CCRN (Adult) Certification Exam — Questions and Answers

Question 1: Plateau pressure should be maintained below which value to limit ventilator-induced lung injury?

20 cm H2O
40 cm H2O
30 cm H2O (Correct answer)
50 cm H2O

Correct answer: 30 cm H2O

Keeping plateau pressure under 30 cm H2O reduces alveolar overdistension and barotrauma.

Question 2: HIPPA laws require which of the following ethical principles?

Patient fidelity
Patient veracity
Patient justice
Patient confidentiality (Correct answer)

Correct answer: Patient confidentiality

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law primarily enacted to protect the privacy and security of individuals' protected health information (PHI). A core ethical and legal principle mandated by HIPAA is patient confidentiality, ensuring that sensitive medical information is handled securely and disclosed only with proper authorization or under specific legal circumstances.

Question 3: A patient develops dyspnea, hypoxemia, and bilateral infiltrates within 6 hours of transfusion. Which reaction is most likely?

Acute hemolytic reaction
Transfusion-related acute lung injury (TRALI) (Correct answer)
Allergic reaction
Bacterial contamination

Correct answer: Transfusion-related acute lung injury (TRALI)

TRALI presents with acute non-cardiogenic pulmonary edema within 6 hours of transfusion and is a leading cause of transfusion-related death.

Question 4: Which coagulation abnormality is a hallmark of disseminated intravascular coagulation (DIC) in severe sepsis?

Isolated elevated platelet count
Simultaneous bleeding and microvascular thrombosis (Correct answer)
Shortened PT and PTT
Decreased D-dimer levels

Correct answer: Simultaneous bleeding and microvascular thrombosis

DIC produces both clotting and bleeding due to consumption of clotting factors.

Question 5: A patient post-MI is started on a beta-blocker. What is the primary rationale?

Reduce myocardial oxygen demand and prevent arrhythmias (Correct answer)
Increase contractility
Dilate coronary arteries directly
Promote diuresis

Correct answer: Reduce myocardial oxygen demand and prevent arrhythmias

Beta-blockers lower heart rate and contractility, reducing oxygen demand and the risk of lethal arrhythmias.

Question 6: A patient in thyroid storm has a temperature of 105.8°F and heart rate of 160. Which medication is given to block peripheral conversion of T4 to T3 and reduce thyroid output?

Furosemide
Levothyroxine
Aspirin
Propylthiouracil (PTU) (Correct answer)

Correct answer: Propylthiouracil (PTU)

PTU both inhibits thyroid hormone synthesis and blocks peripheral conversion of T4 to the more active T3.

Question 7: Before administering IV alteplase (tPA) for ischemic stroke, which study must be completed to exclude hemorrhage?

Lumbar puncture
Carotid ultrasound
EEG
Noncontrast CT of the head (Correct answer)

Correct answer: Noncontrast CT of the head

A noncontrast head CT must confirm there is no hemorrhage before giving tPA.

Question 8: A patient with a severe traumatic brain injury has an ICP of 25 mmHg and a MAP of 80 mmHg. What is the cerebral perfusion pressure (CPP)?

55 mmHg (Correct answer)
65 mmHg
105 mmHg
45 mmHg

Correct answer: 55 mmHg

CPP equals MAP minus ICP, so 80 minus 25 equals 55 mmHg.

Question 9: During an active generalized tonic-clonic seizure, which nursing action is the priority?

Protect the airway and prevent injury (Correct answer)
Administer oral fluids
Insert a bite block between the teeth
Restrain the extremities firmly

Correct answer: Protect the airway and prevent injury

Maintaining the airway and preventing injury are the priorities during an active seizure.

Question 10: Which arterial blood gas result indicates uncompensated respiratory acidosis?

pH 7.40, PaCO2 40, HCO3 24
pH 7.30, PaCO2 55, HCO3 24 (Correct answer)
pH 7.50, PaCO2 30, HCO3 24
pH 7.34, PaCO2 60, HCO3 32

Correct answer: pH 7.30, PaCO2 55, HCO3 24

Low pH with high PaCO2 and normal HCO3 indicates uncompensated respiratory acidosis.

Question 11: What is the primary goal of maintaining normocapnia (PaCO2 35-45 mmHg) in a patient with elevated ICP?

To stimulate the respiratory drive
To increase cerebral oxygen consumption
To promote metabolic alkalosis
To avoid cerebral vasoconstriction or vasodilation that worsens perfusion or pressure (Correct answer)

Correct answer: To avoid cerebral vasoconstriction or vasodilation that worsens perfusion or pressure

CO2 strongly affects cerebral vessel caliber, so normocapnia prevents harmful vasoconstriction or vasodilation.

Question 12: Beneficence is demonstrated when the critical care nurse:

Repositions a patient to prevent complications and promote comfort (Correct answer)
Tells the patient an uncomfortable truth
Respects a refusal of care
Allocates beds fairly

Correct answer: Repositions a patient to prevent complications and promote comfort

Beneficence is acting for the patient's benefit and well-being.

Question 13: You're using a pulmonary artery catheter to monitor a patient. You are unable to determine the pulmonary artery wedge pressure of the patient. You check the ___________ to get a value that matches to the pulmonary artery wedge pressure.

Right atrial pressure
Right ventricular pressure
Pulmonary artery mean pressure
Pulmonary artery diastolic pressure (Correct answer)

Correct answer: Pulmonary artery diastolic pressure

The pulmonary artery wedge pressure (PAWP) is a critical measurement reflecting left ventricular preload and left atrial pressure. When a PAWP cannot be obtained, the pulmonary artery diastolic pressure (PADP) can serve as a reliable substitute. This is because, in the absence of pulmonary hypertension, the pulmonary valve opens during diastole, allowing the pressures in the pulmonary artery to equilibrate with the left atrial pressure, which the PAWP estimates.

Question 14: Which situation represents a breach of professional boundaries?

Educating the patient about their condition
Accepting expensive gifts and forming a personal relationship with a patient (Correct answer)
Advocating for the patient's preferences
Providing emotional support during a crisis

Correct answer: Accepting expensive gifts and forming a personal relationship with a patient

Accepting valuable gifts and personal involvement crosses professional nurse-patient boundaries.

Question 15: Which intervention is a core component of the ventilator-associated pneumonia (VAP) prevention bundle?

Change the ventilator circuit every 24 hours
Elevate the head of bed 30–45 degrees (Correct answer)
Keep the patient supine and flat
Routine daily prophylactic antibiotics

Correct answer: Elevate the head of bed 30–45 degrees

Semi-recumbent positioning reduces aspiration risk and is a key VAP bundle element.

Question 16: Which lactate value best indicates tissue hypoperfusion and increased mortality risk in sepsis?

Less than 1 mmol/L
Greater than 2 mmol/L (Correct answer)
Greater than 0.5 mmol/L
Exactly 1.5 mmol/L

Correct answer: Greater than 2 mmol/L

A lactate above 2 mmol/L signals tissue hypoperfusion and warrants resuscitation.

Question 17: Which lab finding best distinguishes prerenal azotemia from intrinsic renal failure?

Elevated lipase
BUN-to-creatinine ratio greater than 20:1 (Correct answer)
Elevated white blood cell count
Low hemoglobin

Correct answer: BUN-to-creatinine ratio greater than 20:1

A BUN:creatinine ratio over 20:1 suggests prerenal azotemia from hypoperfusion rather than intrinsic damage.

Question 18: A patient's pulmonary capillary wedge pressure (PCWP) is 4 mmHg with a CVP of 2 mmHg and tachycardia. What does this most likely indicate?

Left ventricular failure
Pulmonary hypertension
Cardiac tamponade
Hypovolemia (Correct answer)

Correct answer: Hypovolemia

Low PCWP and low CVP with compensatory tachycardia indicate reduced preload from hypovolemia.

Question 19: Which sign distinguishes right-sided heart failure from left-sided heart failure?

Jugular venous distention and peripheral edema (Correct answer)
Pink frothy sputum
Orthopnea
Pulmonary crackles

Correct answer: Jugular venous distention and peripheral edema

Right-sided failure causes systemic venous congestion with JVD and peripheral edema, whereas left-sided failure causes pulmonary symptoms.

Question 20: A patient in the ICU is diagnosed with septic shock. The critical care nurse understands that the profound hypotension associated with this condition is primarily caused by which pathophysiological mechanism?

Intense systemic vasoconstriction.
Pathologic myocardial depression.
A severe reduction in absolute intravascular volume.
Massive peripheral vasodilation. (Correct answer)

Correct answer: Massive peripheral vasodilation.

Septic shock is a form of distributive shock. The pathophysiology involves a dysregulated host response to infection, leading to a massive release of inflammatory mediators like nitric oxide. These mediators cause profound systemic vasodilation, which dramatically decreases systemic vascular resistance (SVR) and leads to a relative hypovolemia and hypotension. While myocardial depression and fluid shifts from increased capillary permeability (leading to some volume loss) do occur, the primary and most defining hemodynamic alteration is massive vasodilation.

Question 21: A patient is undergoing a spontaneous breathing trial (SBT) to assess for weaning readiness. Which of the following findings would be the strongest indicator of SBT failure, requiring the patient to be placed back on their previous ventilator settings?

A blood pressure change from 120/80 mmHg to 135/88 mmHg.
A heart rate increase from 88 to 105 beats/min.
A Rapid Shallow Breathing Index (RSBI) of 130 breaths/min/L. (Correct answer)
A slight increase in patient anxiety noted by the nurse.

Correct answer: A Rapid Shallow Breathing Index (RSBI) of 130 breaths/min/L.

The Rapid Shallow Breathing Index (RSBI), calculated as respiratory frequency divided by tidal volume (f/VT), is a key predictor of weaning success. A value greater than 105 breaths/min/L is highly predictive of weaning failure, indicating that the patient is breathing rapidly and shallowly and cannot sustain the work of breathing. While the other options may be signs of intolerance, an RSBI >105 is a more objective and critical indicator of failure.

Question 22: Which ventilator setting most directly improves oxygenation in a hypoxemic patient?

Increasing respiratory rate
Increasing PEEP and FiO2 (Correct answer)
Decreasing tidal volume
Increasing inspiratory time only

Correct answer: Increasing PEEP and FiO2

PEEP and FiO2 are the primary settings adjusted to improve oxygenation.

Question 23: Why is aspirin contraindicated for fever control in thyroid storm?

It blocks beta receptors excessively
It causes severe bradycardia
It displaces thyroid hormone from binding proteins, raising free hormone levels (Correct answer)
It suppresses TSH dangerously

Correct answer: It displaces thyroid hormone from binding proteins, raising free hormone levels

Salicylates displace thyroid hormone from thyroid-binding globulin, increasing free hormone and worsening the storm.

Question 24: A patient with DKA has an arterial blood gas showing pH 7.18, HCO3 8 mEq/L. This represents which acid-base disturbance?

Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis
High anion gap metabolic acidosis (Correct answer)

Correct answer: High anion gap metabolic acidosis

Accumulation of ketoacids in DKA produces a high anion gap metabolic acidosis with low pH and low bicarbonate.

Question 25: Which of the following is the first-line pharmacologic intervention for a patient who has been actively seizing for more than five minutes (status epilepticus)?

Propofol (Diprivan) bolus and infusion.
Lorazepam (Ativan) IV push. (Correct answer)
Levetiracetam (Keppra) IV piggyback.
Phenytoin (Dilantin) IV infusion.

Correct answer: Lorazepam (Ativan) IV push.

For the emergent initial treatment of status epilepticus, a benzodiazepine is the first-line drug class. Lorazepam is a common choice due to its rapid onset and relatively long duration of action compared to other benzodiazepines. While medications like phenytoin, levetiracetam, or propofol are used as second-line or refractory treatments, the immediate priority is to stop the seizure with a fast-acting agent like a benzodiazepine.

Question 26: A spontaneous awakening trial (SAT) paired with a spontaneous breathing trial (SBT) is associated with which outcome?

Reduced ventilator days and shorter ICU stay (Correct answer)
Higher reintubation rates
Longer duration of sedation
Increased delirium

Correct answer: Reduced ventilator days and shorter ICU stay

Coordinated SAT/SBT protocols shorten the duration of mechanical ventilation and ICU length of stay.

Question 27: Which scenario most increases the risk of inaccurate CVP readings?

Patient lying flat
High levels of PEEP (Correct answer)
Use of a calibrated transducer
Reading at end-expiration

Correct answer: High levels of PEEP

High PEEP raises intrathoracic pressure and falsely elevates the measured CVP.

Question 28: A patient with a COPD exacerbation has pH 7.28, PaCO2 68, HCO3 30. This represents:

Fully compensated respiratory acidosis
Pure metabolic acidosis
Acute-on-chronic respiratory acidosis (Correct answer)
Acute respiratory alkalosis

Correct answer: Acute-on-chronic respiratory acidosis

The elevated HCO3 shows chronic retention, while the low pH with high CO2 indicates an acute worsening.

Question 29: A family asks the nurse to not tell the patient about a cancer diagnosis. The best response is to:

Refer the decision entirely to the physician
Immediately disclose all details to the patient
Comply with the family's request
Explore the patient's wishes about how much information they want to receive (Correct answer)

Correct answer: Explore the patient's wishes about how much information they want to receive

Patient autonomy includes the right to decide how much information they wish to know.

Question 30: An advance directive becomes effective when:

The patient is admitted to the ICU
The patient loses decision-making capacity (Correct answer)
It is signed and witnessed
The physician approves it

Correct answer: The patient loses decision-making capacity

Advance directives guide care only once the patient can no longer make decisions.

Question 31: A nurse is asked to perform a procedure outside their scope of practice. The correct action is to:

Perform it and document carefully
Delegate it to an aide
Decline and notify the supervisor, as it falls outside legal scope (Correct answer)
Perform it since a physician ordered it

Correct answer: Decline and notify the supervisor, as it falls outside legal scope

Nurses must not exceed their legal scope of practice even when ordered to do so.

Question 32: According to the PADIS bundle, which approach should be used first when managing pain in ICU patients (analgesia-first strategy)?

Start sedation before assessing pain
Treat pain before titrating sedation (Correct answer)
Administer benzodiazepines before opioids
Use neuromuscular blockade before analgesia

Correct answer: Treat pain before titrating sedation

The analgesia-first (analgo-sedation) approach recommends treating pain first, as untreated pain is a major driver of agitation and over-sedation.

Question 33: When an ethical dilemma cannot be resolved at the bedside, the nurse should:

Request a consultation with the ethics committee (Correct answer)
Avoid documenting the conflict
Defer entirely to the family
Make the decision unilaterally

Correct answer: Request a consultation with the ethics committee

An ethics committee provides structured, multidisciplinary review of complex dilemmas.

Question 34: A patient with severe acute pancreatitis develops sudden, severe flank pain and ecchymosis around the left flank. The nurse recognizes this finding as Grey Turner's sign. This sign is indicative of which life-threatening complication?

Splenic vein thrombosis
Peripancreatic abscess formation
Ruptured pancreatic pseudocyst
Retroperitoneal hemorrhage (Correct answer)

Correct answer: Retroperitoneal hemorrhage

Grey Turner's sign (flank ecchymosis) and Cullen's sign (periumbilical ecchymosis) are clinical signs of retroperitoneal hemorrhage. In severe acute pancreatitis, inflammatory and enzymatic processes can erode blood vessels, leading to significant bleeding into the retroperitoneal space.

Question 35: In ARDS lung-protective ventilation, plateau pressure should generally be kept below:

15 cm H2O
50 cm H2O
30 cm H2O (Correct answer)
60 cm H2O

Correct answer: 30 cm H2O

Keeping plateau pressure < 30 cm H2O limits alveolar overdistension and barotrauma.

Question 36: Which hemodynamic profile is classic for septic shock?

High SVR, low cardiac output, high CVP
Low SVR, low cardiac output, high CVP
High SVR, high cardiac output, normal CVP
Low SVR, high cardiac output, low CVP (Correct answer)

Correct answer: Low SVR, high cardiac output, low CVP

Septic shock typically shows decreased SVR with high cardiac output and low filling pressures.

Question 37: A nurse in the ICU notices that a colleague has become irritable, has had multiple charting errors, and frequently volunteers to administer narcotics for other nurses' patients. The nurse suspects the colleague may be diverting medications. What is the nurse's most appropriate and professional initial action?

Begin an independent investigation by tracking the colleague's medication withdrawals to gather more proof.
Confront the colleague directly during their next shift and demand an explanation.
Warn other nurses on the unit to be cautious of the colleague in question.
Report the specific observations and concerns to the nurse manager or charge nurse according to facility policy. (Correct answer)

Correct answer: Report the specific observations and concerns to the nurse manager or charge nurse according to facility policy.

The nurse's ethical and professional duty is to protect patients from harm. The appropriate action is to follow the established chain of command and report the objective concerns to management. This allows for a formal, confidential investigation while ensuring patient safety. Confronting the colleague can be unsafe, and discussing it with peers is unprofessional.

Question 38: A patient with acute pancreatitis has a serum calcium of 7.0 mg/dL. What causes this finding?

Renal calcium retention
Excess vitamin D
Fat saponification binding calcium (Correct answer)
Increased calcium absorption

Correct answer: Fat saponification binding calcium

Released lipase causes fat necrosis that binds calcium (saponification), lowering serum calcium.

Question 39: Which sign indicates worsening intra-abdominal hypertension toward abdominal compartment syndrome?

Increased bowel sounds
Bradycardia with hypertension
Decreased urine output with elevated peak airway pressures (Correct answer)
Hypothermia

Correct answer: Decreased urine output with elevated peak airway pressures

Rising intra-abdominal pressure reduces renal perfusion and compresses the diaphragm, causing oliguria and high airway pressures.

Question 40: If the PA catheter balloon cannot be deflated and the tracing shows a permanent wedge, the nurse should:

Increase the heparin infusion
Flush the distal port rapidly
Inflate further to confirm position
Notify the provider immediately to prevent pulmonary infarction (Correct answer)

Correct answer: Notify the provider immediately to prevent pulmonary infarction

A continuously wedged catheter can cause pulmonary artery rupture or infarction and requires urgent action.

Question 41: An intra-aortic balloon pump should inflate at which point in the cardiac cycle?

During systolic ejection
At end-diastole
During the QRS complex
At the dicrotic notch (onset of diastole) (Correct answer)

Correct answer: At the dicrotic notch (onset of diastole)

Inflation at the dicrotic notch augments diastolic coronary perfusion.

Question 42: Which neuromuscular blocking agent is preferred in ICU patients with acute respiratory distress syndrome (ARDS) requiring paralysis?

Vecuronium
Rocuronium
Succinylcholine
Cisatracurium (Correct answer)

Correct answer: Cisatracurium

Cisatracurium is preferred in ARDS because it undergoes Hofmann elimination (spontaneous degradation), making it independent of renal and hepatic function.

Question 43: What is the most appropriate immediate treatment for symptomatic third-degree (complete) heart block with bradycardia?

Transcutaneous pacing (Correct answer)
Atropine as definitive therapy
Synchronized cardioversion
Adenosine

Correct answer: Transcutaneous pacing

Atropine is often ineffective in complete heart block, so transcutaneous pacing is the appropriate intervention.

Question 44: A patient is receiving a nicardipine infusion for hypertensive emergency. Which parameter should the nurse monitor most closely?

Serum lactate
Serum potassium
Blood pressure every 5–15 minutes during titration (Correct answer)
12-lead ECG for QT prolongation

Correct answer: Blood pressure every 5–15 minutes during titration

Nicardipine is a titratable IV calcium channel blocker; blood pressure must be monitored every 5–15 minutes during titration to avoid overshoot hypotension.

Question 45: When leveling an arterial line transducer to obtain an accurate reading, the nurse should place it at the phlebostatic axis. This anatomical landmark is located at the intersection of:

The fourth intercostal space and the mid-axillary line (Correct answer)
The second intercostal space and the mid-axillary line
The fifth intercostal space and the anterior axillary line
The fourth intercostal space and the mid-clavicular line

Correct answer: The fourth intercostal space and the mid-axillary line

The phlebostatic axis is the correct reference point for leveling a transducer for hemodynamic monitoring. It is located at the intersection of the fourth intercostal space and the mid-axillary line. This position approximates the level of the right atrium, ensuring accurate pressure measurements.

Question 46: A patient with a known history of Addison's disease is admitted with profound hypotension that is refractory to fluid resuscitation and norepinephrine infusion. Labs reveal hyponatremia and hyperkalemia. Which medication is the priority to administer to treat the underlying cause of this patient's shock?

Desmopressin (DDAVP)
Fludrocortisone
Insulin and D50W
Hydrocortisone (Correct answer)

Correct answer: Hydrocortisone

This patient is in an adrenal (Addisonian) crisis, characterized by a deficiency of cortisol and aldosterone. The refractory shock is due to the lack of cortisol, which is necessary for the vascular system to respond to catecholamines. Immediate administration of IV hydrocortisone is the definitive, life-saving treatment. [3, 8, 18] While fludrocortisone replaces mineralocorticoids, hydrocortisone provides both essential glucocorticoid and some mineralocorticoid effects needed emergently. [32] Insulin/D50W treats hyperkalemia, and DDAVP is for diabetes insipidus.

Question 47: An apnea test for brain death is considered positive (supporting brain death) when which result occurs?

Spontaneous breathing resumes
Oxygen saturation rises to 100%
PaCO2 falls below 30 mmHg
No respiratory effort despite a rising PaCO2 above the threshold (Correct answer)

Correct answer: No respiratory effort despite a rising PaCO2 above the threshold

Absence of respiratory effort despite a markedly elevated PaCO2 supports brain death.

Question 48: What is the priority intervention for a neutropenic patient who develops a fever of 38.5C?

Hold all antibiotics until culture results return
Place the patient in droplet isolation only
Administer acetaminophen and recheck in 4 hours
Obtain cultures and start broad-spectrum antibiotics promptly (Correct answer)

Correct answer: Obtain cultures and start broad-spectrum antibiotics promptly

Neutropenic fever is an emergency requiring blood cultures and empiric broad-spectrum antibiotics within an hour to prevent sepsis.

Question 49: A patient is admitted to the ICU following a ruptured cerebral aneurysm and subsequent subarachnoid hemorrhage (SAH). Which of the following physician's orders should the nurse anticipate to prevent cerebral vasospasm?

Administration of nimodipine 60 mg every 4 hours. (Correct answer)
Strict blood pressure control with a target SBP < 120 mmHg.
Initiation of therapeutic hypothermia.
Intravenous mannitol every 6 hours.

Correct answer: Administration of nimodipine 60 mg every 4 hours.

Nimodipine, a calcium channel blocker, is the standard of care for preventing cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. It has been shown to improve neurological outcomes. While mannitol is used to manage ICP and blood pressure control is crucial, nimodipine specifically targets the prevention of vasospasm, a common and dangerous complication that typically occurs 3 to 14 days after the initial hemorrhage.

Question 50: A patient with thrombotic thrombocytopenic purpura (TTP) presents with the classic pentad. Which finding is part of it?

Hyperglycemia
Hypercalcemia
Hypernatremia
Microangiopathic hemolytic anemia (Correct answer)

Correct answer: Microangiopathic hemolytic anemia

TTP features microangiopathic hemolytic anemia, thrombocytopenia, neurologic changes, renal dysfunction, and fever.

Question 51: Which physiologic change explains why central venous oxygen saturation (ScvO2) may be elevated in late sepsis?

Hyperventilation
Increased oxygen demand by tissues
Profound anemia
Impaired cellular oxygen extraction at the tissue level (Correct answer)

Correct answer: Impaired cellular oxygen extraction at the tissue level

Cytopathic injury prevents tissues from extracting oxygen, raising venous saturation.

Question 52: Which assessment tool is considered the gold standard for detecting ICU delirium in mechanically ventilated patients?

Mini-Mental State Examination (MMSE)
Montreal Cognitive Assessment (MoCA)
Confusion Assessment Method for the ICU (CAM-ICU) (Correct answer)
Delirium Rating Scale

Correct answer: Confusion Assessment Method for the ICU (CAM-ICU)

The CAM-ICU is the gold-standard validated tool for diagnosing delirium in ICU patients, including those on mechanical ventilation.

Question 53: Which electrolyte abnormality is most common in a patient with prolonged nasogastric suction?

Respiratory acidosis
Metabolic acidosis with hyperkalemia
Hyperchloremia
Metabolic alkalosis with hypokalemia (Correct answer)

Correct answer: Metabolic alkalosis with hypokalemia

Loss of gastric acid and potassium from NG suction produces hypokalemic metabolic alkalosis.

Question 54: Which early clinical sign most reliably indicates impending respiratory failure in an alert patient?

Warm dry skin
Decreased urine output
Increasing accessory muscle use with rising respiratory rate (Correct answer)
Bradycardia at rest

Correct answer: Increasing accessory muscle use with rising respiratory rate

Escalating work of breathing and tachypnea signal that the patient is failing to maintain gas exchange.

Question 55: A patient in adrenal crisis is most likely to display which electrolyte pattern?

Hypernatremia and hypokalemia
Hyponatremia and hypokalemia
Hypernatremia and hyperkalemia
Hyponatremia and hyperkalemia (Correct answer)

Correct answer: Hyponatremia and hyperkalemia

Aldosterone deficiency in adrenal crisis causes sodium loss and potassium retention, producing hyponatremia and hyperkalemia.

Question 56: How does an intra-aortic balloon pump improve cardiac function in cardiogenic shock?

It oxygenates blood externally
It directly pumps blood from the ventricle
It increases coronary perfusion during diastole and reduces afterload during systole (Correct answer)
It paces the heart

Correct answer: It increases coronary perfusion during diastole and reduces afterload during systole

The IABP inflates in diastole to augment coronary perfusion and deflates in systole to reduce afterload.

Question 57: Which patient is at highest risk for hyperosmolar hyperglycemic state (HHS)?

An elderly patient with type 2 diabetes and an acute infection (Correct answer)
A young athlete with type 1 diabetes
A patient with well-controlled type 1 diabetes
A child with new-onset diabetes

Correct answer: An elderly patient with type 2 diabetes and an acute infection

HHS classically occurs in older type 2 diabetics with a precipitating illness such as infection causing severe dehydration and hyperglycemia.

Question 58: Tranexamic acid (TXA) is most beneficial when administered to a trauma patient within what timeframe?

Only after 6 hours
Within 24 hours of injury
Within 12 hours of injury
Within 3 hours of injury (Correct answer)

Correct answer: Within 3 hours of injury

TXA reduces mortality when given within 3 hours of injury and may increase harm if given later.

Question 59: Permissive hypercapnia during ARDS ventilation is acceptable as long as:

PaCO2 stays below 40
pH remains within a tolerable range (generally > 7.20) (Correct answer)
Tidal volume is increased to normalize CO2
The patient is fully awake

Correct answer: pH remains within a tolerable range (generally > 7.20)

Allowing CO2 to rise is tolerated to protect the lungs, provided pH stays in an acceptable range.

Question 60: A square wave (fast-flush) test shows excessive oscillations before returning to baseline. This indicates:

An overdamped system
Transducer failure
An optimally damped system
An underdamped system (Correct answer)

Correct answer: An underdamped system

Multiple oscillations after the flush indicate underdamping, which overestimates systolic pressure.

Question 61: A patient with DKA is started on an insulin infusion. The glucose drops from 600 to 250 mg/dL. What is the appropriate next step?

Give a bolus of regular insulin
Stop the insulin infusion immediately
Switch to oral hypoglycemic agents
Add dextrose to the IV fluids while continuing the insulin infusion (Correct answer)

Correct answer: Add dextrose to the IV fluids while continuing the insulin infusion

Once glucose reaches about 200-250 mg/dL, dextrose is added so insulin can continue clearing ketones without causing hypoglycemia.

Question 62: Which medication is a first-line inotrope for a patient in cardiogenic shock with adequate blood pressure?

Vasopressin
Phenylephrine
Norepinephrine
Dobutamine (Correct answer)

Correct answer: Dobutamine

Dobutamine improves contractility and cardiac output and is preferred when blood pressure is marginally adequate.

Question 63: Which lab/monitoring tool provides the EARLIEST noninvasive warning of falling ventilation in a sedated patient?

Daily chest x-ray
Serum lactate
Continuous capnography (end-tidal CO2) (Correct answer)
Intermittent pulse oximetry alone

Correct answer: Continuous capnography (end-tidal CO2)

Capnography detects hypoventilation before oxygen saturation drops, especially with supplemental oxygen.

Question 64: A ventilated patient's high-pressure alarm sounds repeatedly. After ruling out kinks, what should the nurse assess next?

Hyperventilation
Need for suctioning due to secretions (Correct answer)
Disconnection of the circuit
A cuff leak

Correct answer: Need for suctioning due to secretions

Secretions are a common cause of high-pressure alarms; suctioning may relieve the obstruction.

Question 65: A patient has a PaO2 of 55 mmHg on room air with a normal PaCO2. This finding is most consistent with which type of respiratory failure?

Type II (hypercapnic) respiratory failure
Metabolic alkalosis
Chronic compensated respiratory acidosis
Type I (hypoxemic) respiratory failure (Correct answer)

Correct answer: Type I (hypoxemic) respiratory failure

Type I respiratory failure is defined by hypoxemia (PaO2 < 60 mmHg) with a normal or low PaCO2.

Question 66: A patient is admitted to the ICU with multiple stab wounds to the chest. The patient is hypotensive (BP 80/55 mmHg), tachycardic (HR 130 bpm), has muffled heart sounds, and pronounced jugular venous distention (JVD). A bedside ultrasound reveals fluid in the pericardial sac. Which type of shock is this patient experiencing?

Hypovolemic Shock
Cardiogenic Shock
Obstructive Shock (Correct answer)
Distributive Shock

Correct answer: Obstructive Shock

This patient's presentation is classic for cardiac tamponade, a cause of obstructive shock. The combination of hypotension, muffled heart sounds, and JVD is known as Beck's triad. In obstructive shock, a physical obstruction (in this case, fluid in the pericardium) prevents the heart from filling and pumping effectively, leading to decreased cardiac output and shock, despite normal myocardial function and intravascular volume.

Question 67: Which laboratory finding best reflects the adequacy of tissue perfusion in shock?

Serum sodium
Serum potassium
Lactate (Correct answer)
White blood cell count

Correct answer: Lactate

Elevated serum lactate indicates anaerobic metabolism and inadequate tissue oxygen delivery, a key marker of shock severity.

Question 68: During PA catheter insertion, a sustained right ventricular waveform indicates the tip is in the RV and the nurse should:

Inflate the balloon and leave it
Notify the provider to advance or withdraw to reduce arrhythmia risk (Correct answer)
Document and take no action
Flush vigorously and continue monitoring

Correct answer: Notify the provider to advance or withdraw to reduce arrhythmia risk

A catheter tip lodged in the RV can provoke ventricular arrhythmias and must be repositioned.

Question 69: A nurse is caring for a patient with a catastrophic brain injury. The medical team has determined that further treatment is futile, but the family insists on continuing all life-sustaining measures. The nurse feels powerless and emotionally conflicted by providing care they believe is not in the patient's best interest. This feeling is best described as:

Moral distress (Correct answer)
Anxiety disorder
Compassion fatigue
Burnout

Correct answer: Moral distress

Moral distress is the specific psychological and emotional suffering that occurs when a healthcare professional knows the ethically appropriate action to take but is constrained from doing so by institutional or other barriers. In this scenario, the nurse is providing care that conflicts with their professional judgment and values, leading to moral distress.

Question 70: What is the earliest reliable sign of compensated shock in a young trauma patient?

Tachycardia (Correct answer)
Bradycardia
Hypotension
Decreased urine output

Correct answer: Tachycardia

Tachycardia is an early compensatory response, while hypotension is a late and ominous sign.

Question 71: A RASS score of -2 indicates which level of sedation?

Moderate sedation — movement or eye opening without eye contact (Correct answer)
Alert and calm
Deep sedation — no response to voice
Light sedation — briefly awakens to voice

Correct answer: Moderate sedation — movement or eye opening without eye contact

A RASS of -2 indicates light sedation, where the patient briefly awakens (eye opening and contact) to voice for less than 10 seconds.

Question 72: What is the primary goal of fibrinolytic therapy in STEMI when PCI is unavailable?

Dissolve the occluding thrombus and restore perfusion (Correct answer)
Decrease myocardial oxygen demand
Reduce afterload
Prevent reinfarction long-term

Correct answer: Dissolve the occluding thrombus and restore perfusion

Fibrinolytics break down the clot occluding the coronary artery to restore myocardial blood flow.

Question 73: Which is required for valid informed consent?

Only the physician's signature
The patient must be competent and decision given voluntarily (Correct answer)
Approval by the patient's employer
A notarized witness

Correct answer: The patient must be competent and decision given voluntarily

Valid consent requires competence, adequate disclosure, understanding, and voluntariness.

Question 74: Which patient is the BEST candidate for noninvasive positive pressure ventilation (NIPPV)?

Patient with depressed consciousness and absent gag
Patient in cardiac arrest
Patient with active hematemesis
Alert COPD patient with hypercapnic acidosis (Correct answer)

Correct answer: Alert COPD patient with hypercapnic acidosis

Awake, cooperative COPD patients with hypercapnic respiratory failure benefit most from NIPPV.

Question 75: When using a daily spontaneous awakening trial (SAT), which patient condition is an absolute contraindication?

FiO2 requirement of 40%
Mild sedation (RASS -1)
Active seizures (Correct answer)
Heart rate of 90 bpm

Correct answer: Active seizures

Active seizures are an absolute contraindication to SAT because interrupting sedation could precipitate further neurological deterioration.

Question 76: Normal mixed venous oxygen saturation (SvO2) measured from the distal port of a PA catheter is approximately:

45-55%
30-45%
60-80% (Correct answer)
85-95%

Correct answer: 60-80%

Normal SvO2 is 60-80%, reflecting balance between oxygen delivery and consumption.

Question 77: Central diabetes insipidus is most appropriately treated with which medication?

Furosemide
Mannitol
Hydrochlorothiazide alone
Desmopressin (DDAVP) (Correct answer)

Correct answer: Desmopressin (DDAVP)

Central DI results from ADH deficiency, so synthetic ADH (desmopressin) replaces the missing hormone.

Question 78: A patient with chest pain has diffuse ST elevation across multiple leads with PR depression and a pericardial friction rub. What is the likely diagnosis?

Anterior STEMI
Acute pericarditis (Correct answer)
Pulmonary embolism
Aortic dissection

Correct answer: Acute pericarditis

Diffuse ST elevation with PR depression and a friction rub is characteristic of acute pericarditis.

Question 79: A post-operative patient has a sudden drop in blood pressure, tachycardia, and cool clammy skin. Which type of shock is most likely?

Cardiogenic shock from tamponade
Hypovolemic shock (Correct answer)
Anaphylactic shock
Neurogenic shock

Correct answer: Hypovolemic shock

Hemorrhage causing hypovolemia presents with hypotension, tachycardia, and cool clammy skin.

Question 80: Long QT syndrome predisposes a patient to which potentially fatal dysrhythmia?

Torsades de pointes (Correct answer)
Accelerated idioventricular rhythm
Complete heart block
Paroxysmal atrial fibrillation

Correct answer: Torsades de pointes

A prolonged QT interval represents delayed ventricular repolarization, creating a vulnerable window during which a premature beat can trigger torsades de pointes.

Question 81: A widened alveolar-arterial (A-a) oxygen gradient with hypoxemia suggests which mechanism?

Low inspired oxygen concentration
High altitude exposure
Ventilation-perfusion mismatch or shunt (Correct answer)
Pure hypoventilation

Correct answer: Ventilation-perfusion mismatch or shunt

A widened A-a gradient indicates a gas-exchange problem such as V/Q mismatch, shunt, or diffusion impairment.

Question 82: Which finding is an absolute contraindication to fibrinolytic therapy?

Recent ischemic stroke within 3 months (Correct answer)
Current anticoagulant use
Age over 75
Controlled hypertension

Correct answer: Recent ischemic stroke within 3 months

Recent ischemic stroke within 3 months is an absolute contraindication due to high bleeding/conversion risk.

Question 83: A patient develops auto-PEEP (intrinsic PEEP). Which ventilator change most directly addresses it?

Decrease respiratory rate to lengthen expiratory time (Correct answer)
Increase set PEEP above auto-PEEP only
Increase inspiratory flow to extremes
Increase tidal volume

Correct answer: Decrease respiratory rate to lengthen expiratory time

Lowering the rate (and thus extending expiratory time) allows fuller exhalation, reducing air trapping.

Question 84: After IV tPA administration for ischemic stroke, what is the recommended blood pressure goal to reduce hemorrhagic risk?

Below 140/90 mmHg
Above 200/110 mmHg
Below 220/120 mmHg
Below 180/105 mmHg (Correct answer)

Correct answer: Below 180/105 mmHg

Post-tPA blood pressure should be kept below 180/105 mmHg to limit hemorrhagic transformation.

Question 85: Which electrolyte abnormality is the most dangerous complication of aggressive insulin therapy in DKA management?

Hypernatremia
Hypokalemia (Correct answer)
Hypercalcemia
Hyperphosphatemia

Correct answer: Hypokalemia

Insulin shifts potassium intracellularly, and patients with DKA are already total-body potassium depleted; hypokalemia can cause fatal cardiac arrhythmias.

Question 86: Which validated tool is recommended by the Society of Critical Care Medicine (SCCM) for assessing pain in non-verbal ICU patients?

FLACC Scale
Behavioral Pain Scale (BPS) (Correct answer)
Richmond Agitation-Sedation Scale
Glasgow Coma Scale

Correct answer: Behavioral Pain Scale (BPS)

The Behavioral Pain Scale (BPS) is a validated tool for assessing pain in non-verbal, mechanically ventilated ICU patients.

Question 87: What is the recommended endotracheal tube cuff pressure range to prevent both aspiration and tracheal mucosal injury?

50–60 cm H2O
20–30 cm H2O (Correct answer)
5–10 cm H2O
35–45 cm H2O

Correct answer: 20–30 cm H2O

Cuff pressures of 20–30 cm H2O seal the airway while avoiding ischemic mucosal damage.

Question 88: Oxygen delivery (DO2) to the tissues depends primarily on cardiac output and:

Heart rate alone
Arterial oxygen content (Correct answer)
Systemic vascular resistance
Central venous pressure

Correct answer: Arterial oxygen content

DO2 equals cardiac output multiplied by arterial oxygen content.

Question 89: Which lab value is most specific for myocardial cell injury?

Troponin I (Correct answer)
Myoglobin
CK total
LDH

Correct answer: Troponin I

Troponin I is the most cardiac-specific and sensitive marker of myocardial injury.

Question 90: A patient's rhythm strip shows an irregularly irregular ventricular response, absent distinct P waves, and an estimated atrial activity rate of 400–600 bpm. What is this rhythm?

Atrial flutter
Junctional tachycardia
Atrial fibrillation (Correct answer)
Multifocal atrial tachycardia

Correct answer: Atrial fibrillation

Atrial fibrillation is characterized by chaotic atrial activity at 400–600 bpm, absent organized P waves, and an irregularly irregular ventricular response.

Question 91: Which intervention is most appropriate for a patient with symptomatic bradycardia unresponsive to atropine?

Vagal maneuvers
Synchronized cardioversion
Administer beta-blocker
Transcutaneous pacing (Correct answer)

Correct answer: Transcutaneous pacing

Transcutaneous pacing is the next step when atropine fails to treat symptomatic bradycardia.

Question 92: When assessing renal function, a normal BUN-to-creatinine ratio is as:

< 5:1
> 20:1
> 5:1
< 20:1 (Correct answer)

Correct answer: < 20:1

The BUN-to-creatinine ratio is a diagnostic tool used to assess renal function and differentiate causes of kidney injury. A normal ratio typically falls below 20:1, often ranging from 10:1 to 15:1. Ratios significantly higher than this can indicate prerenal causes like dehydration, while a normal ratio with elevated BUN and creatinine suggests intrinsic kidney damage.

Question 93: Which intervention is most important for reducing ventilator-associated complications in a septic ARDS patient?

Avoiding PEEP entirely
Routine deep sedation with paralysis
High tidal volumes to improve oxygenation
Low tidal volume lung-protective ventilation (6 mL/kg) (Correct answer)

Correct answer: Low tidal volume lung-protective ventilation (6 mL/kg)

Low tidal volume ventilation at about 6 mL/kg ideal body weight reduces lung injury in ARDS.

Question 94: A competent adult patient signs a legal document that names a specific person to make healthcare decisions on their behalf ONLY if they become incapacitated and are unable to speak for themselves. This document is known as a:

Living Will
Durable Power of Attorney for Health Care (Correct answer)
Do Not Resuscitate (DNR) Order
Provider Orders for Life-Sustaining Treatment (POLST)

Correct answer: Durable Power of Attorney for Health Care

A Durable Power of Attorney for Health Care (also called a healthcare proxy) is a legal document that appoints a specific agent to make medical decisions for a person if they lose decision-making capacity. A Living Will specifies treatment preferences, a POLST is a medical order, and a DNR is a specific order to withhold CPR.

Question 95: A patient with a left middle cerebral artery stroke is most likely to exhibit which deficit?

Cerebellar ataxia only
Right-sided hemiparesis and aphasia (Correct answer)
Bilateral lower extremity weakness
Left-sided neglect

Correct answer: Right-sided hemiparesis and aphasia

A left MCA stroke typically causes right-sided weakness and aphasia since language is usually left-dominant.

Question 96: A septic patient develops new confusion, increased respiratory rate, and a SBP of 88 mmHg. Using qSOFA, how many criteria are met?

3 (Correct answer)
2
0
1

Correct answer: 3

Altered mentation, RR ≥22, and SBP ≤100 are all three qSOFA criteria.

Question 97: A patient with blunt abdominal trauma has received 12 units of packed red blood cells, 8 units of fresh frozen plasma, and 2 units of platelets. The nurse notes the development of a prolonged QT interval on the cardiac monitor and new-onset muscle tremors. Which electrolyte imbalance should the nurse suspect?

Hyponatremia
Hypermagnesemia
Hypocalcemia (Correct answer)
Hyperkalemia

Correct answer: Hypocalcemia

Blood products are preserved with citrate, which acts as an anticoagulant by binding to calcium. During massive transfusion, the liver's ability to metabolize citrate can be overwhelmed, leading to a rapid decrease in ionized calcium levels (hypocalcemia). Clinical signs of hypocalcemia include muscle tremors, a prolonged QT interval, and myocardial depression.

Question 98: A nurse caring for a stroke patient should screen for which complication before allowing oral intake?

Hyperglycemia
Dysphagia (Correct answer)
Atrial fibrillation
Deep vein thrombosis

Correct answer: Dysphagia

A swallow screen detects dysphagia, preventing aspiration in stroke patients.

Question 99: A patient with an acute MI develops a new harsh holosystolic murmur and pulmonary edema 3 days post-infarction. What complication is most likely?

Ventricular aneurysm
Pericarditis
Atrial fibrillation
Papillary muscle rupture (Correct answer)

Correct answer: Papillary muscle rupture

A new holosystolic murmur with acute pulmonary edema post-MI suggests papillary muscle rupture causing acute mitral regurgitation.

Question 100: Which clinical sign best indicates readiness to begin weaning from mechanical ventilation?

Hemodynamic instability requiring vasopressors
Resolution of the underlying cause with adequate oxygenation on minimal support (Correct answer)
A spontaneous rate over 35
FiO2 requirement above 60%

Correct answer: Resolution of the underlying cause with adequate oxygenation on minimal support

Weaning readiness requires that the precipitating problem has improved and gas exchange is adequate on low support.

Question 101: A patient presents with crushing substernal chest pain and ST-segment elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Left circumflex artery
Left main coronary artery
Left anterior descending artery
Right coronary artery (Correct answer)

Correct answer: Right coronary artery

ST elevation in II, III, and aVF indicates an inferior wall MI, typically caused by right coronary artery occlusion.

Question 102: Which ventilator mode delivers a preset pressure with a decelerating flow pattern and a set rate, often used to limit barotrauma?

Pressure-control ventilation (Correct answer)
Volume-control ventilation
CPAP
Pressure-support ventilation

Correct answer: Pressure-control ventilation

Pressure-control ventilation delivers a targeted pressure with decelerating flow, capping airway pressure to limit barotrauma.

Question 103: Osmotic diuretics include which of the following medications? <br> I. Mannitol <br> II. Furosemide <br> III. Ethacrynic acid

I (Correct answer)
III
I and III
I and II

Correct answer: I

Osmotic diuretics work by increasing the osmolality of the glomerular filtrate, which in turn inhibits water reabsorption in the renal tubules, leading to increased urine output. Mannitol is the classic example of an osmotic diuretic, commonly used to reduce intracranial or intraocular pressure. Furosemide and ethacrynic acid, on the other hand, are loop diuretics with a different mechanism of action.

Question 104: Which rhythm is non-perfusing and requires immediate defibrillation?

Ventricular fibrillation (Correct answer)
First-degree AV block
Sinus tachycardia
Atrial fibrillation

Correct answer: Ventricular fibrillation

Ventricular fibrillation produces no effective cardiac output and must be defibrillated immediately.

Question 105: Which medication is given to reduce the risk of poor outcomes from cerebral vasospasm after subarachnoid hemorrhage?

Labetalol
Phenytoin
Nimodipine (Correct answer)
Mannitol

Correct answer: Nimodipine

Nimodipine, a calcium channel blocker, improves neurologic outcomes after SAH-related vasospasm.

Question 106: Which intervention is part of the ventilator bundle to prevent ventilator-associated pneumonia?

Change the ventilator circuit every 8 hours
Keep the patient flat
Elevate the head of the bed 30–45 degrees (Correct answer)
Routine saline lavage with every suction

Correct answer: Elevate the head of the bed 30–45 degrees

Head-of-bed elevation reduces aspiration risk and is a core VAP prevention measure.

Question 107: A patient with obstructive lung disease on the ventilator develops worsening hypotension shortly after intubation. What is the most likely cause?

Sepsis
Dynamic hyperinflation with auto-PEEP reducing venous return (Correct answer)
Acute hemorrhage
Anaphylaxis

Correct answer: Dynamic hyperinflation with auto-PEEP reducing venous return

Air trapping raises intrathoracic pressure, impeding venous return and causing hypotension; a brief disconnect can confirm and relieve it.

Question 108: The two guideline biochemical operators that are discharged from the endothelium of blood vessels and work to diminish blood flow to destinations of harm and preserve blood volume are:

Fibrogenin and prothrombin
Thromboxane A2 and endothelin (Correct answer)
Thrombin and prothrombin
Serotonin and collagen

Correct answer: Thromboxane A2 and endothelin

Thromboxane A2 (TXA2) is a potent vasoconstrictor and platelet aggregator released by activated platelets, contributing to clot formation and local vasoconstriction. Endothelin is a powerful vasoconstrictor released by endothelial cells in response to injury. Both substances work synergistically to diminish blood flow to sites of harm, thereby helping to preserve blood volume and promote hemostasis.

Question 109: A patient with end-stage renal disease misses dialysis and has peaked T waves on ECG. What is the priority treatment?

Normal saline bolus
Oral potassium supplement
Furosemide alone
IV calcium gluconate (Correct answer)

Correct answer: IV calcium gluconate

Peaked T waves indicate hyperkalemia, and IV calcium gluconate stabilizes the cardiac membrane immediately.

Question 110: A critical care nurse is evaluating laboratory results to determine the cause of a patient's acute kidney injury (AKI). Which set of findings is most consistent with a prerenal cause, such as hypovolemia?

Presence of muddy brown casts in urine, urine sodium > 40 mEq/L
Urine sodium < 20 mEq/L, BUN:Creatinine ratio > 20:1 (Correct answer)
BUN:Creatinine ratio of 10:1, FENa > 2%
Urine sodium > 40 mEq/L, FENa > 2%

Correct answer: Urine sodium < 20 mEq/L, BUN:Creatinine ratio > 20:1

In prerenal AKI, the kidneys are responding to decreased perfusion by avidly conserving sodium and water. This results in a low urine sodium concentration (<20 mEq/L), a high BUN to creatinine ratio (>20:1) due to passive reabsorption of urea with water, and a fractional excretion of sodium (FENa) typically less than 1%.

Question 111: A ventilated patient becomes acutely hypotensive with distended neck veins, absent breath sounds on one side, and tracheal deviation. What is the priority intervention?

Immediate needle decompression for tension pneumothorax (Correct answer)
Obtain a chest x-ray before acting
Administer a fluid bolus and reassess
Increase PEEP

Correct answer: Immediate needle decompression for tension pneumothorax

These signs indicate tension pneumothorax, a life threat requiring immediate decompression, not imaging delay.

Question 112: Cushing's triad, a late sign of increased ICP, consists of which combination?

Hypertension with widening pulse pressure, bradycardia, and irregular respirations (Correct answer)
Hypotension, tachycardia, and tachypnea
Hypotension, bradycardia, and apnea
Fever, tachycardia, and hypertension

Correct answer: Hypertension with widening pulse pressure, bradycardia, and irregular respirations

Cushing's triad is widening pulse pressure (rising systolic), bradycardia, and irregular respirations.

Question 113: Janice is a Type I diabetic who was admitted to the unit after losing consciousness due to a severe hypoglycemia episode. She claims to have experienced numerous episodes of hypoglycemia, but she no longer seems to be able to predict when they will occur. <br> What do you call this phenomenon?

Hypoglycemia tolerance
Hypoglycemia unawareness (Correct answer)
Hypoglycemia latency
Hypoglycemia neurosis

Correct answer: Hypoglycemia unawareness

Hypoglycemia unawareness is a condition where individuals with diabetes, especially Type 1, lose the ability to recognize the typical warning signs of low blood sugar. This phenomenon occurs due to repeated episodes of hypoglycemia, which can blunt the body's counter-regulatory responses, leading to a lack of symptoms like shakiness or sweating. This makes it difficult for patients to intervene before severe hypoglycemia develops.

Question 114: A trauma patient on massive transfusion develops oozing from IV sites and mucous membranes. Which condition should be suspected?

Disseminated intravascular coagulation (Correct answer)
Von Willebrand disease
Hemophilia A
Vitamin K deficiency

Correct answer: Disseminated intravascular coagulation

Diffuse bleeding from multiple sites during major trauma suggests disseminated intravascular coagulation (DIC).

Question 115: A persistently low SvO2 (45%) most likely reflects:

A wedged catheter
Sepsis with impaired extraction
Excess supplemental oxygen
Increased oxygen extraction from inadequate delivery (Correct answer)

Correct answer: Increased oxygen extraction from inadequate delivery

Low SvO2 indicates tissues are extracting more oxygen because delivery is inadequate.

Question 116: The nurse is caring for a patient on mechanical ventilation when the low-pressure alarm sounds. The nurse assesses the patient and finds them with a decreased level of consciousness and diminished breath sounds on the left side. Which of the following is the most likely cause?

There is a mucus plug in the mainstem bronchus.
The patient has developed a tension pneumothorax.
The ventilator tubing has become disconnected from the endotracheal tube. (Correct answer)
The patient is biting the endotracheal tube.

Correct answer: The ventilator tubing has become disconnected from the endotracheal tube.

A low-pressure alarm indicates a loss of pressure in the ventilator circuit. The most common cause is a leak or disconnection somewhere between the ventilator and the patient's airway, such as the ventilator tubing becoming disconnected from the endotracheal tube. Mucus plugs, biting the tube, and tension pneumothorax would all cause a HIGH-pressure alarm due to increased resistance or decreased compliance.

Question 117: Damage to or illness of the adrenal cortex's zona glomerulosa is likely to cause electrolyte imbalance due to dysfunction of:

Cortisol
Aldosterone (Correct answer)
Calcitonin
Vasopressin

Correct answer: Aldosterone

The zona glomerulosa is the outermost layer of the adrenal cortex, responsible for producing mineralocorticoids, primarily aldosterone. Aldosterone's main function is to regulate electrolyte balance by promoting sodium reabsorption and potassium excretion in the kidneys. Therefore, damage to this zone directly impairs aldosterone production, leading to significant electrolyte imbalances.

Question 118: A patient is diagnosed with brain death. Which finding is consistent with this diagnosis?

Decorticate posturing to pain
Reactive pupils to light
Absent brainstem reflexes including no corneal or gag response (Correct answer)
Spontaneous respirations on apnea testing

Correct answer: Absent brainstem reflexes including no corneal or gag response

Brain death requires absence of all brainstem reflexes, including corneal, gag, and pupillary responses.

Question 119: A 25-year-old patient with a C4 spinal cord injury is hypotensive with a blood pressure of 82/46 mmHg and a heart rate of 50 bpm. The skin is warm and dry. Which type of shock is most consistent with this clinical presentation?

Anaphylactic Shock
Hypovolemic Shock
Neurogenic Shock (Correct answer)
Cardiogenic Shock

Correct answer: Neurogenic Shock

Neurogenic shock is characterized by hypotension due to massive vasodilation and bradycardia due to the loss of sympathetic nervous system tone and unopposed vagal (parasympathetic) activity. The presence of hypotension combined with a low heart rate and warm, dry skin is the classic presentation, distinguishing it from other forms of shock that typically involve a compensatory tachycardia.

Question 120: A critical care nurse ensures that a patient fully understands the risks, benefits, and alternatives to a proposed invasive procedure before the patient signs the consent form. This action primarily demonstrates which ethical principle?

Beneficence
Justice
Autonomy (Correct answer)
Non-maleficence

Correct answer: Autonomy

Autonomy is the ethical principle that recognizes a patient's right to make their own informed decisions about their healthcare. By ensuring the patient has all the necessary information to make a choice, the nurse is directly supporting their right to self-determination. Beneficence is doing good, non-maleficence is avoiding harm, and justice relates to fairness in care delivery.

Question 121: A patient in septic shock remains hypotensive after adequate fluid resuscitation. Which vasopressor is the recommended first-line agent?

Dopamine
Norepinephrine (Correct answer)
Phenylephrine
Vasopressin

Correct answer: Norepinephrine

Norepinephrine is the first-line vasopressor for septic shock per current guidelines.

Question 122: A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg and a mean arterial pressure (MAP) of 70 mmHg. The nurse calculates the cerebral perfusion pressure (CPP) and recognizes the need for which immediate intervention?

Administering an antihypertensive agent to lower MAP.
Performing a deep suctioning of the endotracheal tube.
Administering a prescribed vasopressor to increase MAP. (Correct answer)
Increasing the head of the bed to 90 degrees.

Correct answer: Administering a prescribed vasopressor to increase MAP.

The cerebral perfusion pressure (CPP) is calculated as MAP - ICP. In this case, CPP is 70 - 22 = 48 mmHg. The goal CPP for TBI patients is typically 60-70 mmHg. A CPP below 50 mmHg can lead to cerebral ischemia. The most direct way to improve a low CPP in this scenario is to increase the MAP using a vasopressor, as the ICP is already elevated. Lowering MAP would worsen cerebral ischemia. Increasing the head of the bed to 90 degrees could decrease MAP and CPP. Deep suctioning can transiently increase ICP.

Question 123: Which opioid is most commonly used for analgesia in mechanically ventilated ICU patients due to its titratability and short duration of action?

Meperidine
Fentanyl (Correct answer)
Morphine
Codeine

Correct answer: Fentanyl

Fentanyl is preferred in mechanically ventilated ICU patients due to its rapid onset, short duration of action, and ease of titration.

Question 124: Which condition causes hypoxemia that does NOT correct with 100% supplemental oxygen?

V/Q mismatch
Hypoventilation
Low FiO2
Intrapulmonary shunt (Correct answer)

Correct answer: Intrapulmonary shunt

True shunt allows blood to bypass ventilated alveoli, so it responds poorly to increased FiO2.

Question 125: A patient with a hypertensive emergency has a BP of 230/130 with signs of acute end-organ damage. What is the treatment goal in the first hour?

Reduce mean arterial pressure by no more than about 20-25% (Correct answer)
Normalize BP immediately to 120/80
Increase BP to improve perfusion
Withhold all antihypertensives

Correct answer: Reduce mean arterial pressure by no more than about 20-25%

MAP should be lowered gradually by no more than 20-25% in the first hour to avoid organ hypoperfusion.

Question 126: Which finding best indicates effective fluid resuscitation in a patient with septic shock?

Heart rate of 120 bpm
Mean arterial pressure of 55 mmHg
Decreasing level of consciousness
Urine output greater than 0.5 mL/kg/hr (Correct answer)

Correct answer: Urine output greater than 0.5 mL/kg/hr

Adequate urine output indicates restored perfusion to the kidneys and effective resuscitation.

Question 127: A patient with an acute ischemic stroke is found to be outside the treatment window for thrombolysis. The neurologist has ordered permissive hypertension. The nurse understands the rationale for this order is to:

Reduce cerebral edema and lower intracranial pressure.
Improve blood flow to the ischemic penumbra. (Correct answer)
Prevent hemorrhagic conversion of the stroke.
Prepare the patient for emergent craniotomy.

Correct answer: Improve blood flow to the ischemic penumbra.

In an acute ischemic stroke, the area surrounding the core infarct, known as the ischemic penumbra, contains brain tissue that is at risk but still viable. Autoregulation is often impaired, making blood flow to this area passively dependent on systemic blood pressure. Allowing a higher blood pressure (permissive hypertension) helps maintain cerebral perfusion to this salvageable penumbral tissue, potentially reducing the final infarct size. Aggressively lowering blood pressure could worsen the ischemia.

Question 128: Multiple organ dysfunction syndrome (MODS) is best defined as:

Failure of a single organ in a critically ill patient
Progressive dysfunction of two or more organ systems requiring intervention to maintain homeostasis (Correct answer)
Chronic organ failure unrelated to acute illness
Reversible dysfunction of one organ within 24 hours

Correct answer: Progressive dysfunction of two or more organ systems requiring intervention to maintain homeostasis

MODS involves altered function of two or more organ systems requiring support.

Question 129: When acute deterioration occurs and the cause is unclear, what is a key immediate step in the DOPE approach?

Wait for a stat chest x-ray
Disconnect from the ventilator and manually bag with 100% oxygen (Correct answer)
Increase sedation
Increase the set PEEP

Correct answer: Disconnect from the ventilator and manually bag with 100% oxygen

Manual bagging with 100% oxygen distinguishes patient problems from equipment failure and supports oxygenation.

Question 130: Which acid-base disturbance is most characteristic of chronic kidney disease?

Respiratory alkalosis
Respiratory acidosis
Metabolic acidosis (Correct answer)
Metabolic alkalosis

Correct answer: Metabolic acidosis

The failing kidney cannot excrete hydrogen ions or regenerate bicarbonate, causing metabolic acidosis.

Question 131: The initial recommended crystalloid fluid bolus for sepsis-induced hypoperfusion is at least:

5 mL/kg
50 mL/kg
30 mL/kg (Correct answer)
10 mL/kg

Correct answer: 30 mL/kg

At least 30 mL/kg of IV crystalloid is recommended within the first 3 hours.

Question 132: Which corticosteroid is recommended by current Surviving Sepsis guidelines for refractory septic shock (vasopressor-dependent)?

Dexamethasone 10 mg IV q6h
Hydrocortisone 200 mg/day (continuous or divided doses) (Correct answer)
Prednisone 60 mg PO daily
Methylprednisolone 1 g IV daily

Correct answer: Hydrocortisone 200 mg/day (continuous or divided doses)

IV hydrocortisone 200 mg/day is recommended for adult septic shock patients who remain hemodynamically unstable despite adequate fluid resuscitation and vasopressor therapy.

Question 133: A normal wedge pressure, elevated pulmonary artery pressures, and indications of right ventricular failure are all assessed by the nurse. Which condition is this most likely to indicate?

Cardiac-tamponade'
Myocardial infarction
Pulmonary embolism (Correct answer)
Left ventricular failure

Correct answer: Pulmonary embolism

This clinical scenario strongly suggests a pulmonary embolism (PE). A PE obstructs pulmonary blood flow, leading to increased pulmonary vascular resistance and elevated pulmonary artery pressures. This increased workload can cause acute right ventricular failure, while a normal wedge pressure indicates that the left side of the heart is not the primary source of the problem.

Question 134: Which finding suggests that a trauma patient is progressing from compensated to decompensated shock?

Improving mental status
Narrowing pulse pressure with falling blood pressure (Correct answer)
Rising blood pressure
Slowing heart rate to normal

Correct answer: Narrowing pulse pressure with falling blood pressure

A narrowing pulse pressure followed by falling blood pressure signals failing compensation and decompensated shock.

Question 135: What is the priority intervention for a patient in pulseless ventricular tachycardia?

Administer adenosine
Vagal maneuvers
Synchronized cardioversion
Immediate defibrillation (Correct answer)

Correct answer: Immediate defibrillation

Pulseless VT is a shockable rhythm requiring immediate defibrillation.

Question 136: Which anticoagulant requires monitoring with anti-Xa levels rather than aPTT for accurate dosing assessment?

Unfractionated heparin (continuous infusion)
Warfarin
Argatroban
Low-molecular-weight heparin (LMWH) (Correct answer)

Correct answer: Low-molecular-weight heparin (LMWH)

LMWH (e.g., enoxaparin) does not reliably prolong aPTT and requires anti-Xa level monitoring, especially in patients with renal impairment, obesity, or pregnancy.

Question 137: Withdrawal of life-sustaining treatment from a terminally ill patient is ethically permissible when:

The nurse believes recovery is unlikely
It aligns with the patient's autonomous, informed wishes (Correct answer)
The family finds care too expensive
The bed is needed for another patient

Correct answer: It aligns with the patient's autonomous, informed wishes

Withdrawal is justified when it honors the patient's informed and autonomous decision.

Question 138: A trauma patient presents with hypotension, jugular venous distention, and muffled heart sounds. Which condition is most likely?

Hemorrhagic shock
Cardiac tamponade (Correct answer)
Tension pneumothorax
Pulmonary embolism

Correct answer: Cardiac tamponade

Beck's triad (hypotension, JVD, muffled heart sounds) is the classic presentation of cardiac tamponade.

Question 139: The underlying pathophysiology that drives MODS in sepsis is primarily:

Pure cardiogenic pump failure
A localized bacterial abscess
Dysregulated systemic inflammation and microcirculatory failure (Correct answer)
Isolated electrolyte imbalance

Correct answer: Dysregulated systemic inflammation and microcirculatory failure

Uncontrolled inflammation and impaired microcirculation cause widespread organ injury.

Question 140: Which sign in a critically ill patient most strongly suggests hypoglycemia rather than another cause of altered mentation?

Fever and rash
Diaphoresis, tremor, and confusion that resolves with glucose (Correct answer)
Bradycardia and hypothermia
Polyuria and dehydration

Correct answer: Diaphoresis, tremor, and confusion that resolves with glucose

Adrenergic and neuroglycopenic symptoms such as sweating, tremor, and confusion that reverse with glucose are hallmark hypoglycemia findings.

Question 141: Cultural competence in ethical practice requires the nurse to:

Apply personal beliefs to all patients
Ignore cultural differences for consistency
Respect the patient's cultural and religious values in care decisions (Correct answer)
Assume all patients share mainstream values

Correct answer: Respect the patient's cultural and religious values in care decisions

Ethical, patient-centered care incorporates respect for cultural and religious values.

Question 142: Which component of the ABCDEF bundle specifically addresses family engagement and empowerment?

B — Breathing trials
A — Assess and manage pain
F — Family engagement and empowerment (Correct answer)
D — Delirium assessment

Correct answer: F — Family engagement and empowerment

The 'F' in the ABCDEF bundle stands for Family Engagement and Empowerment, recognizing family as partners in care to reduce patient distress and delirium.

Question 143: What is the primary goal when managing a patient with acute respiratory distress syndrome on the ventilator?

Low tidal volume lung-protective ventilation (Correct answer)
Minimizing PEEP
Permissive hyperoxia
High tidal volumes to maximize oxygenation

Correct answer: Low tidal volume lung-protective ventilation

Low tidal volume (6 mL/kg) ventilation reduces ventilator-induced lung injury in ARDS.

Question 144: A patient receiving amiodarone develops blue-gray skin discoloration and thyroid dysfunction. These are examples of which type of adverse effects?

Long-term toxicity effects (Correct answer)
First-dose effects
Anaphylactic reactions
Acute infusion reactions

Correct answer: Long-term toxicity effects

Blue-gray skin discoloration and thyroid dysfunction (hypo- or hyperthyroidism) are well-known long-term toxicities of amiodarone due to its iodine content and tissue accumulation.

Question 145: What is the definitive treatment for thrombotic thrombocytopenic purpura?

Platelet transfusion
High-dose heparin
Splenectomy as first line
Plasma exchange (plasmapheresis) (Correct answer)

Correct answer: Plasma exchange (plasmapheresis)

Plasma exchange removes autoantibodies and replaces ADAMTS13, and is the urgent treatment of choice for TTP.

Question 146: Which value best reflects left ventricular preload?

Central venous pressure
Pulmonary capillary wedge pressure (Correct answer)
Mean arterial pressure
Systemic vascular resistance

Correct answer: Pulmonary capillary wedge pressure

PCWP estimates left atrial and left ventricular end-diastolic pressure, reflecting LV preload.

Question 147: Sodium bicarbonate infusion should NOT be used to treat metabolic acidosis caused by which condition?

Severe hyperchloremic acidosis from normal saline
Ingestion of methanol or ethylene glycol
Bicarbonate-wasting renal tubular acidosis
Diabetic ketoacidosis (DKA) (Correct answer)

Correct answer: Diabetic ketoacidosis (DKA)

In DKA, sodium bicarbonate is generally not recommended because it does not improve outcomes and may worsen hypokalemia, paradoxical CSF acidosis, and delay ketone clearance.

Question 148: Which ECG finding most strongly differentiates ventricular tachycardia from supraventricular tachycardia with aberrant conduction?

AV dissociation visible on the rhythm strip (Correct answer)
Heart rate greater than 150 bpm
Hemodynamic instability in the patient
Left bundle branch block morphology of the QRS

Correct answer: AV dissociation visible on the rhythm strip

AV dissociation — independent P waves unrelated to QRS complexes — is pathognomonic for ventricular tachycardia and cannot occur with SVT.

Question 149: Which measure best evaluates the adequacy of resuscitation and guides ongoing therapy in sepsis?

Serial lactate clearance (Correct answer)
Single baseline white blood cell count
One-time blood pressure reading
Daily weight only

Correct answer: Serial lactate clearance

Trending lactate to assess clearance reflects improving perfusion and guides resuscitation.

Question 150: Which waveform component on a central venous pressure (CVP) tracing corresponds to atrial contraction?

v wave
a wave (Correct answer)
x descent
c wave

Correct answer: a wave

The a wave reflects atrial contraction at end-diastole.

Question 151: Which intervention helps prevent contrast-induced nephropathy in an at-risk patient?

Administering a loop diuretic before contrast
IV hydration before and after contrast (Correct answer)
Giving potassium supplements
Withholding all fluids

Correct answer: IV hydration before and after contrast

Adequate IV hydration maintains renal perfusion and is the primary preventive measure for contrast nephropathy.

CCRN (Adult) Certification Exam

The CCRN (Adult) certification exam, administered by the AACN, validates a registered nurse’s knowledge and clinical judgment in acute and critical care nursing for adult patients.

150

Questions

180 min

Time Limit

66%

To Pass

Checking for saved progress...

Exam Rules

You can skip questions and return to them later
Flag questions for review before submitting
No feedback shown until you submit the entire exam
Unanswered questions count as wrong — answer everything
10 pretest questions are mixed in and don't affect your score
Timer auto-submits when time runs out
Your progress is auto-saved every 30 seconds