenting as distended neck veins. Crackles, rhonchi, and pink frothy sputum are more indicative of pulmonary edema or other respiratory conditions rather than pulmonary hypertension. References : AACN Adult CCRN Certification Review Course, AACN CCRN Exam Handbook.

When a patient exhibits anxiety and threats of harm, it is crucial to de-escalate the situation through verbal communication and engagement. By encouraging the patient to verbalize their feelings, the nurse can address the patient ' s fears and anxieties, reducing the likelihood of aggression. This approach promotes a therapeutic nurse-patient relationship and ensures the safety of both the patient and healthcare staff. References : = CCRN Exam Handbook, AACN Adult CCRN Certification Review Course

The spleen plays a crucial role in filtering bacteria and old or damaged blood cells, as well as mounting an immune response. After a splenectomy, the patient is at increased risk for infections, particularly from encapsulated organisms like Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis. This heightened susceptibility to infection can lead to sepsis, a life-threatening condition. References : AACN Adult CCRN Certification Review Course, AACN CCRN Exam Handbook.

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 - UpToDate 1 , p. 1-2.

Salicylate poisoning - Symptoms, diagnosis and treatment | BMJ Best Practice US 2 , p. 4-5.

brain injury (TBI) is most suggestive of central diabetes insipidus (DI). This condition is caused by damage to the hypothalamus or pituitary gland, leading to insufficient secretion of antidiuretic hormone (ADH). The result is an inability to concentrate urine, leading to polyuria (excessive urine output) and potentially significant dehydration and electrolyte imbalances if not managed appropriately. References : =

CCRN (Adult) Certification Review Course Online: Neurological Disorders and 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

Abdominal aortic aneurysm

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Acute renal failure is one of the possible complications of abdominal aortic aneurysm (AAA) repair, especially after open surgery. Acute renal failure is a sudden loss of kidney function that can cause fluid and electrolyte imbalance, acid-base disturbance, and uremic syndrome. Acute renal failure can occur due to several factors, such as hypoperfusion of the kidneys, atheroembolism, contrast-induced nephropathy, or ischemia-reperfusion injury 1 2 . The incidence of acute renal failure after AAA repair ranges from 2 to 25%, depending on the definition, the type of surgery, and the patient’s risk factors 1 3 . Acute renal failure is associated with increased morbidity, mortality, and length of hospital stay after AAA repair 1 3 .

Other complications of AAA repair include bleeding, infection, wound complications, graft-related complications, bowel ischemia, spinal cord ischemia, and cardiac, pulmonary, or neurological events 1 2 4 . Acute hepatic dysfunction, acute CVA, and atrial fibrillation are not specific complications of AAA repair, but they may occur in any major surgery or in patients with preexisting conditions.

Hypovolemic shock

Hypotension, or low blood pressure, is a late finding in hypovolemic shock, which means that it occurs when the condition has progressed to a severe stage. Hypotension indicates that the body’s compensatory mechanisms, such as vasoconstriction, tachycardia, and increased cardiac output, have failed to maintain adequate perfusion and oxygen delivery to the vital organs. Hypotension is a sign of impending circulatory collapse and organ failure, and requires immediate intervention to restore blood volume and blood pressure. Hypotension is usually defined as a systolic blood pressure below 90 mmHg or a mean arterial pressure below 65 mmHg 1 .

References :

Hypovolemic Shock: Causes, Symptoms and Treatment - Cleveland Clinic : This article states that “As you keep losing blood or fluids, your systolic (top or first number) blood pressure comes down.” and “Your blood pressure drops very low and your heart rate and breathing get faster.”

The nurse ' s role in this situation is to provide clear and compassionate guidance regarding the complex decision about continuing or discontinuing ventilator support. Referring to the hospital ' s policies provides a structured approach to making such decisions and ensures that the decision aligns with ethical and legal standards. This approach also supports the spouse by providing concrete information and a framework within which to make an informed decision. References : = CCRN Exam Handbook, AACN Adult CCRN Certification Review Course

The initial step in facilitating a change in practice regarding visiting hours should involve a literature search on family visitation practices. This allows the nurse to gather evidence-based information that can support any proposed changes. After gathering sufficient evidence, the nurse can then schedule an interdisciplinary team meeting to discuss the findings, consult with medical staff, and draft a new policy if necessary. References : CCRN Exam Handbook, AACN, page 35, section on Professional Caring and Ethical Practice.

Cardiogenic pulmonary edema is primarily caused by left ventricular (LV) noncompliance. When the left ventricle is unable to properly fill or eject blood, pressure increases in the left atrium and pulmonary veins, leading to fluid leakage into the pulmonary interstitium and alveoli, causing pulmonary edema. Elevated PAOP readings, RV chamber enlargement, and pulmonary hypertension are not primary causes of cardiogenic pulmonary edema but can be related to other cardiac conditions. References : = CCRN Exam Handbook, AACN Adult CCRN Certification Review Course

In a patient with head trauma, the primary pathophysiology underlying acute respiratory failure often involves hypercapnia due to decreased minute ventilation. Head trauma can impair the central nervous system ' s ability to regulate breathing, leading to inadequate ventilation and a build-up of carbon dioxide (CO2) in the blood. Other factors like shifting of the oxyhemoglobin dissociation curve, increased intrapulmonary shunt, and dehydration due to diabetes insipidus may be present but are not the primary causes. References : CCRN Exam Handbook, AACN, page 25, section on Respiratory.

In the setting of an acute anterior wall myocardial infarction (MI) with an S3 gallop, the patient is likely experiencing heart failure and possibly acute pulmonary edema. The appropriate treatment includes vasodilators to reduce afterload and diuretics to decrease preload and pulmonary congestion. This combination helps to improve cardiac output and reduce the workload on the heart. References : CCRN Exam Handbook, AACN, page 20, section on Cardiovascular.

The first priority in the management of an acute gastrointestinal (GI) hemorrhage is fluid resuscitation. This is critical to maintaining hemodynamic stability and ensuring adequate perfusion of vital organs. Monitoring of serial hemoglobin and hematocrit (Hgb and Hct) levels, while important for ongoing assessment, is secondary to the immediate need to stabilize the patient ' s circulatory status. Pain relief and insertion of a Sengstaken-Blakemore tube may be part of the overall management plan but are not the first priority. References : CCRN Exam Handbook, AACN, page 27, section on GI emergencies.

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy or " broken heart syndrome, " is characterized by transient left ventricular dysfunction often precipitated by significant emotional or physical stress. The key findings of chest pain and ST elevation without significant coronary artery disease, along with left ventricular dysfunction and apical ballooning observed on imaging, are classic for takotsubo cardiomyopathy. This condition is often reversible and is associated with a temporary reduction in the heart ' s pumping ability, indicated by the reduced ejection fraction (EF) of 35%. References : =

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

Hemothorax

Diminished breath sounds are one of the symptoms that may indicate hemothorax or internal bleeding in a video-assisted thoracic surgery (VATS) patient. VATS is a minimally invasive surgical technique that uses a small video camera (thoracoscope) and special instruments to access the chest cavity through small incisions 1 . Hemothorax is a condition where blood accumulates in the pleural space, the area between the lungs and the chest wall 2 . Hemothorax can occur as a complication of VATS due to injury to the lung, blood vessels, or chest wall during the procedure 3 . Hemothorax can cause compression of the lung and reduce its expansion, leading to diminished breath sounds on the affected side 2 . Other symptoms of hemothorax may include chest pain, shortness of breath, low blood pressure, rapid heart rate, and pale or clammy skin 2 .

Internal bleeding is another possible complication of VATS that can cause similar symptoms as hemothorax. Internal bleeding can occur due to damage to the major vessels, such as the aorta, pulmonary artery, or vena cava, during VATS. Internal bleeding can cause hypovolemia, which is a decrease in the volume of blood in the body, and hypoxemia, which is a low level of oxygen in the blood. These conditions can impair the delivery of oxygen to the tissues and organs, including the lungs, and cause diminished breath sounds, as well as other signs of shock, such as confusion, weakness, dizziness, and loss of consciousness.

Pain with deep inspiration, bradycardia, and hypertension are not typical symptoms of hemothorax or internal bleeding in a VATS patient. Pain with deep inspiration may be a normal postoperative finding after VATS, as the incisions and the chest tube may cause discomfort. Bradycardia and hypertension may be caused by other factors, such as medications, cardiac disorders, or neurological conditions, but they are not directly related to hemothorax or internal bleeding .

References :

1 : Video-Assisted Thoracoscopic Surgery (VATS) | Johns Hopkins Medicine

2 : Hemothorax: Causes, Symptoms, Diagnosis & Treatment - Cleveland Clinic 2

3 : Complications of video-assisted thoracoscopic surgery: a retrospective analysis of 3000 cases - PubMed

: Major vascular complications after video-assisted thoracoscopic surgery: a case report and literature review - PubMed

: Video-Assisted Thoracoscopic Surgery (VATS) | Michigan Medicine

: Bradycardia - Symptoms and causes - Mayo Clinic

: High blood pressure (hypertension) - Symptoms and causes - Mayo Clinic

Glucagon is a hormone that stimulates the liver to release glucose from glycogen stores or from gluconeogenesis. However, when the hepatocytes are damaged by alcoholism or other causes of hepatic failure, glucagon is ineffective because the liver cannot respond to its signal. Glucagon administration is contraindicated for hypoglycemic patients with hepatic failure because it will not raise their blood glucose levels and may worsen their acidosis and electrolyte imbalance 1 2 3

References :

Hypoglycemia in Patients With Hepatic Failure - PubMed

Glucagon - Wikipedia

Frontiers | Glucagon Receptor Signaling and Lipid Metabolism

Left shoulder pain, also known as Kehr sign, is a sign of splenic injury and diaphragmatic irritation. It is caused by the irritation of the phrenic nerve, which innervates both the diaphragm and the shoulder, by blood or other fluids in the left upper quadrant. Tachypnea, flank pain, and hiccoughs are not specific signs of splenic injury or diaphragmatic irritation.

References :

Splenic trauma | Radiology Reference Article | Radiopaedia.org

Recognition and management of diaphragmatic injury in adults

Reference Guide for CCRN (Adult), page 14.

A nurse should expect a plan of care that includes dobutamine (Dobutrex), fluid infusions, and transvenous pacing for a patient with a complicated RV infarction, as these interventions aim to improve RV function, increase cardiac output, and correct bradyarrhythmias. Dobutamine is an inotropic agent that increases myocardial contractility and reduces RV afterload 1 . Fluid infusions are used to optimize RV preload and maintain adequate systemic perfusion 1 2 . Transvenous pacing is indicated for patients with symptomatic bradycardia or high-grade AV block that compromise hemodynamics 1 3 . Dobutamine (Dobutrex), fluid restrictions, and furosemide (Lasix) are not appropriate for a patient with a complicated RV infarction, as they may worsen RV preload and cardiac output. Nitroprusside (Nipride), fluid restrictions, and transvenous pacing are not suitable for a patient with a complicated RV infarction, as they may cause excessive vasodilation and hypotension. Nitroglycerin, fluid infusions, and morphine are not optimal for a patient with a complicated RV infarction, as they may reduce RV preload and increase RV ischemia.

The dysrhythmia shown in the image is likely a rapid ventricular tachycardia (VT), given the hemodynamic instability (BP 83/40, patient pale, diaphoretic, lethargic, and disoriented). Synchronized cardioversion at 100 joules is the appropriate treatment for unstable VT, as it can effectively terminate the arrhythmia and restore normal sinus rhythm, addressing both the dysrhythmia and the patient ' s symptoms. References : = CCRN Exam Handbook, page 33

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.

Pulmonary embolism

Pulmonary angiography is the most definitive diagnostic test for pulmonary embolism, as it provides a clear picture of the blood flow in the arteries of the lungs. It can detect even small clots and determine the location and extent of the obstruction. However, because it requires a high degree of skill to perform and has potentially serious risks, it is usually done when other tests fail to provide a definite diagnosis 1 . Other tests that can be used to diagnose pulmonary embolism include CT pulmonary angiography, ventilation-perfusion scan, D-dimer test, chest X-ray, ultrasound, and MRI 2 3 . However, these tests may have limitations such as low sensitivity, low specificity, radiation exposure, contrast allergy, or availability 4 .

References :

Pulmonary embolism - Diagnosis and treatment - Mayo Clinic , under “Pulmonary angiogram”.

Pulmonary Embolism (PE): Symptoms, Signs & Treatment - Cleveland Clinic , under “How is a pulmonary embolism diagnosed?”.

Diagnosis of Pulmonary embolism and what are its different treatment options? , under “Diagnosis for Pulmonary embolism”.

Diagnosis of pulmonary embolism - UpToDate , under “Overview”.

Meningitis

A positive Kernig’s sign is a clinical test for meningitis that involves flexing the hip and knee of the patient and then extending the knee. If the patient feels pain or resistance in the lower back or hamstring, the test is positive. A positive Kernig’s sign indicates irritation of the meninges, the membranes that cover the brain and spinal cord. A positive Trousseau’s sign is a sign of hypocalcemia that involves carpal spasm after inflating a blood pressure cuff. A positive Cullen’s sign is a sign of retroperitoneal bleeding that involves bruising around the umbilicus. A positive Babinski’s sign is a sign of upper motor neuron lesion that involves fanning of the toes when the sole of the foot is stroked.

References :

Kernig’s sign - Wikipedia

Trousseau’s sign - Wikipedia

Cullen’s sign - Wikipedia

Babinski sign - Wikipedia

Haloperidol

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Haloperidol has a known side effect of prolonging the QT interval, which can lead to cardiac dysrhythmias 1 2 3 . Therefore, after the administration of haloperidol, it is important for a nurse to monitor for a prolonged QT interval and cardiac dysrhythmias 1 2 3 . This is why continuous cardiac monitoring is recommended if repeated doses are given 1 .

Lorazepam (Ativan) is most appropriate to administer in a patient who has smoked crack cocaine and is agitated, particularly after a generalized seizure. Benzodiazepines like lorazepam help to manage agitation and seizure activity associated with cocaine toxicity by providing sedative and anticonvulsant effects. References : = CCRN Exam Handbook, page 53

Nimodipine is a calcium channel blocker that is used to prevent or treat cerebral vasospasm after subarachnoid hemorrhage. It works by relaxing the smooth muscle of the cerebral arteries and improving blood flow to the brain. Nimodipine is the only FDA-approved agent for vasospasm and has been shown to reduce the risk of ischemic complications and improve neurological outcomes 1 2 . Lorazepam, propranolol, and pentobarbital are not effective for treating cerebral vasospasm and may have adverse effects on the patient’s blood pressure, heart rate, and level of consciousness.

The absence of regulators from O2 tanks is a serious issue that can affect patient care 1 . The nurse manager is in a position to address this problem effectively by ensuring the availability of necessary equipment 2 . Therefore, the best action would be to inform the nurse manager of the need for more regulators 1 2 3 . While documenting the issue and reporting to the shift supervisor are important, they do not directly address the problem. Forming a task force could be helpful, but it might take more time to implement solutions 2 3 .

Epidural hematoma

An epidural hematoma is a collection of blood that forms between the skull and the dura mater, the outermost layer of the meninges that cover the brain. The most common cause of an epidural hematoma is a head injury that fractures the temporal bone and tears the middle meningeal artery, which runs along the inner surface of the skull. Arterial bleeding is under high pressure and can rapidly expand the hematoma, compressing the brain and causing neurological deterioration. A typical symptom of an epidural hematoma is a brief loss of consciousness followed by a lucid interval and then a rapid decline in consciousness and brain function. This condition requires urgent surgical evacuation of the hematoma to prevent brain damage or death 1 2 . Venous bleeding, clot formation, and intracranial aneurysm are not the main factors associated with the deterioration of the patient’s condition in this case.

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 guidelines 1 . 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 complications 2 . 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 injury 3 . 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 effects 4 .

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.

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.

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 fibrinolysis 1 . Thus, in severe DIC there is paradoxically simultaneous thrombosis and spontaneous bleeding 2 . This is due to the depletion of clotting factors, which is a key aspect of the underlying pathophysiology of DIC 1 2 .

Phentolamine (Regitine) is the antidote for norepinephrine extravasation, which is the leakage of the vasopressor from the vein into the surrounding tissue. Phentolamine reverses the vasoconstriction and ischemia caused by norepinephrine by blocking the alpha-adrenergic receptors. Phentolamine should be administered intradermally around the site of extravasation as soon as possible, and the infusion should be stopped but the IV catheter should not be removed until some of the norepinephrine is aspirated. A warm compress may worsen the tissue damage by increasing the absorption of norepinephrine, and lowering the extremity may increase the edema and pain. Removing the IV immediately may prevent the aspiration of norepinephrine and the administration of phentolamine.

References :

Episode 240: What to do with norepinephrine extravasation : This article explains the steps to take when norepinephrine extravasates, including the use of phentolamine, and the reasons to avoid cold compress, lowering the extremity, and removing the IV.

What are current recommendations for treatment of drug extravasation? : This article summarizes the latest recommendations for treatment of extravasation, and lists phentolamine as the immediate topical therapy for norepinephrine extravasation.

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.”

The first step in developing an orientation plan is to assess the new nurse’s current knowledge and skills. This helps tailor the orientation to address any gaps and build on existing competencies. Understanding the new nurse ' s background ensures that the training is efficient and effective, focusing on areas that need improvement rather than repeating familiar information. References : = CCRN Exam Handbook, AACN Adult CCRN Certification Review Course

The patient ' s ABG results indicate respiratory acidosis (pH 7.33, PaCO2 48 mm Hg) with a slightly elevated temperature (103.2° F). In the context of fever and acidosis, hemoglobin ' s affinity for oxygen decreases, a phenomenon described by the Bohr effect. This means that hemoglobin will release oxygen more readily to the tissues. Factors like increased temperature and acidosis cause a rightward shift in the oxyhemoglobin dissociation curve, reducing the affinity of hemoglobin for oxygen. References : = CCRN Exam Handbook, page 44

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.

The patient’s findings are consistent with a ruptured diaphragm, which is a tear in the muscle that separates the chest and abdominal cavities. A blunt chest trauma can cause a sudden increase in intra-abdominal pressure, which can rupture the diaphragm and allow abdominal organs to herniate into the thorax. This can cause dyspnea, hypotension, shoulder pain, and bowel sounds over the lower thorax. A ruptured abdominal viscus would cause peritonitis, which would present with abdominal pain, distension, fever, and signs of sepsis. A flail chest would cause paradoxical chest movement, respiratory distress, and cyanosis. A mediastinal shift would cause tracheal deviation, decreased breath sounds, and jugular venous distension.

References :

AACN. (2023). CCRN (Adult) Exam Handbook. Retrieved from [CCRN Exam Handbook], p. 18.

AACN. (2023). CCRN (Adult) Exam Blueprint. Retrieved from [CCRN Exam Blueprint], p. 2.

BCEN. (2020). Trauma Certified Registered Nurse (TCRN) Examination Content Outline. Retrieved from [TCRN Exam Content Outline], p. 8.

Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2017). Medical-surgical nursing: Assessment and management of clinical problems (11th ed.). St. Louis, MO: Elsevier. Retrieved from [Textbook], p. 1789-1790.