Progressive Care RN A Exam Summer
2026/2027 | 120 Questions with Answers &
Rationales | PCCN Prep | Pass Guaranteed
SECTION 1: CARDIOVASCULAR (Questions 1-30)
Question 1
A 62-year-old male presents with chest pressure, diaphoresis, and nausea. ECG
shows ST-segment elevation in leads V1-V4. Troponin I is 8.5 ng/mL (normal
<0.04). Which diagnosis is most appropriate?
• A) NSTEMI
• B) STEMI
• C) Unstable angina
• D) Non-cardiac chest pain
Rationale: STEMI is diagnosed by ST-segment elevation in contiguous leads (V1-
V4 indicate anterior wall involvement) with elevated troponin. NSTEMI (A) shows
ST depression or T-wave inversion without ST elevation. Unstable angina (C) has
similar symptoms but no troponin elevation. Non-cardiac pain (D) would not show
these ECG changes or troponin rise. Per 2026 ACC/AHA guidelines, anterior
STEMI requires emergent reperfusion. PCCN Safety: Door-to-balloon time <90
minutes, door-to-needle <30 minutes if PCI unavailable.
Question 2
A patient with inferior STEMI (ST elevation in II, III, aVF) develops hypotension,
clear lung sounds, and jugular venous distension. Which complication is most
likely?
• A) Cardiogenic shock from left ventricular failure
• B) Right ventricular infarction
• C) Papillary muscle rupture
, • D) Ventricular septal defect
Rationale: Inferior STEMI with hypotension, clear lungs, and JVD is the classic
triad for right ventricular infarction (RCA occlusion). RV infarction causes
decreased preload to the left ventricle. LV failure (A) causes pulmonary edema.
Papillary muscle rupture (C) causes acute MR with pulmonary edema. VSD (D)
causes a new holosystolic murmur and biventricular failure. PCCN Safety: Avoid
nitrates and diuretics in RV infarction—they worsen preload-dependent RV
function.
Question 3
A patient in cardiogenic shock has a cardiac index of 1.8 L/min/m², PCWP 24
mmHg, and SVR 1800 dynes/sec/cm⁵. Which hemodynamic profile is present?
• A) High-output failure
• B) Low-output, high-afterload (cold and wet)
• C) Low-output, low-afterload (warm and dry)
• D) High-output, low-afterload (warm and wet)
Rationale: CI < 2.2 L/min/m² indicates low output; PCWP >18 indicates "wet"
(elevated filling pressures); SVR >1500 indicates high afterload. This is the classic
"cold and wet" profile of cardiogenic shock. High-output failure (A, D) shows CI
>2.5. "Warm and dry" (C) shows normal/low PCWP. PCCN Safety: Inotropes
(dobutamine) and afterload reduction (IABP, Impella) are indicated.
Question 4
An ECG rhythm strip shows irregularly irregular R-R intervals, no discernible P
waves, and narrow QRS complexes at a rate of 140 bpm. Which rhythm is present?
• A) Atrial flutter
• B) Atrial fibrillation with rapid ventricular response
• C) Sinus tachycardia
• D) Ventricular tachycardia
,Rationale: Irregularly irregular rhythm with absent P waves and fibrillatory waves
is diagnostic of atrial fibrillation. The rate of 140 indicates rapid ventricular
response. Atrial flutter (A) shows regular sawtooth flutter waves. Sinus tachycardia
(C) has regular P waves preceding each QRS. VT (D) has wide QRS complexes.
PCCN Safety: Rate control (diltiazem, amiodarone) or rhythm control
(cardioversion if unstable) per ACLS 2026.
Question 5
A patient with new-onset atrial fibrillation and a rate of 160 bpm becomes
hypotensive (SBP 78/52) with altered mental status. What is the priority
intervention?
• A) Administer diltiazem 15 mg IV push
• B) Administer metoprolol 5 mg IV
• C) Synchronized cardioversion at 100-200 J
• D) Administer amiodarone 150 mg IV over 10 minutes
Rationale: Unstable atrial fibrillation (hypotension, altered mental status, signs of
shock) requires immediate synchronized cardioversion (100-200 J biphasic). Rate-
control agents (A, B) are contraindicated in unstable patients as they worsen
hypotension. Amiodarone (D) is appropriate for stable patients or after
cardioversion. PCCN Safety: Synchronized shock avoids R-on-T phenomenon;
defibrillation pads placed anterior-posterior for AFib.
Question 6
An ECG shows progressive prolongation of the PR interval until a QRS complex is
dropped, then the cycle repeats. Which conduction abnormality is present?
• A) First-degree AV block
• B) Second-degree AV block Type I (Wenckebach)
• C) Second-degree AV block Type II (Mobitz II)
• D) Third-degree AV block
, Rationale: Wenckebach (Mobitz I) shows progressive PR prolongation until a
dropped beat, with the PR interval shortening after the dropped beat. First-degree
(A) shows constant PR >0.20 sec without dropped beats. Mobitz II (C) shows
constant PR with intermittent dropped beats. Third-degree (D) shows no
relationship between P waves and QRS complexes.
Question 7
A patient with Mobitz II second-degree AV block has a ventricular rate of 38 bpm,
BP 82/50, and reports dizziness. Which intervention is most appropriate?
• A) Atropine 0.5 mg IV push
• B) Transcutaneous pacing
• C) Dopamine infusion at 5 mcg/kg/min
• D) Observe and monitor
Rationale: Mobitz II with symptomatic bradycardia (hypotension, dizziness)
requires immediate transcutaneous pacing. Atropine is often ineffective for
infranodal blocks like Mobitz II and can worsen ischemia. Dopamine is second-
line if pacing unavailable. Observation is unsafe in symptomatic patient. PCCN
Safety: Prepare for transvenous pacing if TCP fails.
Question 8
A patient with anterior STEMI develops a new systolic murmur heard best at the
apex radiating to the axilla, along with pulmonary edema. What is the most likely
diagnosis?
• A) Ventricular septal rupture
• B) Papillary muscle rupture (mitral regurgitation)
• C) Free wall rupture
• D) Pericarditis
Rationale: Papillary muscle rupture (usually posteromedial in inferior STEMI, but
can occur anteriorly) causes acute severe mitral regurgitation—holosystolic
murmur at apex radiating to axilla, pulmonary edema, cardiogenic shock. VSD (A)
2026/2027 | 120 Questions with Answers &
Rationales | PCCN Prep | Pass Guaranteed
SECTION 1: CARDIOVASCULAR (Questions 1-30)
Question 1
A 62-year-old male presents with chest pressure, diaphoresis, and nausea. ECG
shows ST-segment elevation in leads V1-V4. Troponin I is 8.5 ng/mL (normal
<0.04). Which diagnosis is most appropriate?
• A) NSTEMI
• B) STEMI
• C) Unstable angina
• D) Non-cardiac chest pain
Rationale: STEMI is diagnosed by ST-segment elevation in contiguous leads (V1-
V4 indicate anterior wall involvement) with elevated troponin. NSTEMI (A) shows
ST depression or T-wave inversion without ST elevation. Unstable angina (C) has
similar symptoms but no troponin elevation. Non-cardiac pain (D) would not show
these ECG changes or troponin rise. Per 2026 ACC/AHA guidelines, anterior
STEMI requires emergent reperfusion. PCCN Safety: Door-to-balloon time <90
minutes, door-to-needle <30 minutes if PCI unavailable.
Question 2
A patient with inferior STEMI (ST elevation in II, III, aVF) develops hypotension,
clear lung sounds, and jugular venous distension. Which complication is most
likely?
• A) Cardiogenic shock from left ventricular failure
• B) Right ventricular infarction
• C) Papillary muscle rupture
, • D) Ventricular septal defect
Rationale: Inferior STEMI with hypotension, clear lungs, and JVD is the classic
triad for right ventricular infarction (RCA occlusion). RV infarction causes
decreased preload to the left ventricle. LV failure (A) causes pulmonary edema.
Papillary muscle rupture (C) causes acute MR with pulmonary edema. VSD (D)
causes a new holosystolic murmur and biventricular failure. PCCN Safety: Avoid
nitrates and diuretics in RV infarction—they worsen preload-dependent RV
function.
Question 3
A patient in cardiogenic shock has a cardiac index of 1.8 L/min/m², PCWP 24
mmHg, and SVR 1800 dynes/sec/cm⁵. Which hemodynamic profile is present?
• A) High-output failure
• B) Low-output, high-afterload (cold and wet)
• C) Low-output, low-afterload (warm and dry)
• D) High-output, low-afterload (warm and wet)
Rationale: CI < 2.2 L/min/m² indicates low output; PCWP >18 indicates "wet"
(elevated filling pressures); SVR >1500 indicates high afterload. This is the classic
"cold and wet" profile of cardiogenic shock. High-output failure (A, D) shows CI
>2.5. "Warm and dry" (C) shows normal/low PCWP. PCCN Safety: Inotropes
(dobutamine) and afterload reduction (IABP, Impella) are indicated.
Question 4
An ECG rhythm strip shows irregularly irregular R-R intervals, no discernible P
waves, and narrow QRS complexes at a rate of 140 bpm. Which rhythm is present?
• A) Atrial flutter
• B) Atrial fibrillation with rapid ventricular response
• C) Sinus tachycardia
• D) Ventricular tachycardia
,Rationale: Irregularly irregular rhythm with absent P waves and fibrillatory waves
is diagnostic of atrial fibrillation. The rate of 140 indicates rapid ventricular
response. Atrial flutter (A) shows regular sawtooth flutter waves. Sinus tachycardia
(C) has regular P waves preceding each QRS. VT (D) has wide QRS complexes.
PCCN Safety: Rate control (diltiazem, amiodarone) or rhythm control
(cardioversion if unstable) per ACLS 2026.
Question 5
A patient with new-onset atrial fibrillation and a rate of 160 bpm becomes
hypotensive (SBP 78/52) with altered mental status. What is the priority
intervention?
• A) Administer diltiazem 15 mg IV push
• B) Administer metoprolol 5 mg IV
• C) Synchronized cardioversion at 100-200 J
• D) Administer amiodarone 150 mg IV over 10 minutes
Rationale: Unstable atrial fibrillation (hypotension, altered mental status, signs of
shock) requires immediate synchronized cardioversion (100-200 J biphasic). Rate-
control agents (A, B) are contraindicated in unstable patients as they worsen
hypotension. Amiodarone (D) is appropriate for stable patients or after
cardioversion. PCCN Safety: Synchronized shock avoids R-on-T phenomenon;
defibrillation pads placed anterior-posterior for AFib.
Question 6
An ECG shows progressive prolongation of the PR interval until a QRS complex is
dropped, then the cycle repeats. Which conduction abnormality is present?
• A) First-degree AV block
• B) Second-degree AV block Type I (Wenckebach)
• C) Second-degree AV block Type II (Mobitz II)
• D) Third-degree AV block
, Rationale: Wenckebach (Mobitz I) shows progressive PR prolongation until a
dropped beat, with the PR interval shortening after the dropped beat. First-degree
(A) shows constant PR >0.20 sec without dropped beats. Mobitz II (C) shows
constant PR with intermittent dropped beats. Third-degree (D) shows no
relationship between P waves and QRS complexes.
Question 7
A patient with Mobitz II second-degree AV block has a ventricular rate of 38 bpm,
BP 82/50, and reports dizziness. Which intervention is most appropriate?
• A) Atropine 0.5 mg IV push
• B) Transcutaneous pacing
• C) Dopamine infusion at 5 mcg/kg/min
• D) Observe and monitor
Rationale: Mobitz II with symptomatic bradycardia (hypotension, dizziness)
requires immediate transcutaneous pacing. Atropine is often ineffective for
infranodal blocks like Mobitz II and can worsen ischemia. Dopamine is second-
line if pacing unavailable. Observation is unsafe in symptomatic patient. PCCN
Safety: Prepare for transvenous pacing if TCP fails.
Question 8
A patient with anterior STEMI develops a new systolic murmur heard best at the
apex radiating to the axilla, along with pulmonary edema. What is the most likely
diagnosis?
• A) Ventricular septal rupture
• B) Papillary muscle rupture (mitral regurgitation)
• C) Free wall rupture
• D) Pericarditis
Rationale: Papillary muscle rupture (usually posteromedial in inferior STEMI, but
can occur anteriorly) causes acute severe mitral regurgitation—holosystolic
murmur at apex radiating to axilla, pulmonary edema, cardiogenic shock. VSD (A)
