Carol Ann Rauen, ms, rn-bc, ccrn, pccn, cen, and Sara Knippa, ms, rn, cns, ccrn, pccn, accns-ag, are the column coeditors. Carol is an independent clinical nurse specialist and education consultant in St. Augustine, Florida, and Sara is a clinical nurse specialist/educator in the cardiac intensive care unit at University of Colorado Hospital, Aurora, Colorado. They welcome feedback from readers and practice questions from potential contributors at rauen.carolann@gmail.com or sara.knippa.cns@gmail.com. Sara wrote the introduction.RAUENKNIPPAMaranda Jackson-Parkin, phd, crnp-bc, acnp, ccns, ccrn, is an assistant professor in the Adult-Gerontology Acute Care Nurse Practitioner/Clinical Nurse Specialist Doctor of Nursing Practice Program, University of Maryland School of Nursing, Baltimore, Maryland. She wrote CCRN review questions 1 through 5.JACKSON-PARKINFeri Kiani, msn, rn, ccrn, rrt, nps, is a clinical nurse III in the pediatric intensive care unit, Children’s Hospital, Los Angeles, California. Feri wrote pediatric CCRN review questions 1 through 5.KIANII always write down my to-do list. Writing it helps me prioritize, and I feel such satisfaction in crossing things off. But I often find that some item on my list has not been crossed off by the time I move to a new list, and that item can follow me to several new lists. Why do I put off that one task? Usually because the task is something I tell myself I “have to” do, but I struggle to find the motivation to do it. When I replace “have to” with “want to,” I remind myself why the task was important enough to get onto the list in the first place, and I am much more likely to accomplish it. Is studying for a certification test or registering for the test “that” item on your to-do list? Try reframing your motivation by replacing “have to” with “want to!”The cough reflex is a protective mechanism specific for protection of the airway. The gag reflex (A) is not an effective method for evaluating aspiration risk because the reflex is highly variable between patients, and material that stimulates a gag reflex is not necessarily aspirated into the lungs. Current evidence does not support GRV as a conclusive indicator of the risk for aspiration (C). Numerous factors influence GRV, and standardizing practices is difficult because of the lack of evidence-based guidelines. Testing tracheal secretions for the presence of glucose (D) is not reliable because glucose content within tube feeding formulas varies, yielding abnormal results.At therapeutic doses, sedatives and analgesics improve ventilator synchrony, promoting patient comfort, gas exchange, and oxygenation. Neuromuscular blockade (A) is used to facilitate ventilator management by overriding pulmonary protective reflexes. When started early, the blockade is beneficial at the cellular and tissue level by attenuating inflammatory responses. However, use of sedation and analgesia must be initiated before and during this therapy. Current evidence supports low tidal volumes (B) of 6 mL/kg as effective to reduce alveolar trauma and improve or normalize plateau pressures in the reduced lung compliance of ARDS. Placing patients in the prone position (C) promotes alveolar recruitment in dependent lung areas and may improve the mortality rate in severe cases of ARDS, but sedation and analgesia would be required to facilitate proning protocols.The high sodium content of hypertonic saline osmotically pulls fluid into the vascular space, decreasing cerebral edema and ICP. The formula for CPP is MAP - ICP, and the normal range of CPP is 50 to 70 mm Hg. The CPP of the patient is 46 mm Hg, which is low and denotes cerebral tissue ischemia. Administration of nicardipine (A), a calcium channel blocker and vasodilator, would lower the systolic blood pressure, a situation that would be harmful in patients with increased ICP. Propofol (B), a sedative, is associated with hypotension, which could further lower the CPP. A CPP less than 50 mm Hg indicates decreased intracranial compliance and impaired autoregulation, which are further exacerbated by a febrile state (C).The development of noncardiogenic pulmonary edema (ARDS) after a blood transfusion is known as transfusion-related acute lung injury. Increased airway resistance and decreased alveolar compliance in ARDS cause the PIP to increase, making mechanical ventilation with a volume-cycle mode, such as assist control, difficult. Switching to a pressure-cycle mode will decrease PIP while increasing mean inspiratory pressure, a change that should improve oxygenation. Although beneficial to the tissue, increasing oxygen and decreasing PEEP (B) would not treat the alveolar compliance problem or hypoxemia. Dobutamine (C), a sympathomimetic, increases cardiac output and stroke volume by increasing heart rate and contractility. Dobutamine is beneficial in pulmonary edema due to a cardiac origin but is not helpful for noncardiac pulmonary edema. Although suctioning and sedation (D) are interventions for ARDS, the data presented do not indicate a need for either.Among the 3 types of delirium (hyperactive, mixed, and hypoactive), hypoactive delirium is associated with worse outcomes and is often underdiagnosed. Hyperactive delirium is more easily recognized, yet the hyperactive form (A) occurs in less than 5% of patients who have delirium. Substances such as medications and toxins (C) are a possible cause of delirium, but the complication can also be caused by general medical conditions (eg, hypoxia, acidosis, concussion) or have multiple causes. Delirium is an abrupt yet reversible change in mentation, whereas dementia (D) has a progressive onset and is irreversible, with decreases in memory, cognition, and executive function.Intubation and mechanical ventilation are indicated to relieve air trapping in status asthmaticus. Severe air trapping places tension on the pericardium, reducing diastolic filling and cardiac output during inspiration, resulting in pulsus paradoxus. Insertion of an arterial catheter (A) would confirm the pulsus paradoxus suggested by the pulse oximetry signal but is not necessary to treat the patient. Insertion of a chest tube (C) is not indicated because air is trapped in the lungs instead of in the pleural space. Pericardiocentesis (D) would be performed for cardiac tamponade (which also is manifested with pulsus paradoxus) due to an accumulation of fluid in the pericardial space.Allopurinol is a uric acid–lowering agent used to prevent hyperuricemic nephropathy in acute tumor lysis syndrome, an oncological emergency caused by tumor cell lysis with the release of large amounts of potassium, phosphate, and nucleic acids into the systemic circulation. Catabolism of nucleic acids to uric acid leads to hyperuricemia and development of uric acid crystals in the renal tubules, causing acute kidney injury. Administration of sodium polystyrene sulfonate (B) is not the first priority but can be used for hyperkalemia (potassium level ≥ 6.0 mEq/L) or ECG changes. Furosemide (C) is administered to patients at risk for fluid overload due to hyperhydration and acute kidney injury, but it does not treat the underlying problem. Calcium gluconate (D) is not recommended until hyperphosphatemia is corrected unless the patient has neurological signs and symptoms such as seizures or a positive Chvostek or Trousseau sign.Respiratory acidosis can be corrected by decreasing frequency. Oscillatory frequency has an inverse relationship with tidal volume; therefore, decreasing frequency will increase delivered tidal volume and improve carbon dioxide clearance from the lungs. Oscillatory amplitude is directly proportional to tidal volume; therefore, decreasing amplitude (A) will decrease delivered tidal volume, resulting in less carbon dioxide clearance from the lungs and worsening of the respiratory acidosis. Decreasing FIO2 (B) will reduce the level of oxygen in blood and worsen the hypoxemia. Decreasing mean airway pressure (D) will reduce alveolar recruitment and functional residual capacity, worsening the hypoxemia.End tidal carbon dioxide less than 10 mm Hg indicates low pulmonary blood flow due to low cardiac output. Correcting hand position and depth of compression can markedly improve cardiac output. Increasing oxygen flow (A) will have minimal effect on oxygen delivery because the low perfusion is due to low cardiac output. A respiratory rate of 16/min (B) is appropriate for this patient. Chest compression at a rate of 100 to 120 (D) is appropriate for this patient.Acute confusion, inattention, and inconsolability are cardinal indications of delirium, and the Cornell Assessment of Pediatric Delirium can be used to confirm its presence (score ≥ 9). Family engagement is crucial in creating a calm and familiar environment, a nonpharmacological intervention that is helpful in treating a child with delirium. Anxiety disorders (A) are associated with physical signs such as increased heart rate and shortness of breath but not inattention. Sleep deprivation (C) in children often is manifested as hyperactivity, irritability, and short attention span but not confusion and inattention. Posttraumatic stress disorder (D) often is indicated by anxiety, nightmares, disengagement, and emotional withdrawal but not confusion and inattention.AACN Certcorp publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN Certification exam handbook. The contributor of each question written for this column has listed the source used in developing each item.