PCCN Progressive Care Certified Nurse

A 62-year-old patient in the PCU reports new substernal chest pressure radiating to the left arm. The cardiac monitor shows sinus tachycardia. Which initial nursing action is MOST appropriate?

• AObtain a 12-lead ECG, administer aspirin 162 mg chewed, and measure cardiac biomarkers
• BAdminister sublingual nitroglycerin immediately before any assessment
• CApply oxygen at 4 L/min by nasal cannula to all patients regardless of SpO2
• DWait for the provider's order before obtaining the 12-lead ECG

A patient with an ST-elevation myocardial infarction (STEMI) is awaiting transfer for PCI. The cardiac monitor suddenly shows coarse ventricular fibrillation and the patient is unresponsive. What is the FIRST action?

• ACall for help and defibrillate immediately with 200 J (biphasic)
• BAdminister amiodarone 300 mg IV push before any shock
• CBegin carotid pulse assessment for a full 60 seconds
• DInsert an advanced airway before delivering any shock

A patient on a nitroglycerin drip for unstable angina develops a systolic BP of 84 mmHg. Which nursing action is MOST appropriate?

• ADecrease or stop the nitroglycerin infusion and notify the provider
• BIncrease the drip rate to improve coronary perfusion
• CAdminister a 500 mL normal saline fluid bolus without adjusting the drip
• DDocument the finding and recheck BP in 30 minutes

A patient has a chest pain score of 8/10 with suspected acute coronary syndrome. Sublingual nitroglycerin 0.4 mg has been given once with no relief. Vital signs: BP 148/92, HR 102, SpO2 96%. What is the next appropriate step?

• ARepeat sublingual nitroglycerin 0.4 mg every 5 minutes up to a total of 3 doses, monitori…
• BAdminister 40 mg intravenous furosemide to reduce preload
• CGive intravenous labetalol 20 mg to lower both pain and blood pressure
• DApply a non-rebreather mask at 15 L/min even though SpO2 is 96%

A patient with acute decompensated heart failure has the following arterial line waveform. MAP = 58 mmHg, HR 118, SpO2 90% on 4 L O2. Bilateral crackles to mid-lung. Which intervention should the nurse anticipate FIRST?

• AAdminister IV furosemide 40 mg and initiate noninvasive positive pressure ventilation (Bi…
• BGive a 500 mL crystalloid bolus to improve MAP
• CStart a dobutamine drip at 5 mcg/kg/min to support cardiac output
• DAdminister IV metoprolol 5 mg to control heart rate

A patient on amiodarone 1 mg/min maintenance infusion after cardiac arrest develops a widened QRS and prolonged QT interval. Which action is MOST important?

• AMonitor for torsades de pointes and hold the infusion if QTc exceeds 500 ms or QRS widens…
• BIncrease the amiodarone rate to 2 mg/min for better dysrhythmia control
• CAdminister IV calcium gluconate 1 g to reverse the ECG changes
• DDiscontinue all cardiac monitoring to reduce alarm fatigue

A PCU patient with acute MI develops third-degree AV block with a ventricular rate of 38 bpm and SBP 78 mmHg. What is the priority intervention?

• AApply transcutaneous pacing pads and begin TCP at 60-80 mA until capture is achieved
• BAdminister adenosine 6 mg rapid IV push to convert the rhythm
• CGive atropine 1 mg IV push and repeat up to 3 mg total
• DStart a dopamine drip at 20 mcg/kg/min as the sole intervention

A patient with cardiogenic shock has a pulmonary artery catheter showing: PCWP 28 mmHg (elevated), CI 1.8 L/min/m^2 (low), SVR high. Which pharmacologic combination is most consistent with guideline-directed therapy?

• ADobutamine (inotrope) to improve cardiac output and a low-dose vasopressor only if MAP re…
• BAggressive 30 mL/kg crystalloid bolus followed by norepinephrine alone
• CNitroprusside alone to reduce afterload without any inotropic support
• DFurosemide infusion plus beta-blocker to reduce myocardial oxygen demand

A patient is on a norepinephrine drip at 0.3 mcg/kg/min for septic shock. The IV site is swollen, cool, and pale. What is the priority nursing action?

• AStop the infusion at that site, notify the provider, and prepare for local vasodilator (p…
• BIncrease the drip rate to overcome the extravasation effect
• CApply a cold compress to the site to reduce swelling
• DDocument the finding and continue the infusion through the same IV

A patient with new-onset atrial fibrillation has a ventricular rate of 148 and BP 80/50. Which intervention is MOST appropriate per ACLS?

• ASynchronized cardioversion beginning at 120-200 J (biphasic)
• BAdminister diltiazem 0.25 mg/kg IV to slow the rate
• CGive amiodarone 150 mg IV over 10 minutes as first-line for the unstable patient
• DAdminister adenosine 6 mg rapid IV push to attempt rhythm conversion

A PCU patient has a pulmonary artery (PA) catheter. The PA waveform shows a sudden dampening with loss of the dichrotic notch and the PCWP reading is 35 mmHg on a flat plane. The patient is in a supine, flat position. What should the nurse do FIRST?

• ARe-level the transducer to the phlebostatic axis (4th ICS mid-axillary line) and re-zero,…
• BDocument the elevated PCWP and administer IV furosemide 80 mg immediately
• CReposition the patient to Trendelenburg to increase venous return and improve the waveform
• DWithdraw the PA catheter 5 cm to obtain a clearer arterial waveform

A patient with hypertensive crisis has BP 220/118 and complains of severe headache and visual changes. Which IV medication and target are most appropriate?

• ANicardipine or labetalol IV to reduce MAP by no more than 20-25% in the first hour
• BRapid-acting oral captopril 50 mg to normalize BP to 120/80 within 30 minutes
• CSodium nitroprusside titrated to reduce SBP to <140 within 15 minutes
• DSublingual nifedipine 10 mg for rapid BP reduction

A patient with aortic dissection (type B) is receiving an esmolol infusion. The HR is 88 and SBP is 156. What is the goal HR and SBP per standard protocols?

• AHR <60 bpm and SBP 100-120 mmHg
• BHR 80-100 bpm and SBP <140 mmHg
• CHR <50 bpm and SBP <90 mmHg to minimize shear stress
• DHR 60-80 bpm and SBP 140-160 mmHg to ensure spinal cord perfusion

A patient 6 hours post-PCI via right femoral access develops a firm, pulsatile mass at the groin with bruit and dropping hematocrit. What is the most likely complication and priority action?

• APseudoaneurysm: apply prolonged supervised compression, notify provider, and prepare for…
• BSimple hematoma: apply a cold pack and observe for 4 hours
• CRetroperitoneal bleed: ambulate the patient to redistribute the hematoma
• DFemoral nerve compression: administer IV morphine and continue bedrest without further wo…

A patient is receiving a heparin infusion at 18 units/kg/hr. The aPTT comes back at 110 seconds (control 30). Which action is MOST appropriate per standard heparin nomograms?

• AStop the infusion for 30-60 minutes, reduce the rate per nomogram, and repeat aPTT in 6 h…
• BContinue the infusion at the same rate; aPTT up to 120 is acceptable
• CAdminister protamine sulfate 50 mg IV to reverse all heparin
• DIncrease the rate by 3 units/kg/hr to achieve therapeutic anticoagulation

A patient 2 days post-MI develops sudden dyspnea, hypoxia, and a loud holosystolic murmur at the apex. PA catheter shows a step-up in oxygen saturation from RA to RV. What is the most likely diagnosis?

• AVentricular septal rupture (VSD) complicating the MI
• BAcute mitral valve prolapse with regurgitation
• CPulmonary embolism with right-heart strain
• DRe-infarction of the anterior wall