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2026 Edition

CCRN Practice Test

Take this free CCRN practice test to study for the Critical Care Registered Nurse certification exam.

The CCRN exam is a 3 hour exam covering 150 multiple choice questions. The exam focuses on three general populations: adult, pediatric and neonatal patients.  Within the three general populations, the following subject categories are covered: Cardiovascular, Respiratory, Endocrine, Hematology / Immunity, Neurology, Gastrointestinal, Renal, Integumentary, Multisystem, Mental Health and Professional Care and Ethical Practice. Each exam is age specific and a large percentage of each test focuses on clinical judgment. 

For complete practice, check out the CCRN Practice Exam Kit with 750 questions and fully explained answers.  It is written by CCRN experts and nursing instructors. Our interactive test platform allows you to simulate the exam. Take as many practice tests as you need. There's no time limit or recurring charges.

For more information on the CCRN exam and test prep, see our CCRN Study Guide.

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Cardiovascular 

1 A 47-year-old male has been admitted to the CCU from the emergency room with a history of sudden diaphoresis, nausea, vomiting and radiating pain down his left arm. He reports no significant medical history, and has been a two PPD smoker since his early twenties. His admitting diagnosis is UA/NSTEMI and he is being prepped for cardiac catheterization for possible angioplasty with stent placement. What type of medication orders might the nurse see prior to his procedure?
Incorrect. Please choose another answer.
In 2011, a joint task force of the American College of Cardiology Foundation and the American Heart Association published updated guidelines for the treatment of unstable angina (UA) with non-ST elevation myocardial infarction (NSTEMI). These guidelines recommend that all patients with this diagnosis receive ASA on admission, and throughout hospitalization, if tolerated. If a patient is scheduled for percutaneous coronary intervention (PCI), it is recommended that a second anti-platelet therapy be added, such as clopidogrel (Plavix).

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2 A 62-year-old male presents to the emergency department with complaints of sudden onset chest pain, shortness of breath, and dizziness. The nurse places the client on a cardiac monitor and notes the attached rhythm. Which intervention is most appropriate for this client?
Incorrect. Please choose another answer.
The client's heart rhythm demonstrates ventricular fibrillation. Ventricular fibrillation is an arrythmia that occurs in the bottom chambers of the heart and can be life threatening. Symptoms include chest pain, dyspnea, nausea, dizziness, palpitations, and hypotension. It requires immediate intervention and cardiopulmonary resuscitation should be started immediately. Putting ice to the client's face is the appropriate intervention for a client who is experiencing supraventricular tachycardia. Synchronized cardioversion is the appropriate intervention for a client who is experiencing atrial fibrillation, atrial flutter, or atrial tachycardia. Atropine is a medication used for symptomatic bradycardia. Image by Antoine Ayer, CC BY-SA 4.0 , via Wikimedia Commons.
3 A 43-year-old female with a past medical history of coronary artery disease is admitted to the CCU for concerns of acute onset dyspnea and chest pain. The client's troponin level is 0.02 ng/mL and CK-MB is 2%. The client's oxygen saturation is 95% and blood pressure is 200/120 mm Hg. Which medication would the nurse expect the provider to order?
Incorrect. Please choose another answer.
The client is experiencing a hypertensive crisis. A hypertensive crisis occurs when there is a sudden increase in the client's blood pressure that is greater than or equal to 180/120 mmHg. Intravenous nicardipine is the medication of choice when a client presents with a hypertensive crisis. Nicardipine is a calcium channel blocker that is used to treat hypertension. The medication would be administered intravenously to rapidly lower the client's blood pressure. Oral clonidine and nifedipine would not be appropriate medications for a client diagnosed with a hypertensive crisis due the length of time oral medications would take to lower the client's blood pressure. Norepinephrine is a medication used to treat hypotension.

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4 A 75-year-old male with a past medical history of chronic hypertension and ischemic heart disease presents to the CCU on 3L of oxygen therapy with abnormal laboratory results. Which assessment finding would be associated with left-sided heart failure?
Incorrect. Please choose another answer.
Symptoms of left-sided heart failure include dyspnea, orthopnea, and paroxysmal nocturnal dyspnea due to pulmonary congestion. This occurs due to the failure of the heart to pump adequate venous return from the lungs. Right-sided heart failure symptoms include hepatomegaly, peripheral edema, increased jugular venous pressure, and ascites due to increased central venous pressure.
5 Agnes is a 65-year-old white female who has a history of pulmonary fibrosis with steroid use for the past two years with concomitant hypertension. She has been on oxygen therapy at 4L per nasal cannula for the past 3 years. Recently, her first great-grandchild was born, and she decided to quit smoking. Three days ago, she experienced nausea and dizziness and was admitted to the CCU with a diagnosis of acute myocardial infarction. During shift change, Agnes' low blood pressure alarm sounds. Upon assessment, she is diaphoretic and has severe dyspnea. What is the most likely cause of her symptoms?
Incorrect. Please choose another answer.
Myocardial rupture can be a catastrophic sequelae of acute myocardial infarction. It can occur in several sites in the heart after AMI, including the left papillary muscle. This event typically occurs 3-5 days after the AMI has occurred, and is more common in women who have a history of hypertension and are over the age of 60. The posteromedial papillary muscle is twice as likely to rupture as the anterolateral papillary muscle, due to the additional blood supply to the latter. Symptoms may include hypotension, shortness of breath, acute pulmonary edema and shock. Generally, mitral valve replacement is the most effective treatment.

Respiratory 

Refer to the following for questions 6 and 7:

Norman is a 65 year old paraplegic who resides in a nursing home. He presents with a 3-day history of increased temperature, productive cough, and increased weakness. His caregiver states that he had developed a decubitis ulcer, and has not been able to tolerate sitting in his wheelchair, so has been in bed for the past week. Bibasilar crackles are audible on auscultation, with overall diminished breath sounds bilaterally. Obvious respiratory distress is apparent with tachypnea, suprasternal retractions and use of accessory muscles. Vitals: T-100.2F, HR-120, RR-28, BP 104/50, O2 Sat on RA - 88%. An initial chest x-ray reveals the "spine sign" and a normal cardiac silhouette.
6 What is the most likely cause of Norman's condition?
Incorrect. Please choose another answer.
The most likely cause for Norman's condition is nursing home-associated pneumonia (NHAP). NHAP is a subcategory of institutional-acquired pneumonia (IAP), which also includes healthcare associated pneumonia (HCAP). Patients in these settings are at increased risk for exposure to multi-drug resistant (MDR) bacteria. Debility and compromised health status increase the potential for infection.

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7 What does the finding of "spine sign" on Norman's chest x-ray indicate?
Incorrect. Please choose another answer.
The presence of the "spine sign" on chest x-ray is indicative of bilateral lower lobe pneumonia. The spinal markings disappear at the level of bilateral lower lobe pulmonary infiltrates, which occlude visibility of the vertebrae.
8 A client who has a history of COPD and is admitted for pneumonia and hypoxia. An arterial blood gas is drawn and results indicate the following: pH 7.12, pCO2 61 mm Hg, and HCO3- of 28 mEq/L. The results indicate which condition?
Incorrect. Please choose another answer.
This client is experiencing partially compensated respiratory acidosis. A normal pH is 7.35 to 7.45. A normal pCO2 is 35-45 mm Hg. A normal HCO3- is 22-27 mEg/L. In respiratory acidosis, the pH is low and the pCO2 is increased. The client is partially compensated because the HCO3- is also increased. Respiratory acidosis occurs when there is an increased amount of carbon dioxide in the lungs.
9 A 36-year-old client is admitted to the ICU for acute respiratory distress syndrome and is intubated on admission. The client is agitated and is requiring 60% FiO2 to maintain oxygen saturations greater than 93%. The provider has placed an order to increase the client's PEEP from 10 to 15 cm H2O. The nurse would monitor for which complication?
Incorrect. Please choose another answer.
A client who is requiring a high positive end-expiratory pressure is at an increased risk for barotrauma due to the increased pressure being delivered into the alveoli. Other complications of a high positive end-expiratory pressure include decreased preload, increased afterload, and increased intracranial pressure.
10 A 40-year-old client was admitted with dyspnea, unilateral breath sounds, tracheal deviation and a chest tube was inserted. Upon assessment, the nurse notes there is no tidaling in the water-seal chamber of the chest tube. Which order would the nurse anticipate the provider place given the client's findings?
Incorrect. Please choose another answer.
The client has a chest tube due to a pneumothorax. A patent chest tube would have tidaling in the water-seal chamber. A chest tube that has no tidaling in the water-seal chamber may indicate that the client's lung has expanded, there is a disconnect in the chest tube system, the chest tube is blocked, or there has been complete lung collapse. The nurse would anticipate the provider to order a chest x-ray to assess the client's lung. The chest tube should never be stripped by the nurse.

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Endocrine 

11 If a patient is suspected of having an episode of acute hypoglycemia, which of the following is NOT the most appropriate first intervention?
Incorrect. Please choose another answer.
Although drawing a STAT blood glucose level may be part of a number of initial interventions, it should not be the first, since results will take too long to obtain. Patients who are suffering from acute hypoglycemia are at high risk of incurring permanent neurological damage, since the primary energy source for the brain is sugar. Patients who are conscious should consume a simple sugar which will absorb rapidly, like orange juice or glucose tablets. Patients who are unconscious outside the hospital setting or without IV access in the hospital setting should receive IM glucagon. Patients who are conscious in the hospital setting with IV access may be given IV dextrose.
12 The nurse is conducting an assessment on a 19-year-old client in the emergency department. The client's respiratory rate is 25 breaths per minute, heart rate 128 beats per minute, blood pressure 102/60 mm Hg, and oxygen saturation 87% on room air. The client briefly awakens to vigorous stimulation. Labs include a glucose of 630 mg/dL, pH 7.1, serum bicarb 12 mEq/L, potassium 7.1 mEq/L and sodium 130 mEq/L. Which fluid would the nurse expect the provider to order for this client?
Incorrect. Please choose another answer.
The client is presenting with diabetic ketoacidosis given their assessment and laboratory findings. Diabetic ketoacidosis occurs in client's with diabetes and presenting findings include hyperglycemia, a low pH, and ketone production. The fluids the nurse would expect the provider to order initially for this client is 0.9 NaCl given the client's sodium is low. The client would receive 0.45 NaCl if their sodium was normal or high. It is important for a client presenting in DKA to receive isotonic solution initially to help with volume replacement and to prevent cerebral edema.
13 A 45-year-old client underwent a craniotomy for tumor resection and is now 48 hours postop. The client's urine output in the last 24 hours was 20 liters. Labs include a urine osmolality of 200 mmol/L, urine specific gravity of 1.000 and sodium of 145. Which medication is appropriate for this client's diagnosis?
Incorrect. Please choose another answer.
The client is experiencing diabetes insipidus following a craniotomy. Diabetes insipidus occurs when the client excretes a large volume of urine. The appropriate medication to treat this condition is desmopressin which helps to reduce urine output and increased thirst. Furosemide is a diuretic and would not be used for a client who is excreting large amounts of urine. Also, a client who presents with diabetes insipidus would not be given hypertonic solutions such as D10W and 3% saline.

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14 Which lab findings would be seen in a client who presents with syndrome of inappropriate antidiuretic hormone secretion?
Incorrect. Please choose another answer.
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) occurs when there is a large release of vasopressin which causes hyponatremia, decreased urine osmolality and decreased serum osmolality. Client's will have a decreased urine output due to concentrated urine production. Diabetes insipidus causes decreased urine osmolality, increased serum osmolality and a normal to high sodium level.
15 Marilyn is a Type I diabetic who has been admitted to the unit after a severe hypoglycemic episode in which she lost consciousness. She states that she has had many episode of hypoglycemia, but just does not seem to know when they are coming on anymore. What is the term for this phenomenon?
Incorrect. Please choose another answer.
When frequent episodes of hypoglycemia occur, the phenomenon of hypoglycemia unawareness can occur. This is more common in Type I diabetics, and is the result of the body's loss of ability to release epinephrine and other stress hormones during episodes of hypoglycemia. Without the symptoms associated with the release of epinephrine and stress hormones, an individual is not aware that blood sugar levels are dropping, which prevents them from taking early action to correct hypoglycemia. Another term for this condition is hypoglycemia-associated autonomic failure (HAAF).

Hematology / Immunology 

16 Of the following, which is included in the etiology of idiopathic thrombocytopenic purpura (ITP)?
Incorrect. Please choose another answer.
Idiopathic thrombocytopenic purpura (ITP) is caused by the presence of Immunoglobulin G (IgG) autoantibodies on the surface of the platelets. It is defined as isolated thrombocytopenia with normal bone marrow function and the absence of other causes of thrombocytopenia. Clinically, there are two syndromes which manifest; acute in children and chronic in adults. Depending on the patient's status, treatment may or may not be indicated. If indicated, glucocorticoids and IVIg are the typical mainstays of medical therapy, and surgical options may include splenectomy in adults.

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17 A 45-year-old client is admitted for severe anemia secondary to chemotherapy. The nurse started the client's blood transfusion approximately 1 hour ago. The nurse is assessing vital signs and notes a heart rate of 162 beats per minute, respiratory rate of 18 breaths per minute, blood pressure of 84/58 mm Hg, and temperature of 101.5 degrees F. The client is vomiting and has severe agitation. Which type of transfusion reaction is this client most likely experiencing?
Incorrect. Please choose another answer.
Acute hemolytic transfusion reactions occur within twenty-four hours of transfusion and occurs when there is incompatibility between the receipt and donor's blood. This incompatibility causes a systemic inflammatory response. Symptoms include tachycardia, hypotension, fever, nausea and vomiting, agitation, flank pain, and hemoglobinuria. An allergic transfusion reaction occurs when a client has an allergic reaction to the blood and symptoms include hives and pruritus. Transfusion-associated circulatory overload symptoms include dyspnea, pulmonary edema, and cough. Septic transfusion reaction symptoms include fever, disseminated intravascular coagulation, hypotension, and organ failure.
18 A 55-year-old male has a history of lymphoma and has been receiving chemotherapy treatment for the past 3 months. The client presents to the emergency department with concerns for weakness, nausea, and decreased urine output. Labs include a potassium of 6.9 mmol/L, phosphate of 8.9 mg/dL, uric acid of 12.4 mg/dL, creatinine of 2.3 mg/dL, and calcium of 7.7 mg/dL. Which intervention is priority given the client's assessment and lab results?
Incorrect. Please choose another answer.
The client is presenting with signs and symptoms of tumor lysis syndrome which is a complication of chemotherapy. Tumor lysis syndrome occurs when cancer cells die and are released into the bloodstream causing severe electrolyte imbalances such as hyperkalemia, hyperphosphatemia, and hypocalcemia. The first priority is to administer normal saline to prevent complications such as renal damage and help correct electrolyte imbalances. Normal saline helps to dilute uric acid and promote excretion. Administering calcium supplements, allopurinol, and recombinant urate oxidase are treatments used for tumor lysis syndrome but are not the initial priority.
19 Which lab findings would be seen in a client who presents with disseminated intravascular coagulation?
Incorrect. Please choose another answer.
Disseminated intravascular coagulation occurs when there is an excess of thrombin which can cause an increased INR, increased PTT, increased d-dimer, and decreased fibrinogen. A normal INR is less than or equal to 1.1, a normal PTT is 25-35 seconds, and a normal fibrinogen is 200-400 mg/dL. Thrombotic thrombocytopenia purpura occurs when there is an endothelial defect which can cause a normal to slightly increased INR, a normal to slightly increased PTT, a normal fibrinogen, and slightly increased d-dimer. Immune thrombocytopenia occurs when there are anti-platelet antibodies. Clients presenting with ITP will have normal labs.
20 Of the following, which is NOT a consideration when administering IVIg therapy?
Incorrect. Please choose another answer.
Although IVIg is quite expensive, socioeconomic status should never be a consideration in whether a patient receives needed therapy. IVIg contains immunoglobulins which are extracted from thousands of human donors, so it carries some of the same risks as other blood products, but is generally much safer. Various brands of IVIg are available, and differ in how they're prepared. Some manufacturers use sucrose as a stabilizing agent, others may use maltose or amino acids. This is a consideration in choosing the correct brand match regarding the effect on the patient in light of medical history and comorbidities.

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Neurology 

21 What is the most common site of rupture of a cerebral aneurysm with resulting subarachnoid hemorrhage (SAH)?
Incorrect. Please choose another answer.
The anterior communicating artery is the most common site of cerebral aneurysm rupture with resultant subarachnoid hemorrhage (SAH). There are usually no precipitating signs prior to rupture at this site, but afterward various abnormal signs may be present, including nuchal rigidity, decreased level of consciousness, and abnormal pupillary findings (usually dilation).
22 A client was in a motor vehicle accident and underwent a craniotomy yesterday. The client has an external ventricular drain set at 15 mm Hg which has drained 50 cc of cerebral spinal fluid the past hour. The client's current intracranial pressure is 32. Which intervention is appropriate?
Incorrect. Please choose another answer.
This client is experiencing an increased intracranial pressure and is having an excessive amount of cerebral spinal fluid drained due to the increased pressure. A normal ICP is 0-15 mmHg. It is important for the nurse to elevate the client's head of bed to 30 degrees to help promote venous drainage which helps decrease intracranial pressure. Suctioning the client's ET tube, clamping the external ventricular drain, and increasing the external ventricular drain to 20 mm Hg can all increase the client's intracranial pressure.
23 A client presents to the emergency room after getting hit in the head from a baseball. The client has clear leakage from the right ear, hemotympanum and a positive battle sign. Which type of skull fracture is the client most likely presenting with?
Incorrect. Please choose another answer.
A basilar skull fracture occurs when severe head trauma causes at least one bone at the base of the skull to fracture. Most common findings include cerebral spinal fluid leakage from one ear, blood in the tympanic cavity, and ecchymosis behind the ear. A linear skull fracture occurs when there is a thin linear fracture in the skull. A depressed skull fracture occurs when the skull depresses inward toward the brain. A diastatic skull fracture occurs when there is a separation of the sutures.

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24 Which lab findings in cerebral spinal fluid would be most suggestive of a client presenting with bacterial meningitis?
Incorrect. Please choose another answer.
The cerebral spinal fluid findings in a client who presents with bacterial meningitis would include an elevated white blood cell count (>1000 cells/uL), an elevated protein level (>100 mg/dL) and decreased glucose levels (<40 mg/dL). A normal cerebral spinal fluid WBC is 0-5 cells/uL. A normal cerebral spinal fluid protein level is 15-45 mg/dL. A normal cerebral spinal fluid glucose level is 50-80 mg/dL.
25 Donna is a 43-year-old teacher who was admitted 6 days ago with a ruptured middle cerebral artery (MCA) aneurysm with subarachnoid hemorrhage (SAH). She underwent surgery for aneurysm clipping 12 hours after admission, and has had an excellent post-operative course. However, this morning, she complained of a severe headache, became acutely confused and quickly progressed to unresponsiveness. What is the likely cause for Donna's change of status?
Incorrect. Please choose another answer.
Donna is most likely experiencing vasospasm of one or more of her cerebral arteries. When this occurs, it is generally within 4-14 days for patients who have never had a cerebral bleed in the past, and sooner if this bleed is a recurrence. Usually, the site of spasm is unrelated to the site of rupture. Vasospasm is a serious complication, as it can lead to impaired cerebral autoregulation, cerebral ischemia, and infarction.

Gastrointestinal 

26 Matthew is a 26-year-old who has been admitted to the ICU following a motor vehicle accident. Upon assessment, it is noted that he has a positive Cullen sign. What does this indicate?
Incorrect. Please choose another answer.
A Cullen sign is defined as ecchymosis involving the umbilicus, and is an indication of retroperitoneal hemorrhage. Ecchymosis which involves the flanks is called the Grey Turner sign, and also indicates retroperitoneal hemorrhage. Retroperitoneal hemorrhage is difficult to diagnosis clinically, and these signs typically take hours or days to appear.

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27 A 60-year-old client reports to emergency room with concerns for severe abdominal pain and distention, nausea and vomiting for 24 hours. On assessment, the client has hyperactive bowel sounds and 10 out of 10 abdominal pain. An abdominal x-ray reveals multiple air-fluid levels. Which intervention is appropriate for this client?
Incorrect. Please choose another answer.
A client who presents with concerns for a small bowel obstruction would have a Repogle tube inserted to help decompress the bowel and remove gas. A small bowel obstruction occurs when there is a blockage in the bowels. The client would be placed nothing by mouth (NPO). Also, a colonoscopy is not required for diagnosis of small bowel obstruction.
28 A client presents to the emergency department with complaints of hematemesis and melena. The client has a history of esophageal varices. Where is the most likely origin of the bleeding?
Incorrect. Please choose another answer.
Signs of an upper GI bleed include hematemesis, melena, decreased hemoglobin and hematocrit and elevated BUN. Esophageal varices can cause upper GI bleeding. The bleeding originates proximal to the duodenal jejunal juncture in upper GI bleeds. Lower GI bleeds occur distal to the ileocecal valve which includes the small intestine and colon.
29 The nurse is assessing a client in the emergency department and notes the client has a grey turner's sign and Cullen sign. The client's heart rate is 142 beats per minute, respiratory rate is 22 breaths per minute, and blood pressure is 92/68 mm Hg. Which diagnosis is most likely given the client's findings?
Incorrect. Please choose another answer.
Pancreatitis occurs when there is inflammation of the pancreas. A grey turner's sign and Cullen sign are both associated with retroperitoneal bleeding which can occur when a client has pancreatitis. A grey turner's sign is ecchymosis to the client's flank area. A Cullen sign is ecchymosis around the umbilicus. It is also common to see tachycardia, tachypnea, and hypotension when a client presents with pancreatitis.
30 If bowel sounds are audible when auscultating Matthew's lungs, what injury may he have sustained?
Incorrect. Please choose another answer.
If bowels sounds are audible when auscultating Matthew's breath sounds, a diaphragmatic tear should be suspected. Assessment of the trauma victim must be very systematic, and focuses on priorities in resuscitation and diagnosis based on hemodynamic stability and amount of injury. The ACLS protocol is followed, which includes identifying and treating the most life-threatening injuries first. Significant blunt trauma injuries are easily missed if a systematic process is not followed, as more dramatic injuries may receive the most attention.

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Renal 

31 If a patient sustains acute renal failure (ARF) secondary to cardiogenic shock, what type of renal failure is this considered?
Incorrect. Please choose another answer.
Acute renal failure (ARF) which occurs secondary to cardiogenic shock is considered prerenal failure. ARF, also known as acute kidney injury (AKI) is classified according to etiology: prerenal failure occurs as a response to hypotension and volume depletion, intrinsic failure occurs in response to damage within the kidney itself from various toxic, ischemic or inflammatory causes, and postrenal failure occurs from urinary flow obstruction of any cause.
Refer to the following for questions 32 and 33:

A 62-year-old male with a past medical history of hypertension and type 2 diabetes mellitus presents to the emergency department with concerns for decreased urine output, fatigue, and edema in lower extremities for the past week. Vital signs include a heart rate of 92 beats per minute, respiratory rate of 18 breaths per minute, blood pressure of 160/90 mmHg and temperature of 98.7 degrees F. Labs include a serum creatinine of 4.6 mg/dL, potassium of 6.5 mmol/L, sodium 136 mmol/L, and blood urea nitrogen of 52 mg/dL. Urinalysis shows 3+ proteinuria, 1+ hematuria, and elevated specific gravity. 
32 Which type of renal failure is this client presenting with?
Incorrect. Please choose another answer.
This client is presenting with intra-renal failure which is caused by acute damage to the kidney which leads to impaired function. During this phase, the client presents with decreased urine output, edema in the lower extremities, elevated creatinine and BUN, and elevated potassium. Pre-renal failure occurs when there is deceased renal perfusion which resolves once underlying cause is corrected. Post-renal failure occurs when there is an obstruction of urinary flow that leads to impaired function. Chronic renal failure occurs when the impaired kidney function is long term.
33 Which intervention is most appropriate for the client?
Incorrect. Please choose another answer.
The client's potassium level is at a dangerous level and the most appropriate intervention is to administer kayexalate. This medication helps to lower elevated potassium by excreting it through the gastrointestinal tract. An elevated potassium can lead to arrhythmias. Administer diuretics for a client who presents with acute kidney injury can worsen electrolyte imbalances and lead to dehydration. Peritoneal dialysis can help lower potassium levels but is not the most immediate intervention to decrease levels quickly. Restricting fluids would not help correct the client's elevated potassium level.
34 Which order would the nurse question for a client who is in severe kidney failure?
Incorrect. Please choose another answer.
A client who has severe kidney injury should not undergo imaging that administer contrast. Contrast is nephrotoxic and can worsen kidney function. Calcium gluconate can be given for a client in severe kidney failure to help counteract the effects of hyperkalemia. Hemodialysis is the treatment for a client in severe kidney failure to assist in removing waste products from the bloodstream. Lactated ringers solution is used for fluid resuscitation in a client with severe kidney injury as it does not damage the kidneys.

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35 The RIFLE classification system provides a definition and classification system for acute renal failure (ARF). What does the "R" in the RIFLE acronym refer to?
Incorrect. Please choose another answer.
The "R" in RIFLE stands for Risk of renal dysfunction. The remainder of the acronym represents the following: Injury to the kidney, Failure or Loss of kidney function, and End-stage kidney disease. These indicators are used in the context of glomerular filtration rate (GFR) or urine output (UO) criteria, or both.

Multisystem 

36 A 22-year-old client presents to the emergency department with concerns for tremors, confusion and agitation. The client has a history of major depressive syndrome and was recently started on a new antidepressant medications. Vital signs include a heart rate of 120 beats per minute, respiratory rate of 24 breaths per minute, blood pressure of 150/90 mmHg, and temperature of 103.2 degrees F. On examination, client has 4+ reflexes and muscle rigidity. Labs include a normal basic metabolic panel, normal electrolytes, and an elevated serum creatinine kinase. Which intervention is most appropriate for this client?
Incorrect. Please choose another answer.
The client is presenting with serotonin syndrome which occurs when there is an excess amount of serotonin in the body. This can be caused by taking selective serotonin reuptake inhibitors for mental health illnesses. Symptoms include tremors, confusion, agitation, hyperreflexia, muscle rigidity, increased temperature, and tachycardia. The priority intervention is to discontinue the serotonergic medications to prevent worsening symptoms.
37 A 6-month-old infant presents to the emergency department with concerns for poor feedings, emesis, and a seizure-like episode. Vital signs include a heart rate of 162 beats per minute, respiratory rate of 30 breaths per minute, blood pressure of 90/60 mmHg, and temperature of 100.8 degrees F. The infant is lethargic with poor muscle tone. Which assessment finding is diagnostic for a child who presents with shaken baby syndrome?
Incorrect. Please choose another answer.
Shaken baby syndrome occurs when a child has been shaken which leads to serious brain injuries. Symptoms include irritability, emesis, poor feedings, lethargy, and seizures. A hallmark sign of shaken baby syndrome includes retinal hemorrhages which is caused by the force of shaking breaking the blood vessels in the eye. Pulsating anterior fontanelle, postauricular ecchymosis, and hemotympanum can be seen in a child with head trauma but is not specific to shaken baby syndrome.
38 Andrew is a 47-year-old with advanced amyotrophic lateralizing sclerosis (ALS). He requires total assistance for positioning, bathing and mobility. His swallowing is impaired, so he takes nothing by mouth and receives nutrition through tube feedings via a gastrostomy tube. Based on his current condition, what type of asphyxia may Andrew be most susceptible to?
Incorrect. Please choose another answer.
Due to his weakness and inability to position himself, Andrew is susceptible to positional asphyxia. Positional asphyxia is associated with compromised respiratory function due to external factors which impair chest expansion, or create occlusion of the upper airway due to abnormal body position. Victims of positional asphyxia are unable to remove themselves from situations which compromise their respiratory status for various reasons, including cognitive and coordination impairment due to intoxication, sedation, neurological abnormalities, impaired consciousness, physical impairment or restraint.
Refer to the following for questions 40 and 41:

A 30-year-old underwent an emergency cesarean section secondary to placental abruption. The client is now in the postpartum unit. Upon assessment, the nurse notes the client has an altered mental status, dyspnea, and cyanosis. Vital signs include a respiratory rate of 45 breaths per minute, heart rate of 138 beats per minute, and blood pressure of 64/40 mm Hg. 
39 Which diagnosis is most likely given the client's findings?
Incorrect. Please choose another answer.
The client is experiencing an amniotic embolism. An amniotic embolism occurs when amniotic fluid, debris, and fetal cells enter into the mother's pulmonary circulation. The symptoms include acute dyspnea, altered mental status, tachycardia, tachypnea, cyanosis, and hypotension. Postpartum hemorrhage occurs in the postpartum period but would include significant vaginal bleeding. Eclampsia occurs due to high blood pressure which causes seizures. This can occur during pregnancy or shortly after giving birth. Acute respiratory distress syndrome presents with bilateral pulmonary infiltrates and occurs most often after trauma or sepsis.

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40 Which intervention is most appropriate for the client?
Incorrect. Please choose another answer.
A client who presents with an amniotic embolism with a severely low blood pressure would indicate the need for fluid resuscitation. Isotonic crystalloids such as normal saline should be administered to help improve the client's blood pressure. Misoprostol would be administered for a client who presents with postpartum hemorrhage to help stop bleeding. Magnesium sulfate would be administered for a client who presents with eclampsia to help decrease blood pressure. Nicardipine is also used to help lower blood pressure.
41 A client presents to the emergency department after falling off a ladder and is diagnosed with a spinal cord injury in the lower cervical area. Upon assessment, the client is awake and alert and their skin is warm and dry. The client reports severe headache, neck pain, and weakness in extremities. Vital signs include a heart rate of 118 beats per minute, respiratory rate of 27 breaths per minute, oxygen saturation of 87% on room air, and blood pressure of 78/42 mm Hg. Which assessment finding is most suggestive of neurogenic shock?
Incorrect. Please choose another answer.
Neurogenic shock occurs when there is a loss of sympathetic tone which results in peripheral vasodilation. Warm and dry skin is a hallmark sign due to vasodilation which leads the blood flow away from the skin. Tachycardia and tachypnea are seen initially in a client who presents with neurogenic shock but are not most suggestive of neurogenic shock. They occur due to compensatory mechanisms. A headache could be associated with a head injury and is not suggestive of neurogenic shock.
42 Ramona is a 21-year-old who has been admitted to the ICU after suffering an anaphylactic reaction during dinner due to peanut sauce in a dish that the host didn't tell her about. She was stabilized in the emergency room with IV epinephrine and IV diphenhydramine. However, 4 hours after being admitted to the ICU she becomes anxious, develops hives and begins to have difficulty breathing. What is the most likely cause for Ramona's symptoms?
Incorrect. Please choose another answer.
Ramona is experiencing biphasic anaphylaxis. The onset of the late phase varies, but usually occurs within 8-10 hours. Risk factors associated with biphasic anaphylaxis include severity of the initial phase, delayed or subtherapeutic dosing of epinephrine, initial airway edema or hypotension, delayed onset of symptoms after exposure, and a history of previous episodes of biphasic anaphylaxis.

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Behavior / Psychological 

43 A client is admitted following a motor vehicle accident and has severe anxiety and nightmares. The client reports intrusive thoughts and flashbacks related to the incident. The client has a history of post-traumatic stress disorder. Which intervention would the nurse prioritize in the management of this client?
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Post-traumatic stress disorder occurs when a client has experienced a traumatic event in their life which causes anxiety, flashbacks and nightmares. The most effective treatment for PTSD is cognitive-behavioral therapy. Alprazolam is a type of benzodiazepine which can help short-term with symptoms of anxiety but are not recommended due to concern for dependence. Fluoxetine is a type of selective serotonin reuptake inhibitor which is used as long term management in treating PTSD. A client taking medications should also always be in cognitive-behavioral therapy. Social work consult is not a priority at this time.
44 Madge is a 91-year-old nursing home resident with a history of dementia and atrial fibrillation who has been admitted to the ICU for treatment of pneumonia. As you are performing her bed bath, you note bruising around her breasts and genital area. What potential issue should be of major concern in Madge's situation?
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Bruising around the breasts and genitals should trigger concern for sexual abuse. Elder abuse is a growing problem in America, and nurses are uniquely positioned to recognize and intervene on the behalf of vulnerable populations, such as the elderly. According to the National Center of Elder Abuse (NCEA), major types of elder abuse include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation and self-neglect.
45 Jerry is a 55-year-old veteran who has been admitted after a motor vehicle accident with multiple injuries. His friend reported that he had been using synthetic marijuana prior to the accident, and that he also sees a psychiatrist at the VA hospital for an unknown diagnosis. He stated that Jerry sometimes gets "hyper" for no reason, starts "ranting" and becomes violent. Of the following, which general psychiatric disorder is characterized by a pattern of aggression or violence which includes irritability, agitation, and violent behavior during manic or psychotic episodes?
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The pattern of aggression or violence of bipolar disorder includes irritability, agitation, and violent behavior during manic or psychotic episodes, which is highly co-morbid with substance use, which worsens the prognosis. The Diagnostic and Statistical Manual of Mental Disorders identifies several disorders which may carry a higher risk for violent and/or aggressive behaviors, which is a concern when patients with co-morbid psychiatric disorders are admitted to the ICU or general floor for medical-surgical needs.

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Professional Caring and Ethical Practice 

46 Emily has been admitted to the ICU after being found unconscious on the street. She was found to be in diabetic ketoacidosis (DKA) with a blood sugar of 785. Emily is homeless, has had multiple admissions for DKA, and could benefit from use of an insulin pump, but says she has been repeatedly told, "Those are for rich people." What ethical principle supports Emily's right to have an insulin pump?
Incorrect. Please choose another answer.
The ethical principle of justice supports Emily's right to access of an insulin pump, since her socioeconomic status should not impact her ability to receive care. Nurses must advocate for equal treatment for all patients, regardless of circumstances.
47 Tonya is a 44-year-old with a history of substance abuse who has been admitted to the ICU status-post left lateral thoracotomy. She has been clean and sober for 14 years, and discussed her status with her physician prior to her surgery. When she arrives from the operating room, she is in a great deal of pain. Post-operative pain management orders are for acetaminophen only. When you ask the surgeon for an opioid for pain management, he states, "She's an addict. She doesn't need anything for pain." What should your first response be?
Incorrect. Please choose another answer.
Discussing the situation with the doctor privately and professionally will allow the doctor the opportunity to feel less threatened by your concerns. This provides the opportunity for both parties to express viewpoints, understand each other's perspectives, and build rapport, which will ultimately benefit the patient.

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48 The emergency room nurse is caring for a client who is admitted to the trauma bay after a motor vehicle accident. The nurse notes that the healthcare provider is rushing through the assessment and is not paying close attention to the client's neurological status or vital signs. The healthcare provider has ordered fentanyl to be administered. Which action would the nurse take to prioritize proper ethical care of the client?
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The nurse should advocate for the client because nurses have a duty to client safety which includes advocating for appropriate interventions to prevent harm. Nonmaleficence is the duty to do no harm and it is important for the nurse to promote client safety. Administering the ordered medication would go against the theory of nonmaleficence. Documenting a note in client's chart regarding the healthcare provider's actions in inappropriate and the nurse should directly talk to the healthcare provider regarding their concerns. Also, contacting the hospital's ethical committee would not be priority at this time.
49 The nurse is caring for a pediatric oncology client that has been withdrawn during this admission. The nurse sits with the client each day to play arts and crafts to help engage the client. Which ethical principle is the nurse demonstrating?
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Beneficence is the ethical principle that focuses on the duty to do good and promote well-being of others. The nurse is demonstrating beneficence because the nurse is spending time with the client to help engage them given they have been withdrawn. Nonmaleficence is the ethical principle that focuses on the duty to do no harm. Autonomy is the ethical principle that focuses on respecting the client's rights to make their own decisions regarding their care. Justice is the ethical principle that focuses on fairness regarding resources and treatment.

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50 Which ethical principle should the nurse uphold when a client reports past sexual abuse but asks that the nurse not repeat this information?
Incorrect. Please choose another answer.
Privacy is the ethical principle that focuses on respecting the client's right to maintain confidentiality. The nurse has to maintain confidentiality unless the client discloses they are wanting to harm themselves or others. Beneficence is the ethical principle that focuses on the duty to do good and promote well-being of others. Autonomy is the ethical principle that focuses on respecting the client's rights to make their own decisions regarding their care. Justice is the ethical principle that focuses on fairness regarding resources and treatment.

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Quality starts with who wrote the material. Our writers:

Sarah Morris, RN, MSN, CCRN,, is an adjunct instructor in the nursing program at The College of the Canyons. She also works in the neuro/trauma ICU at the UCLA Medical Center. Sarah has been in nursing for over ten years and a CCRN for over seven years.

Brynn Knibbe, RN, BSN, CCRN, has lectured at the University of Arizona BSN-MSN program on advanced CCRN level topics and precepted and mentored many nurse graduates in the ICU setting. She works in an intensive care unit at the Cleveland Clinic.

Shamin Hampton, RN, MSN, CCRN, worked as a critical care clinical unit leader in a hospital in Charlotte, North Carolina. He has worked in critical care for over ten years and is now an NP.

The CCRN focuses on two domains: Clinical Judgement and Professional Caring and Ethical Practice. Within these two domains, the following subject categories are covered:
  • Cardiovascular 
  • Respiratory
  • Endocrine
  • Hematology / Immunity
  • Integumentary
  • Musculoskeletal
  • Physiosocial
  • Neurology
  • Gastrointestinal
  • Renal
  • Multisystem
  • Caring Practices
  • Collaboration
  • Systems Thinking
  • Clinical Inquiry
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