CCRN (Adult): Direct Care Preparation Guide Study Guide

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An adult develops a regular narrow-complex rhythm at 190/min, blood pressure 74/42 mm Hg and new confusion. Recognize rhythm-related instability, activate assistance and prepare synchronized cardioversion while maintaining monitoring and supporting oxygenation as needed.

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An adult with recent viral symptoms develops chest pain, ST elevation and elevated troponin. Support urgent coronary assessment rather than assuming myocarditis.

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An adult with a ventricular rate of 32/min becomes diaphoretic and hypotensive despite initial treatment. Prepare pacing equipment and prescribed circulatory support. After pacing begins, assess a corresponding effective pulse, arterial pressure and perfusion rather than relying on pacing spikes alone.

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A hypotensive adult has pulmonary congestion and severe ventricular dysfunction without pericardial compression. Escalate for pump-failure management rather than assuming low pressure means volume depletion.

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A monitored patient develops sustained twisting, variable wide-complex tachycardia and loses consciousness while a pulse is initially detectable. Prepare immediate unsynchronized shock; afterward, review the preceding QT interval, electrolytes and potentially contributory medications.

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A patient with a known pericardial effusion develops hypotension, rising jugular venous pressure and echocardiographic right-sided chamber collapse. Escalate immediately and prepare for urgent drainage while maintaining close hemodynamic monitoring and procedural readiness.

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A patient recovering from aortic repair develops new back pain, pallor and rapidly falling blood pressure while receiving a prescribed vasodilator. Activate urgent assistance, stop the hypotension-aggravating infusion under the emergency protocol and prepare for surgical reassessment and hemorrhage management.

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An alert, hypertensive patient with acute cardiogenic pulmonary edema has severe work of breathing without shock. Prepare prescribed CPAP or bilevel NIV and reassess breathing, oxygenation and blood pressure while the team treats the cardiac cause.

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A ventilated adult has a supplied predicted body weight of 70 kg and actual weight of 112 kg. A 6 mL/kg starting target is 420 mL. Reassess plateau pressure, gas exchange and synchrony after implementation.

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A passive ventilated patient has peak pressure 39 cm H2O and plateau pressure 24 cm H2O. Consider increased airway resistance when investigating the pressure rise, rather than assuming the alveolar distending pressure equals the peak reading.

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An adult meeting the other Berlin criteria has PaO2 72 mm Hg on FiO2 0.80 and PEEP 8 cm H2O. The ratio is 90 mm Hg, indicating severe ARDS. Prepare coordinated prolonged proning with airway security, eye and pressure-point protection, and ongoing hemodynamic reassessment.

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After a prescribed PEEP increase, oxygenation improves but blood pressure falls and vasopressor requirements rise. Report both effects and reassess the overall response with the team rather than treating the saturation improvement as sufficient evidence of benefit.

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An adult with COPD remains tachypneic after initial treatment, with pH 7.28 and PaCO2 64 mm Hg. Prepare a monitored bilevel NIV trial and reassess effort, mental status, pH and respiratory rate promptly.

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An adult receiving supplemental oxygen has saturation 96% but becomes drowsy; arterial pH is 7.22 and PaCO2 is 68 mm Hg. Recognize ventilatory failure and promptly reassess respiratory support rather than reducing concern because saturation appears acceptable.

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A ventilated adult with obstructive lung disease develops hypotension and ineffective triggering. Assess for intrinsic PEEP and dynamic hyperinflation with the respiratory team, then reassess circulation and synchrony after prescribed ventilator adjustments.

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A patient taking an SGLT2 inhibitor has vomiting, glucose 184 mg/dL, beta-hydroxybutyrate 5.1 mmol/L, pH 7.24 and known diabetes. Recognize that the modest glucose does not exclude DKA and escalate for treatment.

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An adult with confirmed DKA has potassium 3.2 mmol/L before insulin starts. Identify the need for potassium replacement and reassessment before insulin, while continuing the prescribed initial fluid management and cardiac monitoring.

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During treatment, glucose reaches 172 mg/dL, but beta-hydroxybutyrate remains 2.4 mmol/L and venous pH is 7.27. Recognize unresolved DKA and anticipate continued insulin with prescribed dextrose support rather than stopping treatment for ketosis.

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An adult with HHS has improving glucose and a modest sodium rise, while measured osmolality declines steadily within the recommended range. Assess the integrated fluid and osmotic response rather than requesting hypotonic fluid solely because sodium increased.

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A patient's platelets fall from 310 to 145 × 10^9/L on day seven of heparin exposure, with a new thrombosis and no clear alternative cause. Recognize the relative fall and assess all four probability domains promptly.

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A patient has a high 4Ts score and new limb thrombosis. Identify heparin infusions and flushes, communicate the need to stop all exposure and prepare prescribed therapeutic-intensity non-heparin anticoagulation while laboratory confirmation is arranged.

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An adult's creatinine rises from 0.8 to 1.2 mg/dL over 36 hours. The absolute increase meets AKI criteria even though the new value may fall near the laboratory reference range. Review exposures, perfusion and urine output.

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A 90-kg patient produces 270 mL over nine hours: 270 ÷ 90 ÷ 9 equals 0.33 mL/kg/h. This meets urine-output stage 1 at that time; continue monitoring because longer duration can change staging.

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An oliguric patient has worsening pulmonary edema and persistent severe hyperkalemia despite prescribed temporizing measures. Prepare for urgent renal replacement therapy and continued monitoring rather than waiting for creatinine to cross an arbitrary numerical threshold.

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During transfusion, an adult develops dyspnea, crackles, hypertension and raised jugular venous pressure. Stop the transfusion, support breathing and escalate for suspected overload while the reaction is investigated.

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An adult with mild pancreatitis is improving, reports hunger and has no ongoing vomiting. Discuss early oral feeding with a low-fat solid diet as tolerated rather than continuing fasting solely because lipase remains elevated.

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A patient with severe pancreatitis cannot meet needs orally but has a usable gastrointestinal tract. Prepare the prescribed enteral route and monitor tolerance rather than assuming that pancreatic inflammation requires exclusive intravenous nutrition or mandatory jejunal access.

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A sedated patient develops nonblanchable sacral erythema and becomes hypotensive with full turns. Offload the sacrum using tolerated incremental shifts, check that devices do not create new pressure, and reassess skin, circulation and the repositioning plan.

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A severe TBI patient has MAP 88 mm Hg and ICP 29 mm Hg. CPP is 59 mm Hg. Communicate the below-target result and evaluate both systemic pressure and intracranial pressure within the prescribed management plan.

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A monitored TBI patient has sustained ICP readings of 25–27 mm Hg and declining responsiveness. Verify the monitoring system and immediately communicate the combined pressure and examination changes while implementing the established intracranial-pressure management plan.

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A stable severe TBI patient has PaCO2 38 mm Hg and controlled ICP. Question a plan to routinely drive PaCO2 to 23 mm Hg merely to prevent future swelling, and clarify the intended physiological goal.

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An awake patient with intracerebral hemorrhage asks for water and scheduled oral medication. Confirm completion and results of the formal swallow screen before either is given; arrange an appropriate alternative route when screening indicates unsafe swallowing.

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An ICH patient develops recurrent unexplained episodes of reduced responsiveness without limb jerking. Report the pattern and discuss continuous EEG while assessing oxygenation, glucose, medications and the need for urgent neurological reassessment or imaging.

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An older ventilated adult becomes quiet, inattentive and inconsistently follows commands despite light sedation. Use the unit's validated delirium assessment and review reversible contributors rather than assuming the absence of agitation means normal cognition.

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A confused patient has missing hearing aids, fragmented nighttime sleep and little daytime activity. Arrange hearing support, orientation, coordinated overnight care and suitable mobility while reviewing pain, oxygenation and medication contributors with the team.

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A lightly sedated ventilated patient grimaces and resists care during repositioning. Assess pain with the appropriate tool and evaluate prescribed analgesia before requesting deeper sedation solely to eliminate movement or improve apparent cooperation.

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An intubated adult is awake and physiologically stable with secured devices. Coordinate an appropriate mobilization assessment rather than assuming the endotracheal tube requires complete bed rest; monitor tolerance and stop or modify activity if instability develops.

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A sedated trauma patient has a high-risk tibial fracture and increasing lower-leg swelling. Communicate that the examination is unreliable and prepare for repeated or continuous compartment-pressure monitoring with urgent surgical reassessment rather than relying on distal pulses.

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An awake intubated patient repeatedly gestures and appears frightened. Offer a communication board, assess pain and breathing discomfort, and clarify the concern before escalating medication. Use a preferred supportive intervention and reassess the patient's reported or observed response.

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After initial sepsis treatment, passive leg raising produces no meaningful stroke-volume increase, pulmonary edema worsens and lactate remains elevated. Communicate the poor expected benefit of additional fluid, continue serial perfusion assessment and evaluate other contributors to the lactate elevation.

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An adult remains septic despite antimicrobials, and imaging identifies a drainable intra-abdominal abscess. Arrange early drainage planning and procedural preparation while continuing resuscitation, aiming for the guideline's suggested timeframe when feasible.

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A septic adult remains hypotensive after initial treatment, with no meaningful response to a dynamic preload challenge and worsening lung congestion. Prepare prescribed vasopressor support and ongoing perfusion reassessment rather than assuming every low pressure requires another bolus.

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An anuric adult's potassium falls from 7.1 to 5.3 mmol/L after insulin and glucose, then rises to 6.6 mmol/L. Recognize recurrent danger and coordinate urgent potassium removal rather than treating the first reduction as durable resolution.

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A patient becomes afebrile after antibiotics but develops increasing oxygen requirements, falling urine output and new confusion. Communicate the combined deterioration and review perfusion and source control rather than documenting fever resolution as overall clinical improvement.

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During preparation for a central venous catheter, the operator has sterile gloves and gown but only a small local drape. Identify the missing full-body drape and complete the required barrier setup before the procedure proceeds.

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A central catheter remains after vasoactive infusions and invasive monitoring have ended, and required medications can use existing peripheral access. Raise removal during rounds and coordinate it promptly once the team confirms that central access is no longer essential.

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After extensive treatment, a patient's chloride rises, beta-hydroxybutyrate is 0.4 mmol/L and venous pH is 7.33 despite bicarbonate 17 mmol/L. Recognize that the ketone and pH criteria support resolution rather than assuming low bicarbonate proves persistent DKA.

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A patient receiving full sepsis treatment has severe distress and a family uncertain about likely outcomes. Advocate for symptom relief and a structured goals discussion while continuing current treatment, rather than waiting for a decision to withdraw support.

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One recommendation calls for another fluid bolus while another calls for fluid restriction. The nurse reports the patient's congestion and perfusion findings, brings the clinicians together to clarify the immediate plan and confirms which response will trigger reassessment.

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An informed patient states that a proposed intervention conflicts with personal goals, but the team has not discussed alternatives. Clarify the patient's understanding, communicate the preference to the responsible clinician and support a timely shared discussion before proceeding.

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A patient with a documented DNR order develops pain and a treatable infection. Continue assessment and prescribed care consistent with the treatment plan, while clarifying any separate limits rather than assuming all active therapies should stop.

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Before an uncomfortable procedure, a nurse explains what the patient will experience, checks preferred coping strategies, protects privacy and reassesses distress throughout. These actions combine anticipation, responsiveness and comfort within the technical procedure itself.

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A unit notices inconsistent delirium assessment. A nurse reviews evidence, examines barriers, pilots a standardized approach and compares assessment completion and clinical follow-up before and after the change. The evaluation determines whether to revise or expand the intervention.

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A patient wants to regain independent eating but has weakness and swallowing limitations. Coordinate nursing, speech-language pathology, nutrition and rehabilitation input with the patient so that safety, nutrition and functional goals become one coherent plan.

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After medication teaching, a patient describes taking a daily medicine only when symptoms worsen. Re-explain the schedule using simpler language and a practical routine, then ask the patient to describe how it will be taken at home.

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A patient requests that a spiritual practice be considered before a procedure. Ask what the practice involves and what accommodation matters most, then coordinate a feasible plan that addresses the patient's preference and the clinical timing.

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A recovering patient understands the treatment plan but lacks transport to essential follow-up and cannot obtain prescribed equipment. Coordinate case management and community resources before discharge so that the plan can actually be carried out.

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A patient currently has normal vital signs but a newly evolving condition with an uncertain course and little ability to report symptoms. Recognize that present stability does not remove the need for vigilant assessment and anticipatory planning.

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A profoundly weak patient cannot turn independently but reliably communicates using eye movements. Include the patient in treatment discussions and preference assessment while providing full physical assistance, rather than transferring all decisions to family because self-care is impossible.

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A protocol discussion describes higher PEEP as mandatory for every patient with ARDS. Compare that statement with the conditional recommendation's severity range and discuss how oxygenation, respiratory mechanics and blood-pressure response should inform individual application.