CCRN (Adult) Critical care certification
validating advanced knowledge managing
critically ill adult patients requiring intensive
monitoring and specialized interventions.
Domain 1: Cardiovascular – Hemodynamics & Arrhythmias (Questions 1-15)
1. A patient with septic shock has a pulmonary artery catheter in place.
Hemodynamic values: cardiac index (CI) 1.8 L/min/m², systemic vascular
resistance (SVR) 400 dyne·sec·cm⁻⁵, pulmonary artery occlusion pressure
(PAOP) 6 mm Hg. Which intervention should the nurse anticipate first?
A. Start norepinephrine infusion
B. Administer a 500 mL bolus of crystalloid
C. Begin dobutamine infusion
D. Increase the rate of mechanical ventilation
Correct Answer: B
Rationale: The patient has low PAOP (preload), low CI (low output), and low
SVR (vasodilation). In septic shock, initial resuscitation is fluid bolus (30 mL/kg)
to increase preload. Norepinephrine is added after fluids if hypotension persists.
2. A patient with an intra-aortic balloon pump (IABP) has a heart rate of 140
bpm (sinus tachycardia). The nurse notes that the IABP waveform shows
inflation at the dicrotic notch and deflation just before the next QRS complex.
What is the most appropriate action?
A. Increase the augmentation ratio to 1:2
B. Adjust the trigger mode to R-wave trigger
C. Administer a beta-blocker to slow the heart rate
D. Change the balloon catheter size
Correct Answer: C
Rationale: IABP timing is optimal at heart rates between 80-110 bpm.
Tachycardia (>120-130 bpm) reduces diastolic filling time and impairs balloon
effectiveness. Beta-blockers may be used to slow rate if not contraindicated.
Augmentation ratio change does not fix timing.
,3. A patient in the ICU has the following arterial blood gas (ABG) while on
mechanical ventilation: pH 7.48, PaCO2 30 mm Hg, HCO3 24 mEq/L. Which
ventilator adjustment is indicated?
A. Increase respiratory rate
B. Decrease tidal volume
C. Increase PEEP
D. Increase FiO2
Correct Answer: B
Rationale: The ABG shows respiratory alkalosis (high pH, low PaCO2, normal
HCO3). To reduce minute ventilation and increase PaCO2, decrease tidal volume
or respiratory rate. Option B (decrease tidal volume) is appropriate.
4. A patient with acute myocardial infarction develops a new systolic murmur,
hypotension, and pulmonary edema. The murmur is holosystolic, loudest at
the apex with radiation to the axilla. Which complication is most likely?
A. Acute mitral regurgitation due to papillary muscle rupture
B. Ventricular septal defect
C. Aortic stenosis
D. Pericarditis
Correct Answer: A
Rationale: Acute papillary muscle rupture after MI causes severe mitral
regurgitation, holosystolic murmur at the apex radiating to axilla, and abrupt
pulmonary edema. VSD murmur is harsh, best at left sternal border.
5. A patient’s pulmonary artery catheter shows: PAOP 22 mm Hg, cardiac
output 3.0 L/min, SVR 1800 dyne·sec·cm⁻⁵, and BP 90/60 mm Hg. Which
diagnosis is most consistent?
A. Distributive shock (sepsis)
B. Cardiogenic shock
C. Hypovolemic shock
D. Obstructive shock (PE)
Correct Answer: B
Rationale: Cardiogenic shock: elevated PAOP (>15-18), low cardiac output,
elevated SVR (compensatory vasoconstriction). Distributive shock has low SVR,
low PAOP initially.
Q6: A patient’s ECG shows pacing spikes without any QRS complexes following
,them. This indicates:
A. Loss of capture
B. Failure to sense
C. Proper sensing
D. Oversensing
Correct Answer: A
Rationale: Loss of capture occurs when the pacing stimulus fails to depolarize the
myocardium. Pacing spikes are seen but no QRS.
7. A patient in cardiogenic shock is on milrinone and norepinephrine. The
nurse notes worsening hypotension and a decrease in cardiac output. Which
additional medication is most appropriate?
A. Dobutamine
B. Levosimendan (not available in US – but maybe)
C. Vasopressin
D. Nitroprusside
Correct Answer: C
Rationale: Vasopressin can be added as a second-line vasopressor in refractory
shock. It does not have beta-adrenergic effects and may be helpful in combination.
8. A patient with massive pulmonary embolism has a BP of 70/40 mm Hg,
right ventricular dilation on echocardiogram, and a normal PAOP. The most
appropriate immediate intervention is:
A. IV unfractionated heparin alone
B. Thrombolytic therapy
C. Embolectomy
D. High-dose diuretics
Correct Answer: B
Rationale: Massive PE with hypotension and RV dysfunction is an indication for
thrombolytics (unless contraindicated). Heparin alone is insufficient. Embolectomy
if thrombolytics contraindicated.
9. A patient with atrial fibrillation and rapid ventricular response (HR 150)
has a BP of 85/50 mm Hg, chest pain, and altered mental status. The most
appropriate immediate intervention is:
A. IV metoprolol
B. Synchronized cardioversion
C. IV amiodarone
, D. IV digoxin
Correct Answer: B
Rationale: Unstable patient with tachycardia (hypotension, altered mental status,
chest pain) requires immediate synchronized cardioversion. Medication is for
stable patients.
10. A patient post-cardiac arrest has a Glasgow Coma Scale (GCS) of 4, no
brainstem reflexes, and myoclonus. Therapeutic hypothermia (TTM) was
initiated. Which finding after rewarming indicates poor neurological
prognosis?
A. Presence of pupillary light reflex
B. Status myoclonus at normothermia
C. Normal brain CT
D. Somatosensory evoked potentials (SSEP) present bilaterally
Correct Answer: B
Rationale: Status myoclonus (generalized, persistent myoclonus) within 48 hours
after cardiac arrest, after rewarming, is associated with poor neurological outcome.
Bilateral absent SSEP is also poor.
11. A patient with an Impella CP device has a mean arterial pressure (MAP)
of 55 mm Hg, a pulsatility index of 0.8 (low), and an increasing lactate. What
is the priority intervention?
A. Increase PEEP
B. Decrease Impella flow rate
C. Ensure adequate preload (IV fluids) and assess for cardiac tamponade or device
malposition
D. Administer a beta-blocker
Correct Answer: C
Rationale: Low MAP, low pulsatility, and rising lactate suggest inadequate
perfusion. Impella requires adequate preload; hypovolemia or tamponade reduces
flow. Assess and correct.
12. A patient with a pulmonary artery catheter has an oxygen saturation of
mixed venous blood (SvO2) of 50% (normal 60-75%). The cardiac output is
3.0 L/min. Which condition is most likely?
A. Low oxygen delivery (e.g., cardiogenic shock, severe anemia)
B. Sepsis with high output
C. Hypothermia
validating advanced knowledge managing
critically ill adult patients requiring intensive
monitoring and specialized interventions.
Domain 1: Cardiovascular – Hemodynamics & Arrhythmias (Questions 1-15)
1. A patient with septic shock has a pulmonary artery catheter in place.
Hemodynamic values: cardiac index (CI) 1.8 L/min/m², systemic vascular
resistance (SVR) 400 dyne·sec·cm⁻⁵, pulmonary artery occlusion pressure
(PAOP) 6 mm Hg. Which intervention should the nurse anticipate first?
A. Start norepinephrine infusion
B. Administer a 500 mL bolus of crystalloid
C. Begin dobutamine infusion
D. Increase the rate of mechanical ventilation
Correct Answer: B
Rationale: The patient has low PAOP (preload), low CI (low output), and low
SVR (vasodilation). In septic shock, initial resuscitation is fluid bolus (30 mL/kg)
to increase preload. Norepinephrine is added after fluids if hypotension persists.
2. A patient with an intra-aortic balloon pump (IABP) has a heart rate of 140
bpm (sinus tachycardia). The nurse notes that the IABP waveform shows
inflation at the dicrotic notch and deflation just before the next QRS complex.
What is the most appropriate action?
A. Increase the augmentation ratio to 1:2
B. Adjust the trigger mode to R-wave trigger
C. Administer a beta-blocker to slow the heart rate
D. Change the balloon catheter size
Correct Answer: C
Rationale: IABP timing is optimal at heart rates between 80-110 bpm.
Tachycardia (>120-130 bpm) reduces diastolic filling time and impairs balloon
effectiveness. Beta-blockers may be used to slow rate if not contraindicated.
Augmentation ratio change does not fix timing.
,3. A patient in the ICU has the following arterial blood gas (ABG) while on
mechanical ventilation: pH 7.48, PaCO2 30 mm Hg, HCO3 24 mEq/L. Which
ventilator adjustment is indicated?
A. Increase respiratory rate
B. Decrease tidal volume
C. Increase PEEP
D. Increase FiO2
Correct Answer: B
Rationale: The ABG shows respiratory alkalosis (high pH, low PaCO2, normal
HCO3). To reduce minute ventilation and increase PaCO2, decrease tidal volume
or respiratory rate. Option B (decrease tidal volume) is appropriate.
4. A patient with acute myocardial infarction develops a new systolic murmur,
hypotension, and pulmonary edema. The murmur is holosystolic, loudest at
the apex with radiation to the axilla. Which complication is most likely?
A. Acute mitral regurgitation due to papillary muscle rupture
B. Ventricular septal defect
C. Aortic stenosis
D. Pericarditis
Correct Answer: A
Rationale: Acute papillary muscle rupture after MI causes severe mitral
regurgitation, holosystolic murmur at the apex radiating to axilla, and abrupt
pulmonary edema. VSD murmur is harsh, best at left sternal border.
5. A patient’s pulmonary artery catheter shows: PAOP 22 mm Hg, cardiac
output 3.0 L/min, SVR 1800 dyne·sec·cm⁻⁵, and BP 90/60 mm Hg. Which
diagnosis is most consistent?
A. Distributive shock (sepsis)
B. Cardiogenic shock
C. Hypovolemic shock
D. Obstructive shock (PE)
Correct Answer: B
Rationale: Cardiogenic shock: elevated PAOP (>15-18), low cardiac output,
elevated SVR (compensatory vasoconstriction). Distributive shock has low SVR,
low PAOP initially.
Q6: A patient’s ECG shows pacing spikes without any QRS complexes following
,them. This indicates:
A. Loss of capture
B. Failure to sense
C. Proper sensing
D. Oversensing
Correct Answer: A
Rationale: Loss of capture occurs when the pacing stimulus fails to depolarize the
myocardium. Pacing spikes are seen but no QRS.
7. A patient in cardiogenic shock is on milrinone and norepinephrine. The
nurse notes worsening hypotension and a decrease in cardiac output. Which
additional medication is most appropriate?
A. Dobutamine
B. Levosimendan (not available in US – but maybe)
C. Vasopressin
D. Nitroprusside
Correct Answer: C
Rationale: Vasopressin can be added as a second-line vasopressor in refractory
shock. It does not have beta-adrenergic effects and may be helpful in combination.
8. A patient with massive pulmonary embolism has a BP of 70/40 mm Hg,
right ventricular dilation on echocardiogram, and a normal PAOP. The most
appropriate immediate intervention is:
A. IV unfractionated heparin alone
B. Thrombolytic therapy
C. Embolectomy
D. High-dose diuretics
Correct Answer: B
Rationale: Massive PE with hypotension and RV dysfunction is an indication for
thrombolytics (unless contraindicated). Heparin alone is insufficient. Embolectomy
if thrombolytics contraindicated.
9. A patient with atrial fibrillation and rapid ventricular response (HR 150)
has a BP of 85/50 mm Hg, chest pain, and altered mental status. The most
appropriate immediate intervention is:
A. IV metoprolol
B. Synchronized cardioversion
C. IV amiodarone
, D. IV digoxin
Correct Answer: B
Rationale: Unstable patient with tachycardia (hypotension, altered mental status,
chest pain) requires immediate synchronized cardioversion. Medication is for
stable patients.
10. A patient post-cardiac arrest has a Glasgow Coma Scale (GCS) of 4, no
brainstem reflexes, and myoclonus. Therapeutic hypothermia (TTM) was
initiated. Which finding after rewarming indicates poor neurological
prognosis?
A. Presence of pupillary light reflex
B. Status myoclonus at normothermia
C. Normal brain CT
D. Somatosensory evoked potentials (SSEP) present bilaterally
Correct Answer: B
Rationale: Status myoclonus (generalized, persistent myoclonus) within 48 hours
after cardiac arrest, after rewarming, is associated with poor neurological outcome.
Bilateral absent SSEP is also poor.
11. A patient with an Impella CP device has a mean arterial pressure (MAP)
of 55 mm Hg, a pulsatility index of 0.8 (low), and an increasing lactate. What
is the priority intervention?
A. Increase PEEP
B. Decrease Impella flow rate
C. Ensure adequate preload (IV fluids) and assess for cardiac tamponade or device
malposition
D. Administer a beta-blocker
Correct Answer: C
Rationale: Low MAP, low pulsatility, and rising lactate suggest inadequate
perfusion. Impella requires adequate preload; hypovolemia or tamponade reduces
flow. Assess and correct.
12. A patient with a pulmonary artery catheter has an oxygen saturation of
mixed venous blood (SvO2) of 50% (normal 60-75%). The cardiac output is
3.0 L/min. Which condition is most likely?
A. Low oxygen delivery (e.g., cardiogenic shock, severe anemia)
B. Sepsis with high output
C. Hypothermia
