Quiz CCRN-Adult: AACN CCRN (Adult)-Direct Care Eligibility Pathway

Beta-agonists are the first-line drugs for acute asthma exacerbations because they rapidly reverse
bronchoconstriction and improve airflow. They act by stimulating beta-2 receptors in the smooth
muscle of the airways, causing relaxation and dilation. Beta-agonists can be administered by
inhalation, nebulization, or injection. Examples of beta-agonists include albuterol, levalbuterol, and
terbutaline.
Reference:
Management of Acute Asthma Exacerbations | AAFP: This article states that “Quick-relief medicines
include: Albuterol (ProAir HFA, Proventil-HFA, Ventolin HFA, others). Levalbuterol (Xopenex, Xopenex
HFA).”
Asthma attack - Diagnosis and treatment - Mayo Clinic: This article states that “If you’re in the yellow
zone, the plan will tell you how many puffs of your quick-relief medicine to take and how often you
can repeat the dose. Young children or people who have difficulty with an inhaler use a device called
a nebulizer to inhale the medicine in a mist. Quick-relief medicines include: Albuterol (ProAir HFA,
Proventil-HFA, Ventolin HFA, others). Levalbuterol (Xopenex, Xopenex HFA).”

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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.
Reference:
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.”

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.
Reference:
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.

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.
Reference:
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.”

Sequential compression devices (SCDs) are not recommended for patients receiving therapeutic
hypothermia (TH) post-cardiac arrest, because they may interfere with the cooling process and
increase the risk of skin injury. SCDs are used to prevent deep vein thrombosis (DVT) by applying
intermittent pneumatic pressure to the lower extremities, but they may also increase peripheral
blood flow and heat exchange, which can counteract the effects of TH. SCDs may also cause skin
breakdown, blisters, or burns in patients with impaired sensation and reduced perfusion due to TH.
Therefore, a nurse should clarify the order for SCDs and consider alternative methods of DVT
prophylaxis, such as pharmacological agents or early mobilization.
Reference:
Therapeutic Hypothermia (TH) Education Components: This document states that “Avoid use of
sequential compression devices (SCDs) during cooling phase as they may interfere with cooling
process and increase risk of skin injury.”
Sequential Compression Devices: Clinical Effectiveness, Cost- Effectiveness and Guidelines: This
document states that “One evidence-based guideline from the American Heart Association (AHA)
and the American Stroke Association (ASA) recommended against the use of SCDs in patients
undergoing therapeutic hypothermia after cardiac arrest, as they may interfere with the cooling
process and increase the risk of skin injury.”

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.
Reference:
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 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.
Reference:
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.”

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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 mmHg1.
Reference:
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 patient’s ABG values show hypoxemia, which is a low level of oxygen in the blood. This can be
caused by various pulmonary disorders that impair gas exchange, such as pneumonia, pulmonary
edema, pulmonary embolism, or acute respiratory distress syndrome (ARDS). The patient’s PAP
(pulmonary artery pressure) is elevated, indicating increased resistance in the pulmonary circulation.
This can also result from pulmonary dysfunction, as the lungs become stiff and inflamed, or from
pulmonary hypertension, which is a chronic condition that affects the small arteries in the lungs. The
patient’s PAOP (pulmonary artery occlusion pressure) is normal, suggesting that the left ventricle is
not failing and that the patient is not hypovolemic or hypervolemic. The patient’s CI (cardiac index) is
also normal, indicating adequate cardiac output. Therefore, the most likely cause of the patient’s
hypoxemia and dyspnea is pulmonary dysfunction.
Reference:
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.

The nurse’s best response is to explore the patient’s reasons for the request and understanding of
potential consequences, as this demonstrates respect for the patient’s autonomy and dignity, as well
as provides an opportunity to assess the patient’s decision-making capacity, goals of care, and
preferences for end-of-life care. The nurse should also provide emotional support, education, and
symptom management to the patient and family. Advocating with the care team for a withdrawal of
treatment plan, encouraging the patient to continue with current medications and attempts to wean,
or referring the patient’s request to the healthcare facility’s ethics committee for review are not
appropriate responses, as they may undermine the patient’s right to self-determination, impose the
nurse’s own values or beliefs, or delay the implementation of the patient’s wishes.
Reference:
AACN. (2023). CCRN (Adult) Exam Handbook. Retrieved from [CCRN Exam Handbook], p. 19.
AACN. (2023). CCRN (Adult) Exam Blueprint. Retrieved from [CCRN Exam Blueprint], p. 2.
AACN. (2020). Practice Recommendations for End-of-Life Care in the Intensive Care Unit. Retrieved
from [Practice Recommendations], p. 14-15.
NICE. (2019). End of life care for adults: service delivery. Retrieved from [NICE Guidance], p. 4.