In a patient with a hemorrhaging renal laceration who remains hypotensive despite fluid

resuscitation with two units of PRBCs and 500 mL of NS, administering norepinephrine (Levophed) is

appropriate. Norepinephrine is a potent vasopressor that helps to increase blood pressure by

vasoconstriction and improving cardiac output, which is critical in stabilizing a patient with severe

hemorrhagic shock prior to surgery.

Reference: = CCRN Exam Handbook, page 38

The most appropriate therapy for carboxyhemoglobinemia, which is carbon monoxide poisoning, is

the administration of 100% oxygen. This treatment helps to displace carbon monoxide from

hemoglobin, allowing oxygen to bind to hemoglobin and be transported to tissues more effectively.

High-flow oxygen can significantly reduce the half-life of carboxyhemoglobin, facilitating faster

recovery.

Reference: = CCRN Exam Handbook, page 30

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.”

For a patient with unstable angina, the major goal of treatment is to decrease myocardial oxygen

consumption. This can be achieved by reducing heart rate, blood pressure, and myocardial

contractility to lessen the workload on the heart and reduce the demand for oxygen. This helps in

preventing further ischemia and potential myocardial infarction. Treatment strategies may include

the use of medications such as beta-blockers, nitrates, and calcium channel blockers, which all help

in decreasing the oxygen demand of the heart.

Reference: = CCRN Exam Handbook, page 10

When seeking to make changes to a documentation screen in the electronic health record (EHR), it is

crucial to involve all relevant stakeholders to ensure their buy-in and support. This includes

discussing the proposed changes with those who will be directly impacted by it and obtaining their

feedback. This collaborative approach can help in identifying potential issues and garnering the

necessary support for the proposal, increasing the likelihood of it being accepted by the EHR

committee in the future.

Reference: = CCRN Exam Handbook, page 58

For postural drainage of the right lower lobe, the patient should be positioned on their left side in

the Trendelenburg position. This positioning utilizes gravity to facilitate the drainage of secretions

from the right lower lobe of the lungs. In the Trendelenburg position, the body is laid flat on the back

with the feet higher than the head, which helps drain the lower lobes effectively.

Reference: = CCRN Exam Handbook, page 22

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.”

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.

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Acute renal failure is one of the possible complications of abdominal aortic aneurysm (AAA) repair,

especially after open surgery. Acute renal failure is a sudden loss of kidney function that can cause

fluid and electrolyte imbalance, acid-base disturbance, and uremic syndrome. Acute renal failure can

occur due to several factors, such as hypoperfusion of the kidneys, atheroembolism, contrast-

induced nephropathy, or ischemia-reperfusion injury12. The incidence of acute renal failure after

AAA repair ranges from 2 to 25%, depending on the definition, the type of surgery, and the patient’s

risk factors13. Acute renal failure is associated with increased morbidity, mortality, and length of

hospital stay after AAA repair13.

Other complications of AAA repair include bleeding, infection, wound complications, graft-related

complications, bowel ischemia, spinal cord ischemia, and cardiac, pulmonary, or neurological

events124. Acute hepatic dysfunction, acute CVA, and atrial fibrillation are not specific complications

of AAA repair, but they may occur in any major surgery or in patients with preexisting conditions.

Cardiogenic pulmonary edema is primarily caused by left ventricular (LV) noncompliance. When the

left ventricle is unable to properly fill or eject blood, pressure increases in the left atrium and

pulmonary veins, leading to fluid leakage into the pulmonary interstitium and alveoli, causing

pulmonary edema. Elevated PAOP readings, RV chamber enlargement, and pulmonary hypertension

are not primary causes of cardiogenic pulmonary edema but can be related to other cardiac

conditions. Reference: = CCRN Exam Handbook, AACN Adult CCRN Certification Review Course