Critical Care Certification Examination Practice Questions: Answers
PRACTICE QUESTIONS
for the Certified Nurse in Critical Care – Canada examination
The following questions are intended for practice only and represent a random sampling (but not
exhaustive list) of possible topics that could be tested as part of the critical care certification examination.
Questions have been designed to test assorted competencies listed in the blueprint for the Canadian
Nurses Association Certified Nurse in Critical Care Examination. The blueprint is available from the
Canadian Nurses Association website at:
http://www.cna-aiic.ca/CNA/documents/pdf/publications/CERT_Critical_Care_Adult_e.pdf
The degree of difficulty for these questions may be higher or lower than questions on the actual
examination; questions have been developed to encourage a review of a variety of topic areas. Questions
have been developed independent of the Canadian Nurses Association Critical Care Certification
Examination Committee review.
These practice questions are for use by individual members of the Canadian Association of Critical Care
Nurses (CACCN) only. Reproduction or electronic distribution without expressed written consent by
CACCN is strictly prohibited.
Participant use of these questions does not guarantee success on the national examination. Accuracy of
questions may change without notice based on new research evidence or national practice standards.
CACCN is not responsible for any participant’s clinical decision-making.
CASE 1
Mr. Jackle, 68 yrs old, is admitted with hypotension and respiratory distress requiring intubation following
a large ST elevation anterior-lateral wall myocardial infarction.
Case 1: Question 1
Blueprint Competency Being Tested: 2.1a
1. Shortly after insertion of a right subclavian catheter, he develops worsening shortness of breath and
bibasilar crackles. Blood is noted to be backing up from the central venous catheter and his oxygen
saturation decreases with supine positioning. Which one of the following problems is consistent with
these findings?
a. Pulmonary embolus
b. Right heart failure
c. Cardiac pulmonary edema
d. Hemopneumothorax
Rationale for Correct Response:
c) Anterior wall MI is typically associated with left ventricular dysfunction with increased left ventricular
pressures. High left ventricular pressures back up to the pulmonary system, causing pulmonary
congestion. Hallmarks of cardiac pulmonary edema include bibasilar crackles and orthostatic hypoxemia
or distress. Elevated pulmonary pressures are transmitted to the right side of the heart and cause CVP
elevation (blood backing up from central line) and peripheral edema.
© Canadian Association of Critical Care Nurses (CACCN), October 20, 2010
For use by members of CACCN only. Unauthorized reproduction is strictly prohibited. Page 1
,Critical Care Certification Examination Practice Questions: Answers
Although pulmonary embolus, hemopneumothorax or right heart failure can cause right atrial pressure
elevation, the scenario is more consistent with right atrial pressure elevation secondary to left heart
failure.
Case 1: Question 2
Blueprint Competency Being Tested: 2.1b
2. Mr. Jackle will be monitored for signs of reinfarction. Which one of the following lab tests would best
indicate reinfarction?
a. Creatinine kinase
b. Cardiac troponin
c. Lactate dehydrogenase
d. Venous oxygen saturation
Rationale for Correct Response:
a) Creatinine kinase (CK) and cardiac troponin follow a similar pattern of elevation following myocardial
injury (CK ~2-8; cardiac troponin ~3-12 hours post injury). CK will fall and normalize within 1-3 days, while
cardiac troponin will remain elevated for 5-14 days (There are two subtypes of cardiac troponin. Cardiac
troponin I remains elevated for 5-9 days, whereas, cardiac troponin T can remain elevated for up to two
weeks).
Cardiac troponin is a more specific marker of heart muscle injury than CK, making it a better diagnostic
test of heart muscle damage. On the other hand, the rate of enzyme rise is more dramatic for CK than
troponin, creating a stronger signal for early detection of myocardial infarction. As well, because CK
returns to normal much faster than troponin, the CK is better for detecting reinfarction – as in this scenario
(a second rise in the CK after its return to normal). Conversely, the persistent elevation in the troponin
can be useful in detecting an infarct that is several days old.
LDH would not be useful for detecting reinfarction, because it takes much longer to rise than CK or
troponin (72 hours) and remains elevated for over 2 weeks. Venous oxygen saturation (decrease) is
useful for detecting a low cardiac output but is not specific to myocardial infarction.
Case 1: Question 3
Blueprint Competency Being Tested: 2.1d
3. Mr. Jackle develops cardiogenic shock, respiratory failure and acute kidney injury. He is receiving
epinephrine at 2 ug/min and is fully ventilated on an FiO2 .6 with PEEP 10. His SpO2 is 95%, HR 74
(sinus rhythm), BP 102/58 (MAP 72), CVP 14 mmHg, Hb 82 and central venous oxygen saturation
(ScvO2) 42%. Which one of the following interventions is most appropriate?
a. Metoprolol
b. Captopril
c. Increased FiO2
d. Packed cells
© Canadian Association of Critical Care Nurses (CACCN), October 20, 2010
For use by members of CACCN only. Unauthorized reproduction is strictly prohibited. Page 2
,Critical Care Certification Examination Practice Questions: Answers
Rationale for Correct Response:
d) A venous oxygen saturation below normal (< 70%) indicates increased tissue oxygen extraction (i.e.,
the tissues are removing more oxygen than normal from each hemoglobin molecule at the cell level,
therefore, there is less oxygen “leftover” in the blood returning to the right side of the heart).
Oxygen Delivery is the total amount of oxygen delivered to the tissues. It can be calculated with the
following equation:
Oxygen Delivery = Cardiac Output (HR X SV) X Oxygen Content (SaO2 X Hb)
When there is a need for additional tissue oxygenation (e.g., when metabolic rate increases), we will first
attempt to increase our oxygen delivery. Because we have little ability to raise our oxygen content above
normal, our first compensatory response is to increase our cardiac output.
If we do not meet our tissue oxygen requirements by increasing our cardiac output, our second
compensatory response will be to extract more oxygen than normal at the tissue level. If this fails, our
final attempt at compensation will be through anaerobic metabolism.
In this example, the patient is still in shock (requiring epinephrine). Although we may want to get the
patient converted to beta blockers, the patient is still requiring beta stimulation, therefore, metoprolol
would be contraindicated at this point. ACE inhibitors are also part of the desired treatment following
myocardial infarction, however, we would need to wait until his renal failure resolves to initiate captopril.
This patient is already on 60% oxygen with an SpO2 of 95%. Additional oxygen would have minimal
impact on the oxygen delivery. Anemia drops the oxygen content, and necessitates an increase in the
cardiac output to maintain the oxygen delivery. Although a hemoglobin of 82 is generally well tolerated in
patients without cardiac disease or among those who have an adequate oxygen delivery, in the setting of
coronary artery disease and ongoing shock, transfusion to maintain a hemoglobin of at last 100 is
recommended.
Although there is still much debate regarding when to treat a low hemoglobin, administration of packed
cells is the only appropriate option among the choices provided in this question.
Case 1: Question 4
Blueprint Competency Being Tested: 2.1j
4. Mr. Jackle develops the following rhythm. Interpret this rhythm strip.
a. First degree block
b. Junctional rhythm
c. Second degree block
d. Complete heart block
© Canadian Association of Critical Care Nurses (CACCN), October 20, 2010
For use by members of CACCN only. Unauthorized reproduction is strictly prohibited. Page 3
, Critical Care Certification Examination Practice Questions: Answers
Rationale for Correct Response:
c) This is a sinus rhythm with a 2:1 second degree block. Note that the P waves that precede the QRSs
have a consistent PR interval.
Case 1: Question 5
Blueprint Competency Being Tested: 2.1e
5. Mr. Jackle develops symptomatic bradycardia and requires a temporary pacemaker. The following
rhythm strip displays his rhythm with a VVI pacemaker set at 75 beats/min. Identify the pacemaker
problem.
a. Failure to capture
b. Failure to fire
c. Oversensing
d. Undersensing
Rationale for Correct Response:
c) Oversensing. There is a long pause between the second and third QRS, where there is no ventricular
activity. To determine the ventricular escape interval (the time between from one paced beat to the next
paced beat), measure the distance between the first and second spike. To confirm that this is the correct
interval, you can count the number of small boxes between these two spikes (20) and divide this number
into 1500 to confirm that it matches the set pacemaker rate (1500/20 = 75 beats per minute). The
distance following either a paced or native beat should never exceed the ventricular escape interval. If it
does, the pacemaker did not fire when it should have fired. Note: many pacemakers have a built in pause
following a native beat that prolongs this interval slightly after the patient initiates their own beat. This
pause (hysteresis) gives the patient’s own rhythm a chance to kick in.
The long interval after the third paced beat exceeds the ventricular escape interval. The absence of a
pacemaker spike indicates that the pacemaker was inhibited, therefore, the pacemaker must have
“believed that it saw a ventricular complex”. The pacemaker is oversensing (or too sensitive).
© Canadian Association of Critical Care Nurses (CACCN), October 20, 2010
For use by members of CACCN only. Unauthorized reproduction is strictly prohibited. Page 4
PRACTICE QUESTIONS
for the Certified Nurse in Critical Care – Canada examination
The following questions are intended for practice only and represent a random sampling (but not
exhaustive list) of possible topics that could be tested as part of the critical care certification examination.
Questions have been designed to test assorted competencies listed in the blueprint for the Canadian
Nurses Association Certified Nurse in Critical Care Examination. The blueprint is available from the
Canadian Nurses Association website at:
http://www.cna-aiic.ca/CNA/documents/pdf/publications/CERT_Critical_Care_Adult_e.pdf
The degree of difficulty for these questions may be higher or lower than questions on the actual
examination; questions have been developed to encourage a review of a variety of topic areas. Questions
have been developed independent of the Canadian Nurses Association Critical Care Certification
Examination Committee review.
These practice questions are for use by individual members of the Canadian Association of Critical Care
Nurses (CACCN) only. Reproduction or electronic distribution without expressed written consent by
CACCN is strictly prohibited.
Participant use of these questions does not guarantee success on the national examination. Accuracy of
questions may change without notice based on new research evidence or national practice standards.
CACCN is not responsible for any participant’s clinical decision-making.
CASE 1
Mr. Jackle, 68 yrs old, is admitted with hypotension and respiratory distress requiring intubation following
a large ST elevation anterior-lateral wall myocardial infarction.
Case 1: Question 1
Blueprint Competency Being Tested: 2.1a
1. Shortly after insertion of a right subclavian catheter, he develops worsening shortness of breath and
bibasilar crackles. Blood is noted to be backing up from the central venous catheter and his oxygen
saturation decreases with supine positioning. Which one of the following problems is consistent with
these findings?
a. Pulmonary embolus
b. Right heart failure
c. Cardiac pulmonary edema
d. Hemopneumothorax
Rationale for Correct Response:
c) Anterior wall MI is typically associated with left ventricular dysfunction with increased left ventricular
pressures. High left ventricular pressures back up to the pulmonary system, causing pulmonary
congestion. Hallmarks of cardiac pulmonary edema include bibasilar crackles and orthostatic hypoxemia
or distress. Elevated pulmonary pressures are transmitted to the right side of the heart and cause CVP
elevation (blood backing up from central line) and peripheral edema.
© Canadian Association of Critical Care Nurses (CACCN), October 20, 2010
For use by members of CACCN only. Unauthorized reproduction is strictly prohibited. Page 1
,Critical Care Certification Examination Practice Questions: Answers
Although pulmonary embolus, hemopneumothorax or right heart failure can cause right atrial pressure
elevation, the scenario is more consistent with right atrial pressure elevation secondary to left heart
failure.
Case 1: Question 2
Blueprint Competency Being Tested: 2.1b
2. Mr. Jackle will be monitored for signs of reinfarction. Which one of the following lab tests would best
indicate reinfarction?
a. Creatinine kinase
b. Cardiac troponin
c. Lactate dehydrogenase
d. Venous oxygen saturation
Rationale for Correct Response:
a) Creatinine kinase (CK) and cardiac troponin follow a similar pattern of elevation following myocardial
injury (CK ~2-8; cardiac troponin ~3-12 hours post injury). CK will fall and normalize within 1-3 days, while
cardiac troponin will remain elevated for 5-14 days (There are two subtypes of cardiac troponin. Cardiac
troponin I remains elevated for 5-9 days, whereas, cardiac troponin T can remain elevated for up to two
weeks).
Cardiac troponin is a more specific marker of heart muscle injury than CK, making it a better diagnostic
test of heart muscle damage. On the other hand, the rate of enzyme rise is more dramatic for CK than
troponin, creating a stronger signal for early detection of myocardial infarction. As well, because CK
returns to normal much faster than troponin, the CK is better for detecting reinfarction – as in this scenario
(a second rise in the CK after its return to normal). Conversely, the persistent elevation in the troponin
can be useful in detecting an infarct that is several days old.
LDH would not be useful for detecting reinfarction, because it takes much longer to rise than CK or
troponin (72 hours) and remains elevated for over 2 weeks. Venous oxygen saturation (decrease) is
useful for detecting a low cardiac output but is not specific to myocardial infarction.
Case 1: Question 3
Blueprint Competency Being Tested: 2.1d
3. Mr. Jackle develops cardiogenic shock, respiratory failure and acute kidney injury. He is receiving
epinephrine at 2 ug/min and is fully ventilated on an FiO2 .6 with PEEP 10. His SpO2 is 95%, HR 74
(sinus rhythm), BP 102/58 (MAP 72), CVP 14 mmHg, Hb 82 and central venous oxygen saturation
(ScvO2) 42%. Which one of the following interventions is most appropriate?
a. Metoprolol
b. Captopril
c. Increased FiO2
d. Packed cells
© Canadian Association of Critical Care Nurses (CACCN), October 20, 2010
For use by members of CACCN only. Unauthorized reproduction is strictly prohibited. Page 2
,Critical Care Certification Examination Practice Questions: Answers
Rationale for Correct Response:
d) A venous oxygen saturation below normal (< 70%) indicates increased tissue oxygen extraction (i.e.,
the tissues are removing more oxygen than normal from each hemoglobin molecule at the cell level,
therefore, there is less oxygen “leftover” in the blood returning to the right side of the heart).
Oxygen Delivery is the total amount of oxygen delivered to the tissues. It can be calculated with the
following equation:
Oxygen Delivery = Cardiac Output (HR X SV) X Oxygen Content (SaO2 X Hb)
When there is a need for additional tissue oxygenation (e.g., when metabolic rate increases), we will first
attempt to increase our oxygen delivery. Because we have little ability to raise our oxygen content above
normal, our first compensatory response is to increase our cardiac output.
If we do not meet our tissue oxygen requirements by increasing our cardiac output, our second
compensatory response will be to extract more oxygen than normal at the tissue level. If this fails, our
final attempt at compensation will be through anaerobic metabolism.
In this example, the patient is still in shock (requiring epinephrine). Although we may want to get the
patient converted to beta blockers, the patient is still requiring beta stimulation, therefore, metoprolol
would be contraindicated at this point. ACE inhibitors are also part of the desired treatment following
myocardial infarction, however, we would need to wait until his renal failure resolves to initiate captopril.
This patient is already on 60% oxygen with an SpO2 of 95%. Additional oxygen would have minimal
impact on the oxygen delivery. Anemia drops the oxygen content, and necessitates an increase in the
cardiac output to maintain the oxygen delivery. Although a hemoglobin of 82 is generally well tolerated in
patients without cardiac disease or among those who have an adequate oxygen delivery, in the setting of
coronary artery disease and ongoing shock, transfusion to maintain a hemoglobin of at last 100 is
recommended.
Although there is still much debate regarding when to treat a low hemoglobin, administration of packed
cells is the only appropriate option among the choices provided in this question.
Case 1: Question 4
Blueprint Competency Being Tested: 2.1j
4. Mr. Jackle develops the following rhythm. Interpret this rhythm strip.
a. First degree block
b. Junctional rhythm
c. Second degree block
d. Complete heart block
© Canadian Association of Critical Care Nurses (CACCN), October 20, 2010
For use by members of CACCN only. Unauthorized reproduction is strictly prohibited. Page 3
, Critical Care Certification Examination Practice Questions: Answers
Rationale for Correct Response:
c) This is a sinus rhythm with a 2:1 second degree block. Note that the P waves that precede the QRSs
have a consistent PR interval.
Case 1: Question 5
Blueprint Competency Being Tested: 2.1e
5. Mr. Jackle develops symptomatic bradycardia and requires a temporary pacemaker. The following
rhythm strip displays his rhythm with a VVI pacemaker set at 75 beats/min. Identify the pacemaker
problem.
a. Failure to capture
b. Failure to fire
c. Oversensing
d. Undersensing
Rationale for Correct Response:
c) Oversensing. There is a long pause between the second and third QRS, where there is no ventricular
activity. To determine the ventricular escape interval (the time between from one paced beat to the next
paced beat), measure the distance between the first and second spike. To confirm that this is the correct
interval, you can count the number of small boxes between these two spikes (20) and divide this number
into 1500 to confirm that it matches the set pacemaker rate (1500/20 = 75 beats per minute). The
distance following either a paced or native beat should never exceed the ventricular escape interval. If it
does, the pacemaker did not fire when it should have fired. Note: many pacemakers have a built in pause
following a native beat that prolongs this interval slightly after the patient initiates their own beat. This
pause (hysteresis) gives the patient’s own rhythm a chance to kick in.
The long interval after the third paced beat exceeds the ventricular escape interval. The absence of a
pacemaker spike indicates that the pacemaker was inhibited, therefore, the pacemaker must have
“believed that it saw a ventricular complex”. The pacemaker is oversensing (or too sensitive).
© Canadian Association of Critical Care Nurses (CACCN), October 20, 2010
For use by members of CACCN only. Unauthorized reproduction is strictly prohibited. Page 4
