ICU Basics

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Free PCCN practice questions

15 free PCCN practice questions from the ICU Basics bank of 901, each with the answer and a rationale for every choice. Try them here, then practice the rest free in your browser. No account, no ads.

The PCCN exam has 150 questions (125 scored and 25 unscored pretest questions) with a 3-hour limit. Topic percentages follow the AACN PCCN test plan for exams taken on or after February 6, 2024.

From the live ICU Basics bank. How questions are written and reviewed · PCCN Exam Guide

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Question 1 · Cardiovascular

Four patients with heart failure are being considered for cardiac resynchronization therapy (CRT). Which patient has the STRONGEST indication?

  1. EF 30%, NYHA III, sinus rhythm, LBBB with QRS 162 ms
  2. EF 30%, NYHA III on GDMT, narrow QRS of 98 ms
  3. EF 55%, NYHA II, LBBB with a QRS of 150 ms
  4. EF 30%, NYHA I, RBBB with a QRS of 128 ms
Show the answer and rationale

Answer: A

  • A. Correct. EF of 35% or less, LBBB with QRS of 150 ms or more, sinus rhythm, and symptoms on GDMT is a Class I indication.
  • B. CRT offers no benefit, and may cause harm, with a narrow QRS.
  • C. CRT is indicated for reduced EF, not preserved EF with isolated conduction disease.
  • D. A non-LBBB pattern with a QRS below 150 ms in an asymptomatic patient is a weak or no indication.

CRT (biventricular pacing) paces the RV and LV (through a coronary sinus branch) to correct the delayed lateral wall activation caused by LBBB. This improves EF, reverses remodeling, reduces MR, and lowers mortality. Benefit is greatest with LVEF of 35% or less, LBBB morphology, QRS of 150 ms or more, and symptoms despite at least 3 months of GDMT. Patients often receive a combined CRT-D device. A high percentage of biventricular pacing (above about 98%) is needed for full benefit.

Sources: AHA/ACC/HFSA Heart Failure Guideline (2022); Braunwald's Heart Disease, 12th ed.

Question 2 · Cardiovascular

A 72-year-old woman with newly diagnosed atrial fibrillation has hypertension and type 2 diabetes. She has no history of stroke, HF, or vascular disease. What is her CHA₂DS₂-VASc score, and what does it indicate?

  1. 5; anticoagulation is contraindicated at her age
  2. 2; aspirin alone provides adequate protection
  3. 4; oral anticoagulation is recommended
  4. 3; anticoagulation is optional at this score
Show the answer and rationale

Answer: C

  • A. Age is not a contraindication; older patients benefit most from anticoagulation.
  • B. The score is higher, and aspirin is not an adequate stroke-prevention strategy in AF.
  • C. Correct. Age 65–74, female sex, hypertension, and diabetes each add 1 point.
  • D. The score is 4, and anticoagulation is recommended rather than optional.

CHA₂DS₂-VASc assigns 1 point each for congestive HF, hypertension, age 65–74, diabetes, vascular disease, and female sex, and 2 points each for age 75 or older and prior stroke, TIA, or thromboembolism. This patient scores 4. Oral anticoagulation, preferably with a DOAC, is recommended for a score of 2 or more in men or 3 or more in women (the 2023 ACC/AHA/HRS guideline frames this as an annual stroke risk of about 2% or more). Aspirin is not an adequate alternative.

Sources: ACC/AHA/ACCP/HRS AF Guideline (2023); Jacobson, CV Nursing Practice, 3rd ed.

Question 3 · Cardiovascular

A patient with heart failure with reduced ejection fraction (EF 25%) is ready for discharge on carvedilol, sacubitril-valsartan, spironolactone, and empagliflozin. Which instruction is MOST important to prevent readmission?

  1. Hold the carvedilol on any morning your heart rate is below 70 and restart it the next day
  2. Take the spironolactone with a potassium supplement so your levels do not drop
  3. Weigh yourself each morning and call for a gain of 3 lb in a day or 5 lb in a week
  4. Limit fluids to 500 mL a day and avoid salt entirely until the swelling is gone
Show the answer and rationale

Answer: C

  • A. Beta-blockers are continued unless the patient is symptomatic; a rate of 60 to 70 is the goal, not a reason to stop.
  • B. Spironolactone and sacubitril-valsartan both raise potassium; supplements would risk dangerous hyperkalemia.
  • C. Correct. Daily weights detect fluid retention days before dyspnea, allowing early diuretic adjustment at home.
  • D. Severe restriction is unnecessary and risks dehydration and kidney injury; 1.5 to 2 L is typical only when hyponatremic.

Most heart failure readmissions follow gradual fluid accumulation. Daily morning weights with clear thresholds for calling are the highest-yield self-management teaching, paired with a low-sodium diet and knowing which medications to take. Weight changes precede symptoms by several days.

Sources: AACN Essentials of Progressive Care, 5th ed.; AHA/ACC/HFSA Heart Failure Guideline (2022); ACC Hospitalized HF Decision Pathway (2024)

Question 4 · Respiratory

A patient with a COPD exacerbation has an ABG of pH 7.28, PaCO₂ 65 mm Hg, HCO₃⁻ 30 mEq/L, PaO₂ 55 mm Hg. The patient’s baseline ABG last month was pH 7.36, PaCO₂ 55 mm Hg, HCO₃⁻ 30 mEq/L. Which interpretation is MOST accurate?

  1. Fully compensated respiratory acidosis
  2. Uncompensated acute respiratory acidosis
  3. Metabolic acidosis with respiratory compensation
  4. Partially compensated respiratory acidosis
Show the answer and rationale

Answer: D

  • A. The pH of 7.28 is outside the normal range, so compensation is not complete.
  • B. The elevated HCO₃⁻ reflects preexisting chronic compensation.
  • C. The HCO₃⁻ is elevated, not low. The primary process is respiratory.
  • D. Correct. The PaCO₂ has risen acutely above the chronically compensated baseline, so the pH is no longer normal.

The pH is acidemic with an elevated PaCO₂, so the primary disorder is respiratory acidosis. The HCO₃⁻ is elevated, showing partial compensation. Comparison with the baseline reveals an acute-on-chronic process: the chronic compensation (HCO₃⁻ 30) is now overwhelmed by an acute CO₂ rise. This pattern supports NIV if the pH is 7.35 or below and PaCO₂ is 45 or above. Oxygen is titrated to SpO₂ 88–92%.

Sources: Mosby's Diagnostic & Lab Reference, 17th ed.; AACN Core Curriculum, 8th ed.; GOLD COPD Report (2026)

Question 5 · Respiratory

A patient with multilobar pneumonia on high-flow nasal cannula (60 L/min, FiO₂ 1.0) has RR 38, accessory muscle use, and diaphoresis. ABG: pH 7.21, PaCO₂ 65 mm Hg, PaO₂ 55 mm Hg. The ROX index has fallen over 6 hours. The nurse anticipates:

  1. IV sodium bicarbonate to correct the acidemia
  2. Continuous nebulized albuterol therapy
  3. A trial of BiPAP for 2 hours before deciding
  4. Endotracheal intubation and ventilation
Show the answer and rationale

Answer: D

  • A. The acidosis is respiratory. Bicarbonate does not fix ventilatory failure.
  • B. Bronchodilators do not treat pneumonia-related hypoxemic respiratory failure.
  • C. In severe hypoxemic failure with worsening acidosis, trialing NIV delays needed intubation and raises mortality.
  • D. Correct. Hypoxemia, new hypercapnic acidosis, and exhaustion on maximal HFNC indicate failure.

High-flow nasal cannula provides heated, humidified, high-FiO₂ flow with a small PEEP effect and CO₂ washout. The ROX index ((SpO₂/FiO₂) ÷ RR) helps predict HFNC failure, with values below about 3.85 at 12 hours or a falling trend being concerning. New hypercapnia and acidosis in hypoxemic failure signal fatigue. Delayed intubation after failed noninvasive support is associated with higher mortality, so timely escalation is essential.

Sources: AACN Core Curriculum, 8th ed.; ERS High-Flow Nasal Cannula Guideline (2022)

Question 6 · Endocrine, Heme, Neuro, GI, Renal

A patient is receiving the IV N-acetylcysteine loading infusion for acetaminophen overdose. Twenty minutes in, the patient develops flushing, urticaria, and mild wheezing. BP is 118/72 mm Hg, and SpO₂ is 95%. Which action is MOST appropriate?

  1. Stop NAC permanently and switch to activated charcoal
  2. Give IM epinephrine and cancel all further NAC
  3. Continue the infusion at the same rate and observe
  4. Pause, give an antihistamine, restart slower
Show the answer and rationale

Answer: D

  • A. NAC is essential, and charcoal is useful only very early after ingestion.
  • B. Epinephrine is for severe reactions with hypotension or airway compromise. NAC is rarely abandoned.
  • C. Continuing the loading rate despite symptoms risks progression.
  • D. Correct. Anaphylactoid reactions to IV NAC are rate-related and usually mild, so the infusion can resume once symptoms resolve.

N-acetylcysteine replenishes glutathione and detoxifies NAPQI, the hepatotoxic metabolite of acetaminophen. It is most effective within 8 hours but is still beneficial later, even in established hepatotoxicity. IV NAC causes non-IgE anaphylactoid reactions (flushing, urticaria, bronchospasm) in up to about 15% of patients, mostly during the loading dose. Management is to pause, treat symptoms, and resume at a slower rate. Newer two-bag regimens reduce these reactions.

Sources: Mosby's 2026 Nursing Drug Reference; AACN Core Curriculum, 8th ed.

Question 7 · Endocrine, Heme, Neuro, GI, Renal

Twenty-four hours after subtotal thyroidectomy for poorly controlled Graves disease, a patient develops a temperature of 40.3°C, AF at 162/min, agitation, tremor, and diarrhea. Which condition is MOST likely?

  1. Thyroid storm
  2. Hypocalcemia from parathyroid injury
  3. Malignant hyperthermia
  4. Postoperative sepsis
Show the answer and rationale

Answer: A

  • A. Correct. Surgical stress in inadequately treated hyperthyroidism can trigger a life-threatening hypermetabolic crisis.
  • B. Hypocalcemia causes tetany and paresthesias, not hyperthermia and tachyarrhythmia.
  • C. MH occurs during or soon after anesthesia, with rigidity, hypercarbia, and rising EtCO₂.
  • D. Sepsis is possible, but the timing after thyroid surgery in poorly controlled Graves disease points to thyroid storm.

Thyroid storm is precipitated by surgery, infection, iodinated contrast, or stopping antithyroid drugs. It presents with hyperpyrexia, tachyarrhythmias (often AF), heart failure, agitation or delirium, and GI symptoms. The Burch–Wartofsky score aids diagnosis. Treatment includes β-blockers, thionamides, iodine (at least 1 hour after the thionamide), glucocorticoids, cooling with acetaminophen, and supportive ICU care. Patients are rendered euthyroid before elective thyroid surgery to prevent it.

Sources: AACN Core Curriculum, 8th ed.; Banasik, Pathophysiology, 7th ed.

Question 8 · Endocrine, Heme, Neuro, GI, Renal

A patient with DKA has these initial labs: pH 7.04, HCO₃⁻ 4 mEq/L, K⁺ 4.6 mEq/L, and glucose 480 mg/dL. The resident asks whether sodium bicarbonate should be given. According to ADA guidance, bicarbonate is generally indicated in DKA when the pH is:

  1. Below 7.30
  2. Below 7.00
  3. Only after the potassium is above 5.5 mEq/L
  4. Below 7.20
Show the answer and rationale

Answer: B

  • A. This is the diagnostic threshold for DKA, not a treatment threshold for bicarbonate.
  • B. Correct. Current ADA consensus limits bicarbonate to severe acidemia (pH below 7.0).
  • C. Bicarbonate is not a potassium-lowering strategy in DKA, and the potassium here is normal; the decision rests on the severity of the acidemia alone.
  • D. Bicarbonate at this pH has not been shown to benefit patients and adds risk.

In DKA, insulin and fluids correct the ketoacidosis. Routine bicarbonate does not improve outcomes and can worsen hypokalemia, cause paradoxical CSF acidosis, delay ketone clearance, and cause volume or sodium overload. The 2024 ADA consensus suggests considering bicarbonate only when pH is below 7.0, with potassium replacement if needed. This patient’s pH of 7.04 does not meet the threshold, so fluids and insulin remain the priority.

Sources: ADA Standards of Care in Diabetes (2025); ADA Hyperglycemic Crises Consensus (2024)

Question 9 · Endocrine, Heme, Neuro, GI, Renal

A patient with an acute ischemic stroke is otherwise eligible for IV thrombolysis, but BP is 220/120 mm Hg. Which action by the nurse is the priority?

  1. Start the thrombolytic now, since the BP is compensatory
  2. Give labetalol or nicardipine to below 185/110, then treat
  3. Use nitroprusside to lower the BP below 140/90 first
  4. Hold thrombolysis, since any hypertension excludes it
Show the answer and rationale

Answer: B

  • A. Thrombolysis with BP above 185/110 greatly increases the risk of hemorrhage.
  • B. Correct. BP must be lowered below 185/110 before thrombolysis and kept below 180/105 for 24 hours afterward.
  • C. An aggressive target and rapid drop can reduce penumbral perfusion.
  • D. Hypertension that can be controlled does not exclude treatment.

Before IV alteplase or tenecteplase, BP must be below 185/110 using labetalol, nicardipine, or clevidipine. If it cannot be controlled, thrombolysis is not given. After treatment, BP is kept below 180/105 for 24 hours, with checks every 15 minutes for 2 hours, every 30 minutes for 6 hours, then hourly for 16 hours, along with neurologic checks, and antithrombotics are held for 24 hours.

Sources: AACN Core Curriculum, 8th ed.; AHA ACLS Provider Manual (2025); AHA/ASA Acute Ischemic Stroke (2026)

Question 10 · Musculoskeletal, Multisystem, Behavioral

A patient recovering from hip surgery becomes increasingly agitated, pacing and shouting at staff. The patient has no history of dementia. Which approach should the nurse use FIRST?

  1. Call security to stand by and prepare restraints in case of escalation
  2. Speak calmly, offer choices, and check for pain, hypoxia, or withdrawal
  3. Leave the room and return in 30 minutes once the patient has settled
  4. Give the ordered PRN haloperidol before approaching the patient
Show the answer and rationale

Answer: B

  • A. A show of force escalates most situations; restraints are a last resort after de-escalation fails and there is imminent danger.
  • B. Correct. Verbal de-escalation combined with a search for a medical cause is the first-line approach to agitation.
  • C. Leaving an escalating patient alone can result in injury and misses a possible acute medical cause.
  • D. Medication is used when de-escalation fails or there is danger, and only after treatable causes are considered.

New agitation in a hospitalized patient is often driven by pain, hypoxia, hypoglycemia, infection, urinary retention, withdrawal, or medication effects. De-escalation includes a calm tone, non-threatening posture, one speaker, listening, setting clear limits, and offering choices. Chemical or physical restraint is reserved for imminent danger, with the least restrictive option used.

Sources: AACN Core Curriculum, 8th ed.; AACN Essentials of Progressive Care, 5th ed.

Question 11 · Musculoskeletal, Multisystem, Behavioral

Which medication overdose is MOST likely to produce a distributive shock profile, with a low SVR and a normal or high cardiac output?

  1. Digoxin
  2. Furosemide
  3. Amlodipine
  4. Metoprolol
Show the answer and rationale

Answer: C

  • A. Digoxin toxicity causes arrhythmias and heart block, not primary vasodilation.
  • B. Diuretic excess causes volume depletion, a hypovolemic profile.
  • C. Correct. Dihydropyridine CCBs cause profound arteriolar vasodilation with reflex tachycardia, a distributive profile.
  • D. β-blocker overdose mainly causes bradycardia and depressed contractility, a cardiogenic profile.

Dihydropyridine calcium channel blockers (amlodipine, nifedipine) mainly block vascular L-type channels and cause vasodilatory shock. At very high doses they lose selectivity and can depress the heart as well. Non-dihydropyridines (verapamil, diltiazem) and β-blockers mainly cause bradycardia and myocardial depression. Management includes calcium, vasopressors, high-dose insulin euglycemia therapy, and, for refractory cases, methylene blue or ECMO. Anesthetic and sedative agents also cause distributive hypotension.

Sources: AACN Core Curriculum, 8th ed.; Sheehy's Manual of Emergency Care, 8th ed.; AHA 2025 Part 10: Special Circumstances

Question 12 · Musculoskeletal, Multisystem, Behavioral

A patient with a gastrointestinal bleed has received 2 units of packed red cells and is on the progressive care unit. HR is 124, BP 88/50 mm Hg, skin is cool and clammy, and urine output has been 15 mL/hr for 3 hours. Which finding BEST indicates that shock is progressing despite treatment?

  1. Hemoglobin of 8.2 g/dL after transfusion
  2. Lactate rising from 2.8 to 5.1 mmol/L
  3. Mild anxiety and restlessness
  4. Capillary refill of 3 seconds
Show the answer and rationale

Answer: B

  • A. Hemoglobin lags behind acute bleeding and does not reflect perfusion.
  • B. Correct. A rising lactate reflects worsening tissue hypoperfusion and anaerobic metabolism, the defining feature of progressing shock.
  • C. Anxiety can be an early sign of hypoperfusion but is nonspecific.
  • D. Delayed capillary refill suggests poor perfusion but is less reliable than lactate trend.

Hypovolemic shock from hemorrhage causes compensatory tachycardia and vasoconstriction. Cool skin, low urine output, and rising lactate show that compensation is failing. Management is stopping the bleeding (endoscopy, surgery, or interventional radiology), balanced transfusion, and correcting coagulopathy. A rising lactate after treatment means escalation is needed.

Sources: AACN Core Curriculum, 8th ed.; Baird, Manual of Critical Care, 8th ed.

Question 13 · Professional Caring & Ethical Practice

After the surgeon explains a proposed procedure and leaves, the patient tells the nurse, “I didn’t understand what he said, but I signed the paper anyway.” The procedure is scheduled for later today. What is the nurse’s MOST appropriate action?

  1. Explain the procedure’s risks and benefits to the patient
  2. Notify the surgeon that the patient needs more explanation first
  3. Send the patient, since the consent form is already signed
  4. Explain the procedure to the patient yourself and have the form re-signed
Show the answer and rationale

Answer: B

  • A. The consent discussion is the performing provider’s responsibility, although the nurse can clarify and reinforce.
  • B. Correct. The nurse advocates by pausing the process until the patient understands.
  • C. A signature without understanding is not valid informed consent.
  • D. Informed consent is obtained by the person performing the procedure. The nurse can reinforce information but cannot substitute for the surgeon’s explanation.

Informed consent is a process, not a signature. It requires disclosure, understanding, voluntariness, and capacity. When a patient indicates that they do not understand, the nurse should notify the provider, arrange an interpreter or teaching aids if needed, and ensure the procedure does not proceed until valid consent is obtained. Afterward, the nurse can reinforce and clarify information within their scope.

Sources: ANA Code of Ethics for Nurses (2025); Morton, Critical Care Nursing, 12th ed.

Question 14 · Professional Caring & Ethical Practice

A patient asks the nurse, “Did the team make a mistake with my medication yesterday?” A dose was in fact given 4 hours late. Which ethical principle MOST directly guides an honest answer?

  1. Veracity
  2. Paternalism
  3. Justice
  4. Fidelity
Show the answer and rationale

Answer: A

  • A. Correct. Veracity is the duty to tell the truth.
  • B. Paternalism means overriding a person’s wishes for their supposed good.
  • C. Justice concerns fair distribution of resources and treatment.
  • D. Fidelity is keeping promises and commitments.

Veracity (truthfulness) supports honest communication with patients, including disclosure of errors, which is also expected by professional and regulatory standards. Disclosure typically involves acknowledging what happened, expressing regret, explaining what is being done, and describing steps to prevent recurrence, often coordinated with the provider and risk management. Honest disclosure maintains trust.

Sources: ANA Code of Ethics for Nurses (2025); Johnstone, Bioethics, 7th ed.

Question 15 · Professional Caring & Ethical Practice

Over 2 years, an experienced ICU nurse has helped a newer colleague through difficult cases, discussed career goals and certification, and offered emotional support after patient deaths. This relationship BEST describes the experienced nurse as a:

  1. Mentor
  2. Clinical educator
  3. Preceptor
  4. Charge nurse
Show the answer and rationale

Answer: A

  • A. Correct. Mentoring is a longer-term, voluntary relationship focused on holistic professional growth.
  • B. An educator provides formal, structured education programs.
  • C. A preceptor provides time-limited clinical orientation to skills and unit routines.
  • D. A charge nurse coordinates unit operations during a shift.

Preceptorship is a structured, time-limited relationship for orienting a nurse to a role and its skills. Mentorship is a longer, often informal relationship that supports career development, professional identity, resilience, and navigating the organization. Mentoring improves retention and job satisfaction, especially for newer critical care nurses, and supports a healthy work environment.

Sources: Synergy for Clinical Excellence, 2nd ed.; AACN Synergy Model for Patient Care

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