PCC IV Comprehensive Mock Exam

What is the priority nursing assessment for a client arriving after a motor vehicle crash with a suspected cervical spinal cord injury who is breathing shallowly and unable to move their legs?

Respiratory effort and adequacy of ventilation, because cervical injuries can impair respiratory muscles.

A client with a new C7 spinal cord injury presents with a blood pressure of $80/42\,\text{mmHg}$, a heart rate of $42\,\text{beats/min}$, and warm skin. Which complication should the nurse suspect?

Neurogenic shock, caused by a loss of sympathetic tone leading to vasodilation, hypotension, and bradycardia.

What condition is characterized by temporary flaccid paralysis, absent reflexes, and loss of bowel and bladder function below the level of injury following a spinal cord injury?

Spinal shock.

What is the priority immediate nursing intervention when a client with a T2 spinal cord injury develops a pounding headache, facial sweating, and a blood pressure of $218/112\,\text{mmHg}$?

Sit the client upright immediately to help lower blood pressure while identifying and removing the trigger.

During an episode of autonomic dysreflexia, the nurse identifies that the client's indwelling urinary catheter tubing is kinked. What is the most appropriate action?

Straighten the tubing and restore urine drainage to relieve bladder distention, which is a common sympathetic trigger.

Which airway opening technique should the nurse initially use for an unresponsive client with suspected cervical spinal trauma?

The jaw-thrust maneuver with cervical stabilization.

What is the nurse's priority action upon observing that the weights used for a client's cervical traction are resting on the floor?

Restore the prescribed traction setup so the weights hang freely and maintain the prescribed traction force.

Why is maintaining the prescribed blood pressure goal critical in the acute management of a spinal cord injury?

Hypotension reduces spinal cord perfusion and exacerbates secondary ischemic injury.

Following chest trauma, a client presents with severe respiratory distress, absent right-sided breath sounds, hypotension, and a trachea shifted to the left. What intervention should the nurse anticipate?

Immediate emergency needle decompression followed by chest tube placement for tension pneumothorax.

What clinical condition is identified when a blunt chest trauma client exhibits a paradoxical chest segment that moves inward during inspiration and outward during expiration?

Flail chest.

Where should a chest drainage system be positioned relative to the client's body?

Upright and below chest level to facilitate gravity drainage and prevent backflow into the pleural space.

What does continuous bubbling in the water-seal chamber of a chest drainage unit indicate?

An air leak within the client or the drainage system that requires immediate assessment.

What should the nurse do first if tidaling suddenly stops in the water-seal chamber of a chest tube drainage unit?

Assess the client's respiratory status and inspect the tubing for an obstruction or kink (or evaluate if the lung has fully re-expanded).

A client's chest tube suddenly drains $250\,\text{mL}$ of bright red blood within one hour after having previously minimal output. What is the priority nursing action?

Assess hemodynamic status and promptly notify the surgical team for potential active hemorrhage.

Which life-threatening complication is indicated by Beck's triad (hypotension, jugular venous distention, and muffled heart sounds) after blunt chest trauma?

Cardiac tamponade.

Which blunt chest trauma injury typically presents with worsening hypoxemia, crackles, and localized edema several hours after the initial event?

Pulmonary contusion.

What is the most concerning early sign of neurologic deterioration in a client with traumatic brain injury (TBI)?

Increasing restlessness and difficulty staying awake (changes in level of consciousness).

What clinical signs comprise Cushing's triad, indicating a late neurologic emergency from severely increased intracranial pressure?

Bradycardia, a widening pulse pressure (systolic hypertension), and irregular respirations.

Why is the insertion of a nasogastric tube through the nose contraindicated in a client with a suspected basilar skull fracture?

Nasal tube insertion risks accidental penetration through the fractured cribriform plate into the cranial vault.

What is the optimal bed position for a hemodynamically stable client with elevated intracranial pressure without positioning restrictions?

Head of the bed elevated about $30^\circ$ with the head kept in a midline position to maximize cerebral venous drainage.

What is the Glasgow Coma Scale (GCS) score for a client who opens eyes to speech ($3$), uses confused conversation ($4$), and follows commands ($6$)?

A score of $13$.

Which intracranial complication is classically characterized by a brief loss of consciousness, an alert lucid interval, and subsequent rapid neurologic deterioration?

An epidural hematoma.

What essential laboratory value must be monitored closely when administering hypertonic saline for cerebral edema?

Serum sodium.

If a traumatic brain injury client has a Mean Arterial Pressure (MAP) of $85\,\text{mmHg}$ and an Intracranial Pressure (ICP) of $25\,\text{mmHg}$, what is the Cerebral Perfusion Pressure (CPP)?

$\text{CPP} = \text{MAP} - \text{ICP} = 85 - 25 = 60\,\text{mmHg}$.

What is the nurse's immediate bedside intervention for a client experiencing heavy postpartum bleeding and a boggy uterus two hours after delivery?

Perform fundal massage to stimulate uterine contraction.

What should the nurse suspect if a postpartum client experiences continuous bright red vaginal bleeding while the fundus remains firm and midline?

A genital tract laceration (cervical or vaginal wall tear).

Why is methylergonovine contraindicated in a postpartum hemorrhage client with a blood pressure of $168/104\,\text{mmHg}$?

Methylergonovine causes peripheral vasoconstriction and can trigger severe, dangerous hypertension.

What is the therapeutic mechanism of tranexamic acid (TXA) in the treatment of postpartum hemorrhage?

It acts as an antifibrinolytic that prevents the breakdown of formed fibrin blood clots.

Which clinical finding distinguishes neurogenic shock from hypovolemic shock?

Bradycardia accompanied by vasodilation and warm extremities (hypovolemic shock causes compensatory tachycardia and cool skin).

What is the first-line emergency medication for a client presenting with acute anaphylaxis?

Intramuscular epinephrine.

What is the calculated Mean Arterial Pressure (MAP) for a client with a blood pressure of $78/42\,\text{mmHg}$?

$\text{MAP} \approx \frac{\text{SBP} + 2 \times \text{DBP}}{3} = \frac{78 + 2(42)}{3} = \frac{78 + 84}{3} = 54\,\text{mmHg}$.

What is the priority intervention for a client rescued from an enclosed-space fire who presents with facial burns, soot around the mouth, and progressive hoarseness?

Prepare for early airway management (endotracheal intubation) before progressive upper airway edema causes complete obstruction.

According to the adult Rule of Nines, what is the total percentage of body surface area burned (%TBSA) for burns involving both entire legs, the lower posterior trunk, and the perineum?

$46\%$ ($36\%$ for both legs + $9\%$ for the lower posterior trunk + $1\%$ for the perineum).

Using the Parkland formula ($4\,\text{mL} \times \text{kg} \times \%\text{TBSA}$), what is the total fluid volume required in the first 24 hours for a $60\,\text{kg}$ adult with $30\%$ TBSA burns?

$4 \times 60 \times 30 = 7,200\,\text{mL}$.

A $60\,\text{kg}$ client with a 24-hour Parkland fluid calculation of $7,200\,\text{mL}$ arrives two hours post-injury with no fluid given. What infusion rate is needed to deliver the first half of the volume by hour 8?

$600\,\text{mL/hr}$ (half of the volume is $3,600\,\text{mL}$, divided across the remaining $6\,\text{hours}$).

What emergency procedure should the nurse anticipate for a circumferential extremity burn presenting with severe pain, paresthesias, tense tissue, and diminished distal perfusion?

An escharotomy to relieve compartment pressure.

What classic laboratory profile indicates acute disseminated intravascular coagulation (DIC)?

Low platelets, low fibrinogen, prolonged clotting times (PT/INR, PTT), and an elevated D-dimer level.

What is the cornerstone priority in managing disseminated intravascular coagulation (DIC)?

Identifying and treating the underlying causative condition (e.g., sepsis, trauma, or obstetric complication).

Which specific blood product is administered to directly replace dangerously depleted fibrinogen in a bleeding client with DIC?

Cryoprecipitate.

What factors appropriately guide the allocation of deceased-donor organs according to standard transplant policy?

Organ-specific medical urgency, immunological compatibility (blood/tissue match), and logistical variables (wealth and social status are never considered).

How should a nurse explain the clinical definition of brain death to a patient's family?

Brain death is death; it represents the permanent, irreversible loss of function of the entire brain, including the brainstem, verified through formal evaluation.

What two critical confounding factors must be corrected or excluded before a formal brain-death examination can take place?

Severe hypothermia and the presence of CNS-depressant or sedating medications.

What oncologic emergency should be suspected in a chemotherapy client who develops muscle cramps, a potassium of $6.2\,\text{mEq/L}$, hyperphosphatemia, hyperuricemia, and hypocalcemia?

Tumor lysis syndrome.

What key clinical findings differentiate placental abruption from placenta previa?

Placental abruption features painful vaginal bleeding with a rigid, tender uterus; placenta previa typically presents with painless bright red bleeding.

What is the nurse's immediate priority when an inpatient pregnant client experiences an eclamptic seizure?

Call for help, protect the client from injury, position the client laterally as safely as possible, maintain airway safety, and prepare prescribed magnesium sulfate.

What is the recommended first-line vasopressor for an adult in septic shock who remains hypotensive despite adequate fluid resuscitation?

Norepinephrine.

Why is nitroglycerin contraindicated in a client with an acute inferior-wall myocardial infarction with suspected right ventricular involvement?

Nitroglycerin reduces cardiac preload, which can cause severe hemodynamic collapse in preload-dependent right ventricular infarctions.

What is the priority intervention for an unresponsive, pulseless patient with a monitor displaying ventricular fibrillation?

Deliver an immediate unsynchronized shock (defibrillation) and perform high-quality CPR.

Which evidence-based non-pharmacologic intervention should be anticipated to improve oxygenation and V/Q matching in a mechanically ventilated client with severe ARDS?

Prone positioning executed with a trained multidisciplinary team.

What is the priority nursing intervention for a client with shallow respirations, declining alertness, and arterial blood gas values of pH $7.25$, PaCO₂ $62\,\text{mmHg}$, and PaO₂ $54\,\text{mmHg}$?

Obtain immediate respiratory support and prepare for assisted mechanical ventilation due to acute respiratory failure.