Free CCRN (Adult) practice questions

Answer: D

• A. Increased work of breathing raises oxygen consumption.
• B. Lower hemoglobin reduces oxygen delivery, which lowers SvO₂.
• C. Fever increases metabolic rate and oxygen consumption, which lowers SvO₂.
• D. Correct. Reducing pain, agitation, and work of breathing lowers VO₂, so more oxygen remains in venous blood.

SvO₂ (normal 60–75%) reflects the balance between oxygen delivery (cardiac output, hemoglobin, SaO₂) and consumption (VO₂). It falls when delivery drops or consumption rises (fever, shivering, pain, agitation, seizures, work of breathing, suctioning). It rises when consumption falls (sedation, paralysis, hypothermia) or delivery improves. Brief drops during turning or suctioning that recover quickly are expected. Sustained drops require investigation.

Sources: Lough, Hemodynamic Monitoring (2015); AACN Essentials of Critical Care, 5th ed.

Answer: C

• A. Flexion of the cannulated leg can kink the catheter or impair distal perfusion.
• B. Sitting in a chair flexes the hip, which is not appropriate with a femoral IABP.
• C. Correct. Limiting hip flexion prevents catheter kinking, migration, and limb ischemia.
• D. Sharp hip flexion can kink or displace the catheter and push the balloon upward.

With a femoral IABP, the head of the bed is generally kept at 30° or less, the cannulated leg straight (a knee immobilizer may be used), and the patient is log-rolled to turn. This prevents kinking, migration, and bleeding. Hourly checks include distal pulses and limb perfusion on the insertion side, left radial pulse (to detect proximal migration), urine output (to detect distal migration), insertion-site bleeding, platelet count, and IABP timing. Axillary IABP insertion allows more mobility when prolonged support is needed.

Sources: AACN Procedure Manual, 8th ed.; AACN Essentials of Critical Care, 5th ed.

Answer: D

• A. Paralysis can be used in either position when indicated.
• B. Neuromuscular blockade is suggested for ARDS with P/F below 150 and persistent hypoxemia or dyssynchrony despite sedation, not as a condition of proning; a well-synchronized, deeply sedated patient can be proned without it.
• C. Many patients are proned safely with deep sedation alone.
• D. Correct. The benefit comes from gravitational and mechanical effects. NMBAs are added for persistent hypoxemia or dyssynchrony not controlled by sedation, not for the turn itself.

Prone positioning improves oxygenation and survival through mechanical effects (recruiting dorsal lung, making ventilation more even, relieving cardiac compression) that do not depend on muscle tone. Adequate sedation is needed to tolerate the position and turn. SCCM 2026 found equipoise on giving NMBAs because a patient is proned, so paralysis is not a prerequisite for turning. It suggests NMBAs when P/F is below 150 and the patient stays hypoxemic or misses ventilator targets on sedation (ongoing dyssynchrony, high respiratory drive, or inability to maintain lung-protective settings), and ATS 2024 suggests them in early severe ARDS (P/F 100 or less, within 48 hours of onset). Avoiding unnecessary paralysis reduces weakness and other complications.

Sources: Urden, Critical Care Nursing, 10th ed.; SCCM NMB in ARDS Guideline (2026); ATS ARDS Guideline Update (2024)

Answer: B

• A. Ambrisentan treats group 1 PAH, but in interstitial lung disease it was associated with more clinical worsening, with or without PH.
• B. Correct. Inhaled treprostinil is approved for pulmonary hypertension associated with interstitial lung disease (WHO group 3) to improve exercise ability.
• C. Riociguat is approved for CTEPH and PAH but is contraindicated in pulmonary hypertension with idiopathic interstitial pneumonias, where it was linked to worse outcomes.
• D. Sildenafil treats group 1 PAH, but its phase 3 trials in interstitial lung disease were negative.

Pulmonary hypertension caused by lung disease is WHO group 3, and treatment starts with the lung disease itself: oxygen, ventilatory support where indicated and rehabilitation. Drugs approved for group 1 PAH are not routinely recommended in this group, and endothelin receptor antagonists, sildenafil and riociguat have failed or caused harm in interstitial lung disease. Inhaled treprostinil, a prostacyclin analog, improved 6-minute walk distance in the INCREASE trial and is approved for PH-ILD. Cough and headache are its most common adverse effects, it can cause bronchospasm and hypotension, and eligible patients should be referred for transplant evaluation.

Sources: FDA Prescribing Information (DailyMed); StatPearls (NCBI Bookshelf)

Answer: A

• A. Correct. The patient is short of water, not sodium, and the gut works, so enteral water through the tube replaces the deficit gradually.
• B. A concentrated formula delivers even less water with the same solute, so it would push the sodium higher rather than lower.
• C. Saline is tempting for a rising BUN, but the patient is hemodynamically stable, and isotonic saline adds sodium without correcting a free water deficit.
• D. Desmopressin treats central diabetes insipidus, which produces large volumes of dilute urine; this urine is concentrated and the volume is modest.

Hypernatremia is common in older adults receiving tube feedings, because they cannot reach water when thirsty. A urine osmolality of 810 mOsm/kg means the kidneys are concentrating maximally, which rules out diabetes insipidus and points to too little water intake for the solute being delivered; the high BUN-to-creatinine ratio fits that deficit. Replacing the free water deficit is the main goal; water by mouth or tube works when the gut functions, and IV hydration is preferred for severe hypernatremia or when the patient cannot take water enterally. Because this sodium rose over days, it is lowered over about 48 hours, with serum osmolality falling no faster than 0.5 mOsm/L per hour, so cerebral edema does not develop in brain cells that have adapted.

Sources: Merck Manual, Professional Version

Answer: D

• A. This patient is profoundly volume-depleted, so fluids are the priority.
• B. Slow replacement is for the remaining deficit after shock is corrected, not during hypovolemic shock.
• C. Enteral free water does not restore circulating volume quickly enough in shock.
• D. Correct. Shock takes priority. Isotonic boluses restore perfusion, and then the remaining deficit is replaced more gradually.

In HHS or DKA with shock, the first priority is restoring perfusion with rapid isotonic crystalloid boluses (often 1–2 L in the first hour, more as needed), reassessing after each bolus. Once shock resolves, the remaining deficit is replaced over about 24–48 hours with attention to the corrected sodium and osmolality. Older adults with HHS may have heart or kidney disease, which requires careful volume assessment.

Sources: AACN Core Curriculum, 8th ed.; ADA Hyperglycemic Crises Consensus (2024)

Answer: A

• A. Correct. Low magnesium releases inhibition of renal ROMK channels, causing ongoing potassium wasting despite replacement.
• B. Phosphate falls during DKA treatment but does not cause renal potassium wasting.
• C. Hypernatremia does not directly cause renal potassium wasting.
• D. Low calcium does not cause refractory hypokalemia.

Osmotic diuresis in DKA depletes magnesium as well as potassium and phosphate. Intracellular magnesium normally inhibits potassium secretion through ROMK channels in the collecting duct. When magnesium is low, potassium keeps leaking into the urine, so hypokalemia will not correct until magnesium is replaced. Low magnesium and potassium together also increase the risk of arrhythmias (torsades).

Sources: AACN Core Curriculum, 8th ed.; Urden, Critical Care Nursing, 10th ed.; KDIGO Dyskalemia Conference Report (2020)

Answer: B

• A. This is 35 units/kg, the label dose for an INR of 4 to 6; at an INR of 3.4 it overdoses factor concentrate and adds thrombotic risk.
• B. Correct. An INR of 2 to under 4 calls for 25 units/kg (82 kg × 25 = 2,050 units), and vitamin K is given concurrently.
• C. The dose is right, but vitamin K is given with PCC, not after; without it the INR rises again once the infused factors are cleared.
• D. This is the 50 units/kg band for an INR above 6, and the label does not recommend repeat dosing because its safety has not been established.

Kcentra is dosed in units of factor IX by the pretreatment INR: 25 units/kg (maximum 2,500) for an INR of 2 to under 4, 35 units/kg (maximum 3,500) for 4 to 6, and 50 units/kg (maximum 5,000) above 6, using actual weight up to 100 kg. Vitamin K is given concurrently because the infused factors wear off while the liver still cannot make its own. Repeat dosing is not recommended. The boxed warning is arterial and venous thrombosis, a real concern with a mechanical valve, but life-threatening intracranial bleeding takes priority.

Sources: FDA Prescribing Information (DailyMed); Merck Manual, Professional Version

Answer: C

• A. Nicardipine has no antidote properties. Cyanide toxicity is a risk with nitroprusside.
• B. Nitroprusside dilates both arteries and veins.
• C. Correct. Nitric oxide–mediated cerebral vasodilation increases cerebral blood volume and ICP.
• D. Nicardipine is not used for sedation.

Nitroprusside is a potent NO donor that dilates cerebral vessels, which can increase cerebral blood volume and ICP. It also carries a risk of cyanide and thiocyanate toxicity with prolonged or high-dose use, especially in renal or hepatic impairment. Nicardipine, a dihydropyridine calcium channel blocker, provides titratable arterial vasodilation with less effect on ICP. Clevidipine is another option, and labetalol is commonly used as well.

Sources: Hickey & Strayer, Neuro Nursing, 8th ed.; Urden, Critical Care Nursing, 10th ed.

Answer: B

• A. Randomized trials found no benefit from corticosteroids in GBS, and oral steroids worsened outcome, so they are not the response to a fluctuation.
• B. Correct. Worsening within 2 months after an initial response is a treatment-related fluctuation, which usually responds to restarting the therapy already given.
• C. Acute-onset CIDP is considered after three or more fluctuations or deterioration 8 weeks or more after onset; this is a first fluctuation at day 26.
• D. That reasoning fits a patient who never responded; this patient improved first, which suggests the treatment effect wore off while the inflammation continued.

About 6% to 10% of patients with GBS have a treatment-related fluctuation, defined as worsening within 2 months after improvement or stabilization on IVIG or plasma exchange. The usual explanation is that the treatment effect wore off while the inflammatory phase continued, so repeating the full course of the same therapy is common practice, although trial evidence is limited. A fluctuation differs from a patient who never responds, in whom repeating treatment has no proven benefit. New coughing with drinking signals bulbar weakness, so the nurse also checks swallowing and serial vital capacity.

Sources: StatPearls (NCBI Bookshelf)

Answer: C

• A. Although steroids can blunt fever, temperature change is not the therapeutic goal.
• B. Steroids have no antimicrobial activity.
• C. Correct. Cortisol restores vascular responsiveness to catecholamines and speeds shock reversal.
• D. Renal effects are not the expected therapeutic endpoint.

Critical illness–related corticosteroid insufficiency is an inadequate cortisol response for the severity of illness. Hydrocortisone (200 mg/day) enhances α-adrenergic receptor responsiveness and vascular tone, reduces inflammation, and speeds shock reversal, allowing earlier vasopressor weaning. The SSC 2026 guideline suggests IV corticosteroids in septic shock without setting a dose or norepinephrine trigger (the SSC 2021 trigger was 0.25 mcg/kg/min or more); 200 mg/day remains the usual regimen. Adverse effects include hyperglycemia, hypernatremia, muscle weakness, and possible superinfection. It is stopped, with or without a taper, once vasopressors are discontinued.

Sources: AACN Core Curriculum, 8th ed.; Surviving Sepsis Campaign 2026; SCCM Corticosteroid Focused Update (2024)

Answer: C

• A. Higher continuous circuit flow reduces native ejection, so pulsatility decreases.
• B. VA ECMO provides circulatory support and directly changes the arterial pressure profile.
• C. Correct. Continuous flow supplies more of the output and raises LV afterload, so native ejection and pulsatility fall.
• D. Diastolic augmentation is characteristic of an IABP, not ECMO.

VA ECMO drains venous blood, oxygenates it, and returns it to the arterial system, providing both cardiac and respiratory support. As circuit flow rises, it supplies more of the systemic output and increases LV afterload, so native ejection and pulse pressure fall. A pulse pressure below about 10 mm Hg or a flat arterial waveform warns that the aortic valve may not be opening, with a risk of LV distension and thrombus. Some pulsatility is monitored, and inotropes or LV venting are used as needed.

Sources: ELSO Red Book, 6th ed.; Bojar, Cardiac Surgery Periop Care, 6th ed.

Answer: D

• A. Palliative sedation is an accepted practice distinct from euthanasia.
• B. Doses are titrated to comfort, not beyond it.
• C. Decisions about nutrition are separate and individualized.
• D. Correct. Palliative sedation is titrated to relieve refractory suffering, while euthanasia intends death.

Proportional palliative sedation lowers consciousness only as much as needed to relieve refractory symptoms (such as dyspnea, delirium, or pain) in patients near the end of life, after other treatments have failed. It is guided by the principle of double effect: the intended effect is relief of suffering, while a possible hastening of death is foreseen but not intended, and when titrated appropriately it has not been shown to shorten life. Documentation includes the refractory symptoms, goals, consent, and titration.

Sources: ANA Code of Ethics for Nurses (2025); Ferrell, Oxford Palliative Nursing, 5th ed.; Johnstone, Bioethics, 7th ed.

Answer: B

• A. Reporting requires reasonable suspicion, not proof.
• B. Correct. Nurses are mandated reporters and must report reasonable suspicion of elder abuse.
• C. Questioning the suspected abuser can escalate the risk to the patient. The nurse reports to protective services and lets trained investigators proceed.
• D. Confrontation may endanger the patient and is not the reporting process.

Elder abuse includes physical, emotional, and sexual abuse, neglect, and financial exploitation. Warning signs include unexplained injuries in various stages of healing, injuries in protected areas, fear of a caregiver, poor hygiene, and inconsistent explanations. Nurses are mandated reporters in most states and report reasonable suspicion to adult protective services or as policy directs, while documenting objective findings, ensuring the patient’s safety, and involving social work. Proof is not required.

Sources: ANA Code of Ethics for Nurses (2025); Meiner, Gerontologic Nursing, 6th ed.; AACN Core Curriculum, 8th ed.

Answer: D

• A. Teaching the wife is needed, but planning to be the only source of preparation and support, with one strategy, matches the level 1 descriptors: the nurse sees self as the key resource and uses a limited array of strategies.
• B. Tempting because it reaches beyond the nurse, but recognizing how to obtain resources beyond self is a level 3 descriptor; the nurse hands the problem on without anticipating needs or negotiating on the family's behalf.
• C. Seeing the patient and family within the isolated environment of the unit is a level 1 descriptor; the nurse does not see the transition as part of nursing care.
• D. Correct. Anticipating the needs of patients and families as they move through the system, and knowing when and how to negotiate on their behalf, are level 5 descriptors of systems thinking.

In the AACN Synergy Model, systems thinking is the knowledge and tools that let the nurse manage whatever environmental and system resources exist for the patient, family and staff, within and across health care and non-health care systems. Level 1 sees the parts, not the whole, sees the patient only within the unit and the nurse as the key resource. Level 3 builds strategies on the family's needs and knows how to get resources beyond self but may lack a way to negotiate. Level 5 sees the whole, anticipates needs across transitions, negotiates on the family's behalf and uses untapped resources.

Sources: AACN Synergy Model for Patient Care