Comprehensive Critical Care: Pulmonary, Renal, Burn, Cardiac, and Shock Management

1. MCQ — ARDS early recognition

A client with septic shock develops increasing work of breathing, PaO₂ 58 on FiO₂ 60%, and diffuse bilateral infiltrates on CXR. Which finding confirms progression to ARDS?

A. Decreased BNP

B. Non-cardiogenic pulmonary edema

C. Elevated CVP

D. Increased lung compliance

Correct answer: B.

ARDS = refractory hypoxemia + non-cardiogenic pulmonary edema.

2. SATA — Respiratory failure types

Which findings are consistent with hypercapnic respiratory failure?

A. pH 7.28

B. PaCO₂ 64

C. PaO₂ 52

D. Restlessness

E. Bounding pulses

Correct answers: A, B.

Hypercapnia = ↑CO₂ + respiratory acidosis.

3. MCQ — Pulmonary embolism physiology

A PE leads to which immediate physiologic problem?

A. Increased left ventricular preload

B. Ventilation-perfusion mismatch

C. Increased alveolar surface area

D. Pulmonary vasodilation

Correct: B.

PE blocks perfusion → V/Q mismatch → hypoxemia.

4. SATA — Tension pneumothorax signs

Which findings indicate a developing tension pneumothorax?

A. Tracheal deviation

B. Sudden hypotension

C. Diminished lung sounds on both sides

D. Jugular vein distention

E. Hyperresonance on percussion

Correct: A, B, D, E.

Life-threatening pressure buildup shifts mediastinum.

5. MCQ — Chest tube issue

A chest tube drainage system shows continuous bubbling in the water seal chamber. What is the priority action?

A. Clamp the tube immediately

B. Check for an air leak

C. Lower suction pressure

D. Increase suction pressure

Correct: B.

Continuous bubbling = air leak.

6. SATA — ARDS interventions

Which interventions improve oxygenation in ARDS?

A. Prone positioning

B. High PEEP

C. Low tidal volume ventilation

D. High tidal volume ventilation

E. Fluid boluses

Correct: A, B, C.

ARDS requires lung-protective strategies.

7. MCQ — Pleural effusion

A thoracentesis is planned. Which assessment indicates urgent priority before the procedure?

A. Afebrile

B. Respiratory rate 12

C. Platelets 42,000

D. Mild back pain

Correct: C.

Low platelets → bleeding risk.

8. SATA — Ventilator low pressure alarm

Low pressure alarm sounds. What could cause it?

A. Disconnected tubing

B. Cuff leak

C. Secretions

D. Kinked tubing

E. Extubation

Correct: A, B, E.

Low pressure = leak or disconnection.

9. MCQ — Mechanical ventilation settings

A client in respiratory failure is placed on AC ventilation. Which statement is true?

A. The client controls the tidal volume

B. Every breath is given a set tidal volume

C. It reduces risk of barotrauma

D. It is used only for weaning

Correct: B.

AC = guaranteed full-volume breath each time.

10. SATA — Subcutaneous emphysema

Nurse palpates "Rice Krispies" around the chest tube site. What actions are appropriate?

A. Mark the borders

B. Notify provider

C. Increase oxygen

D. Clamp the tube

E. Increase suction

Correct: A, B, C.

May indicate tube obstruction or air leak.

CASE STUDY 1 (Questions 11-14): ARDS secondary to sepsis

HPI

A 54-year-old patient with septic shock is intubated. Settings: VT 450 mL, PEEP 5, FiO₂ 80%. PaO₂ remains 56.

11. MCQ — Vent changes

Which ventilator change is most appropriate?

A. Increase tidal volume

B. Increase PEEP

C. Lower FiO₂

D. Increase respiratory rate

Correct: B.

PEEP recruits alveoli → improved oxygenation.

12. SATA — Complication of higher PEEP

Possible complications of increasing PEEP include:

A. Barotrauma

B. Decreased cardiac output

C. Pulmonary edema

D. Respiratory alkalosis

E. Pneumothorax

Correct: A, B, E.

High PEEP = pressure injury + ↓venous return.

13. MCQ — Sedation

Which assessment best indicates adequate ventilator synchrony?

A. HR 110

B. No visible use of accessory muscles

C. Sudden increase in tidal volume

D. Breath stacking

Correct: B.

Synchrony = relaxed breathing, no dyspnea signs.

14. SATA — Weaning readiness

Which findings support readiness to begin weaning?

A. pH 7.39

B. FiO₂ 70%

C. PEEP 5

D. RR 12

E. Richmond Agitation Score = +2

Correct: A, C, D.

Must be stable, awake enough, low FiO₂ + low PEEP.

15. MCQ — Pulmonary embolism

A client with a PE becomes acutely hypotensive with hemoptysis. Priority action?

A. Increase IV fluids

B. Prepare for thrombolytics

C. Increase oxygen to 2 L

D. Obtain sputum culture

Correct: B.

Massive PE = hemodynamic collapse → thrombolytics.

16. SATA — Indications of hypoxemia

Which symptoms suggest inadequate oxygenation?

A. Confusion

B. Bradycardia

C. Cyanosis

D. Polyuria

E. Irritability

Correct: A, C, E.

Early: restlessness/irritability; late: cyanosis.

17. MCQ — ET tube placement

What confirms correct ET tube placement?

A. Symmetric chest rise

B. "Whooshing" over the stomach

C. End-tidal CO₂ color change

D. SpO₂ of 98%

Correct: C.

ETCO₂ monitoring = gold standard.

18. SATA — Indications for intubation

Which findings indicate need for emergent intubation?

A. Stridor

B. PaO₂ 88

C. GCS 6

D. Respiratory rate 10

E. Use of accessory muscles

Correct: A, C, E.

Airway compromise + low LOC.

19. MCQ — Chest tube removal complication

Immediately after chest tube removal, patient develops dyspnea. Which finding confirms pneumothorax recurrence?

A. Diminished breath sounds on one side

B. Hyperactive bowel sounds

C. Muffled heart tones

D. Crackles in both lungs

Correct: A.

Unilateral diminished sounds = classic sign.

20. SATA — Causes of low PaO₂ despite high FiO₂

A ventilated patient remains hypoxemic even with FiO₂ 100%. This indicates:

A. Shunting

B. ARDS

C. Inadequate tidal volume

D. Severe emphysema

E. Oxygen toxicity

Correct: A, B.

True shunt = refractory hypoxemia.

21. MCQ — Prerenal AKI cause

Which finding is most consistent with prerenal acute kidney injury?

A. Exposure to aminoglycosides

B. Bladder outlet obstruction

C. Blood loss from trauma

D. Immune-complex glomerulonephritis

Correct: C.

Prerenal = decreased perfusion.

22. SATA — Intrarenal AKI signs

Which findings suggest intrarenal injury?

A. Hematuria

B. Proteinuria

C. Elevated creatinine

D. BUN:Cr ratio 10:1

E. Postvoid residual >300 mL

Correct: A, B, C, D.

Direct nephron damage → abnormal urine + ↑Cr.

23. MCQ — Postrenal AKI

A patient has flank pain, oliguria, and hydronephrosis on ultrasound. What is the most likely cause?

A. Hypotension

B. ATN

C. Ureteral obstruction

D. Infection

Correct: C.

Postrenal = obstruction.

24. SATA — Kidney stone risks

Which are risk factors for calcium oxalate stones?

A. Dehydration

B. High sodium intake

C. Hyperparathyroidism

D. Low calcium diet

E. High fluid intake

Correct: A, B, C, D.

Low calcium diet ↑ oxalate absorption.

25. MCQ — AKI nutrition

Which diet order is most appropriate for oliguric AKI?

A. High protein

B. High potassium

C. Low sodium, low potassium

D. High phosphorus

Correct: C.

Electrolyte and fluid control required.

26. SATA — Indications for dialysis

Which findings indicate the need for urgent dialysis?

A. K⁺ 6.8

B. Pulmonary edema

C. BUN 18

D. Uremic pericarditis

E. Metabolic acidosis

Correct: A, B, D, E.

AEIOU criteria for dialysis.

27. MCQ — DI vs SIADH

A client has urine specific gravity 1.002. Which condition is expected?

A. SIADH

B. Diabetes insipidus

C. Renal failure

D. Dehydration

Correct: B.

DI = dilute urine.

28. SATA — SIADH findings

Which findings are expected in SIADH?

A. Low sodium

B. Low serum osmolality

C. High urine sodium

D. High urine osmolality

E. Polyuria

Correct: A, B, C, D.

Water retention → concentrated urine.

29. MCQ — DKA vs HHS

Which assessment differentiates HHS from DKA?

A. Kussmaul respirations

B. Positive ketones

C. Glucose > 600

D. Serum bicarbonate 8

Correct: C.

HHS has extreme hyperglycemia without ketosis.

30. SATA — AKI drug considerations

Which medications must be held or used with caution in AKI?

A. ACE inhibitors

B. NSAIDs

C. IV contrast

D. Calcium channel blockers

E. Gentamicin

Correct: A, B, C, E.

All reduce perfusion or are nephrotoxic.

CASE STUDY 2 (31-34): AKI after contrast dye

HPI

A patient receives IV contrast for CT scan. Next day: UOP 200 mL/24 hr, Cr 3.1 (baseline 0.9).

31. MCQ — Priority nursing action

What is the priority?

A. Encourage oral fluids

B. Hold metformin

C. Start diuretic therapy

D. Increase dietary potassium

Correct: B.

Metformin + AKI → risk of lactic acidosis.

32. SATA — Expected findings

Which are expected in this patient?

A. Hyperkalemia

B. Hyponatremia

C. Elevated BUN

D. Alkalosis

E. High urine specific gravity

Correct: A, B, C.

AKI → fluid shifts + electrolyte imbalance.

33. MCQ — Fluid balance

Which fluid order is most appropriate in early contrast-induced AKI?

A. 0.9% NS bolus

B. D5W at 150 mL/hr

C. LR bolus

D. No IV fluids

Correct: A.

NS helps maintain renal perfusion.

34. SATA — Patient teaching

Which teaching is appropriate?

A. Avoid NSAIDs

B. Recheck kidney labs in 48-72 hr

C. Increase sodium intake

D. Report decreased urine output

E. Take metformin immediately

Correct: A, B, D.

Prevent further injury & monitor recovery.

BURN QUESTIONS (35-40)

35. MCQ — Burn depth

A client has blisters, moist skin, severe pain. What type of burn?

A. Superficial

B. Deep partial-thickness

C. Full-thickness

D. Electrical

Correct: B.

Blistering + pain = partial-thickness.

36. SATA — Rule of Nines

A client has burns to the entire left arm and anterior chest. Estimate TBSA.

A. 4.5%

B. 9%

C. 18%

D. 22.5%

E. 27%

Correct: C (arm 9%) + A (anterior chest 4.5%) = 13.5% → closest is D? WAIT

Correct: D.

Anterior chest 9% + entire arm 9% = 18% → but "anterior chest" often counted as half of anterior torso (18/2 = 9%) → arm 9% → total 18%. Closest option = 18%? But the options given: 4.5, 9, 18, 22.5, 27 → correct = 18 → answer C. Correction below.

Revised Answer: C (18%).

37. MCQ — Parkland formula

80-kg adult, 30% TBSA burn. How much fluid in first 8 hours?

A. 4,800 mL

B. 6,000 mL

C. 9,600 mL

D. 12,000 mL

Correct: C.

4 × kg × TBSA = total → 9,600 first 24h → half in first 8h.

38. SATA — Burn shock priorities

Which are priorities during the emergent phase?

A. Maintain airway

B. Fluid resuscitation

C. Pain management

D. Prevent contractures

E. Emotional support

Correct: A, B, C.

Airway and fluids first; pain always early priority.

39. MCQ — Electrical burn

Which complication is the nurse MOST concerned about after an electrical burn?

A. Infection

B. Rhabdomyolysis

C. Hyperglycemia

D. Hypertension

Correct: B.

Muscle breakdown → kidney injury.

40. SATA — Burn complications

Which complications occur during the acute phase of major burns?

A. Infection

B. Contractures

C. Curling's ulcer

D. Hypovolemic shock

E. Hyponatremia

Correct: A, B, E.

Shock occurs early; contractures/infection appear in acute phase.

1. MCQ — Cardiopulmonary arrest rhythms

Which rhythm is shockable during a code?

A. Asystole

B. PEA

C. VT without a pulse

D. First-degree block

Correct: C.

Only pulseless VT/VF are shockable.

42. SATA — Causes of PEA

Which can cause pulseless electrical activity? (H's & T's)

A. Hypovolemia

B. Hypoxia

C. Tension pneumothorax

D. Cardiac tamponade

E. Hyperthyroidism

Correct: A, B, C, D.

True reversible causes of PEA.

43. MCQ — Post-ROSC care

After ROSC, priority intervention is:

A. Begin chest compressions

B. Maintain O₂ sat 100%

C. Maintain MAP > 65

D. Begin tube feedings

Correct: C.

Perfusion is key after ROSC; avoid hyperoxygenation.

44. SATA — AFib complications

Which are complications of atrial fibrillation?

A. Stroke

B. Heart failure

C. Pulmonary embolism

D. Renal stones

E. Hypoglycemia

Correct: A, B, C.

Loss of atrial kick → clots + HF.

45. MCQ — Pacemaker assessment

A pacemaker-dependent client has a heart rate of 38 and no pacer spikes visible. What is the priority?

A. Call provider

B. Increase oxygen

C. Assess pulse, initiate transcutaneous pacing pads

D. Check potassium level

Correct: C.

Failure to pace = emergency.

46. SATA — Ventricular tachycardia interventions

A patient has stable VT with a pulse. Which interventions apply?

A. Amiodarone

B. Cardioversion

C. CPR

D. Vagal maneuvers

E. Adenosine

Correct: A, B.

Unstable = shock; stable = amiodarone/cardiovert.

47. MCQ — Cardioversion vs Defibrillation

Which statement is true about synchronized cardioversion?

A. Used for pulseless VT

B. Delivers a shock on the R wave

C. Used for asystole

D. Used only during cardiac arrest

Correct: B.

Synchronizes with R wave to avoid R-on-T.

48. SATA — Septic shock early signs

Which are early signs of septic shock?

A. Warm, flushed skin

B. Tachycardia

C. High cardiac output

D. Severe hypotension unresponsive to fluids

E. Elevated lactate

Correct: A, B, C, E.

Early/warm stage = vasodilation & high CO.

49. MCQ — Anaphylactic shock

Which is the FIRST nursing action in anaphylaxis?

A. Start IV fluids

B. Administer epinephrine

C. Apply oxygen

D. Give antihistamines

Correct: B.

Epinephrine is life-saving and FIRST.

50. SATA — DIC findings

Which findings indicate DIC?

A. Oozing from IV sites

B. Elevated D-dimer

C. Low platelets

D. High fibrinogen

E. Decreased clotting time

Correct: A, B, C.

Consumption of clotting factors → bleeding + ↑D-dimer.

CASE STUDY 3 (Questions 51-55) — Septic Shock & MODS

HPI

A 72-year-old with pneumonia develops:

BP 82/48, HR 126

Lactate 5.4

UOP 15 mL/hr

Confused

Cool, mottled skin

51. MCQ — Priority action

What is the FIRST intervention?

A. Norepinephrine

B. 30 mL/kg crystalloid bolus

C. Blood cultures

D. IV antibiotics

Correct: B.

Fluids first in sepsis bundle.

52. SATA — Organ dysfunction

Which findings indicate MODS?

A. UOP 10 mL/hr

B. Elevated bilirubin

C. PaO₂/FiO₂ < 200

D. Platelets 190,000

E. Confusion

Correct: A, B, C, E.

Multiple organ systems failing.

53. MCQ — Vasopressor choice

After fluids, MAP is still 58. Which medication is next?

A. Dopamine

B. Norepinephrine

C. Epinephrine

D. Dobutamine

Correct: B.

NE = first-line vasopressor in septic shock.

54. SATA — Nursing interventions for septic shock

Appropriate interventions include:

A. Trend lactate

B. Maintain glucose <180

C. Give steroids to all patients

D. Monitor CVP and ScvO₂

E. Liberal fluid strategy >6 L/hr

Correct: A, B, D.

Standard sepsis bundle components.

55. MCQ — DIC complication

The patient begins bleeding from gums and IV sites. Which order is expected?

A. Platelet transfusion

B. Diuretics

C. Heparin bolus

D. Antibiotic change

Correct: A.

Supportive transfusions required in DIC bleeding.

56. MCQ — Acute pancreatitis

Which lab is MOST specific for acute pancreatitis?

A. AST

B. Lipase

C. Bilirubin

D. CRP

Correct: B.

Lipase is most specific and stays elevated longer.

57. SATA — Peritonitis signs

Which findings suggest peritonitis?

A. Board-like abdomen

B. Rebound tenderness

C. Hypoactive bowel sounds

D. Low-grade fever

E. Polyuria

Correct: A, B, C, D.

Classic rigid abdomen + signs of infection.

58. MCQ — Esophageal varices

A client with cirrhosis and active bleeding should receive which medication first?

A. Furosemide

B. Octreotide

C. Calcium gluconate

D. Acetaminophen

Correct: B.

Octreotide reduces portal pressures → controls bleeding.

59. SATA — Acute cholecystitis

Which findings indicate acute cholecystitis?

A. RUQ pain

B. Pain radiating to right shoulder

C. Murphy's sign

D. Frothy, fatty stools

E. N/V

Correct: A, B, C, E.

Classic gallbladder inflammation pattern.

60. MCQ — Bowel obstruction

High-pitched bowel sounds and vomiting fecal material indicate:

A. Lower GI bleed

B. Large bowel obstruction

C. Small bowel obstruction

D. Perforated ulcer

Correct: C.

High-pitched + fecal emesis = SBO.

CASE STUDY 4 (61-63): DKA vs HHS

HPI

A 67-year-old diabetic:

Glucose 878

pH 7.38

No ketones

Altered mental status

61. MCQ — Diagnosis

What is the diagnosis?

A. Mild DKA

B. Severe DKA

C. HHS

D. Hypoglycemia

Correct: C.

Very high glucose + no acidosis = HHS.

62. SATA — Priority treatment

Initial management includes:

A. Isotonic fluids

B. IV insulin infusion

C. Bicarbonate

D. Potassium replacement

E. High-dose corticosteroids

Correct: A, B, D.

Standard DKA/HHS protocol.

63. MCQ — Complication prevention

What is the nurse's priority to prevent a complication of insulin therapy?

A. Monitor phosphate

B. Monitor for bradycardia

C. Monitor potassium levels

D. Encourage oral fluids

Correct: C.

Insulin shifts K⁺ into cells → hypokalemia risk.

SPINAL CORD INJURY (64-65)

64. MCQ — Neurogenic shock

A patient with T4 spinal cord injury has BP 78/40, HR 42, warm dry skin. Diagnosis?

A. Septic shock

B. Neurogenic shock

C. Hypovolemic shock

D. Cardiogenic shock

Correct: B.

Loss of sympathetic tone → hypotension + bradycardia.

65. SATA — Autonomic dysreflexia triggers

Which can trigger autonomic dysreflexia in a T6 SCI?

A. Distended bladder

B. Constipation

C. Tight clothing

D. Infection

E. High-sodium foods

Correct: A, B, C, D.

Anything causing noxious stimulus below injury.

MUSCULOSKELETAL TRAUMA (66-67)

66. MCQ — Compartment syndrome

Which finding indicates compartment syndrome?

A. Bounding pulses

B. Pain unrelieved by opioids

C. Decreased capillary refill

D. Low potassium

Correct: B.

Severe pain out of proportion = hallmark.

67. SATA — Fat embolism syndrome

A client with a femur fracture develops which classic signs?

A. Petechiae

B. Dyspnea

C. Tachycardia

D. Hypothermia

E. Confusion

Correct: A, B, C, E.

Triad: petechiae, respiratory distress, neuro changes.

ACUTE NEURO TRAUMA (68-69)

68. MCQ — Increased ICP

Which is the most concerning sign of increasing ICP?

A. Restlessness

B. Irregular respirations

C. Headache

D. Vomiting

Correct: B.

Cushing's triad includes irregular respirations.

69. SATA — Basilar skull fracture signs

Which findings indicate a basilar skull fracture?

A. Battle's sign

B. Raccoon eyes

C. Clear nasal drainage

D. Unequal pupils

E. Bradycardia

Correct: A, B, C.

Classic indicators of base of skull fracture.

EMERGENCY & DISASTER TRIAGE (70)

70. MCQ — Disaster triage

During a mass-casualty incident, which patient receives Immediate (red-tag) priority?

A. Open tibial fracture with controlled bleeding

B. 3rd-degree burn over 50% TBSA

C. Respirations 34, cap refill 4 seconds

D. Minor lacerations

Correct: C.

Resp >30 OR cap refill >2 = immediate priority per START triage.