**The Science of Safe Passage: Critical Care Nursing
Certification Review Exam (CCRN) 2024 – Advanced
Practice Edition**
---
**Question 1**
A nurse in the intensive care unit (ICU) is caring for a client with severe sepsis who is receiving
norepinephrine (Levophed) via central line. The client’s blood pressure is 80/50 mm Hg, heart rate 120
bpm, and central venous pressure (CVP) is 6 mm Hg. Which of the following interventions should the
nurse anticipate first?
A. Increase the norepinephrine infusion rate.
B. Administer a 500 mL bolus of isotonic crystalloid.
C. Start a second vasopressor (vasopressin).
D. Obtain a stat lactate level.
💫RATIONALE✔️✔️: In severe sepsis with hypotension (MAP <65) and CVP <8 mm Hg, the Surviving Sepsis
Campaign guidelines recommend initial fluid resuscitation (30 mL/kg crystalloid) before titrating
vasopressors. Fluid bolus is first-line to increase preload. Vasopressors are added if fluid refractory.
Lactate is important but not the first action.
💫ANSWER✔️✔️: B. Administer a 500 mL bolus of isotonic crystalloid.
---
**Question 2**
A nurse is caring for a client who is mechanically ventilated in pressure control mode. The set inspiratory
pressure is 20 cm H₂O, PEEP 5 cm H₂O, rate 12 breaths/min. The client’s exhaled tidal volume is 350 mL
(ideal body weight 70 kg). Which of the following actions should the nurse take?
A. Increase the inspiratory pressure to 25 cm H₂O.
,B. Decrease the respiratory rate to 10 breaths/min.
C. Notify the provider because tidal volume is low (should be 6-8 mL/kg ideal body weight).
D. Suction the client for possible mucus plug.
💫RATIONALE✔️✔️: Ideal tidal volume for ARDS/lung protection is 6-8 mL/kg ideal body weight. For a 70
kg patient, target VT = 420-560 mL. The current VT of 350 mL is low. The nurse should first assess for
causes (mucus plug, bronchospasm, pneumothorax, inadequate driving pressure). Notify provider after
assessment. Option D is a possible immediate action, but notifying provider after assessment is
appropriate. However, the best answer is to increase inspiratory pressure (A) if no obstruction. But
suction first? Hmm. Given options, A is direct but suction may be needed. I’ll choose A as the likely
order.
💫ANSWER✔️✔️: A. Increase the inspiratory pressure to 25 cm H₂O.
---
**Question 3**
A nurse is caring for a client following a cardiac arrest with return of spontaneous circulation (ROSC).
The client is intubated and has a Glasgow Coma Scale (GCS) score of 6. Which of the following targeted
temperature management (TTM) orders should the nurse anticipate?
A. Maintain core temperature at 37.5°C for 72 hours.
B. Cool the client to 32-36°C for at least 24 hours.
C. Induce fever to 38.5°C to promote neurological recovery.
D. No temperature management is needed because the client is comatose.
💫RATIONALE✔️✔️: Post-cardiac arrest guidelines recommend targeted temperature management (32-
36°C) for at least 24 hours in comatose survivors to reduce neurological injury. Fever is harmful.
Normothermia is not as protective.
💫ANSWER✔️✔️: B. Cool the client to 32-36°C for at least 24 hours.
---
**Question 4**
,A nurse is assessing a client with acute respiratory distress syndrome (ARDS) who is on a ventilator. The
client’s PaO₂ is 55 mm Hg on FiO₂ 0.8, PEEP 10 cm H₂O. Which of the following is the most appropriate
next intervention?
A. Increase FiO₂ to 1.0.
B. Increase PEEP to 15 cm H₂O.
C. Prone the client.
D. Administer a neuromuscular blocking agent.
💫RATIONALE✔️✔️: In moderate to severe ARDS (PaO₂/FiO₂ ratio = 55/0.8 = 68.75, severe), prone
positioning has been shown to reduce mortality (PROSEVA trial) by improving ventilation-perfusion
matching. Increasing PEEP and FiO₂ are also options, but prone positioning is a powerful rescue therapy.
Neuromuscular blockers may be used but not first after failed PEEP/FiO₂.
💫ANSWER✔️✔️: C. Prone the client.
---
**Question 5**
A nurse is caring for a client with a pulmonary artery catheter (Swan-Ganz). The following hemodynamic
values are obtained: cardiac output (CO) 3.0 L/min, cardiac index (CI) 1.6 L/min/m², pulmonary artery
wedge pressure (PAWP) 20 mm Hg, systemic vascular resistance (SVR) 1600 dynes·sec·cm⁻⁵. Which of
the following conditions is most likely?
A. Cardiogenic shock
B. Hypovolemic shock
C. Distributive shock (septic)
D. Obstructive shock (pulmonary embolism)
💫RATIONALE✔️✔️: Low CI (<2.2) with high PAWP (>18) and high SVR (>1200) indicates cardiogenic shock
(pump failure with congestion). Hypovolemic shock would have low PAWP. Distributive shock has low
SVR. Obstructive shock (PE, tamponade) has variable PAWP (high in tamponade, low in PE) but not
typically high SVR.
💫ANSWER✔️✔️: A. Cardiogenic shock
, ---
**Question 6**
A nurse is caring for a client who has a traumatic brain injury (TBI) with an intracranial pressure (ICP)
monitor. The ICP is 22 mm Hg, cerebral perfusion pressure (CPP) is 55 mm Hg, and mean arterial
pressure (MAP) is 77 mm Hg. Which of the following actions should the nurse take first?
A. Administer mannitol 0.5 g/kg IV.
B. Elevate the head of the bed to 30 degrees.
C. Increase the rate of norepinephrine to raise MAP.
D. Hyperventilate the client to a PaCO₂ of 28 mm Hg.
💫RATIONALE✔️✔️: CPP = MAP – ICP. Normal CPP is 60-70 mm Hg. Current CPP 55 is low. ICP 22 is
elevated (>20). First-line interventions: elevate HOB 30°, ensure no jugular compression, and optimize
MAP. Hyperventilation (D) is a temporizing measure but not first due to cerebral ischemia risk. Mannitol
if refractory. Raising MAP with vasopressors is correct but elevating HOB is non-invasive first. The BEST
first step is B.
💫ANSWER✔️✔️: B. Elevate the head of the bed to 30 degrees.
---
**Question 7**
A nurse is caring for a client with acute coronary syndrome (ACS) who develops sudden severe dyspnea,
hypotension (80/50 mm Hg), and jugular venous distention. A bedside echocardiogram reveals a new
interventricular septal defect. Which of the following is the priority intervention?
A. Administer nitroglycerin IV.
B. Insert an intra-aortic balloon pump (IABP).
C. Give furosemide 40 mg IV.
D. Prepare for emergency surgical repair.
💫RATIONALE✔️✔️: Ventricular septal rupture after MI causes acute left-to-right shunt, pulmonary
edema, and cardiogenic shock. IABP is a bridge to surgery to reduce afterload and improve coronary
Certification Review Exam (CCRN) 2024 – Advanced
Practice Edition**
---
**Question 1**
A nurse in the intensive care unit (ICU) is caring for a client with severe sepsis who is receiving
norepinephrine (Levophed) via central line. The client’s blood pressure is 80/50 mm Hg, heart rate 120
bpm, and central venous pressure (CVP) is 6 mm Hg. Which of the following interventions should the
nurse anticipate first?
A. Increase the norepinephrine infusion rate.
B. Administer a 500 mL bolus of isotonic crystalloid.
C. Start a second vasopressor (vasopressin).
D. Obtain a stat lactate level.
💫RATIONALE✔️✔️: In severe sepsis with hypotension (MAP <65) and CVP <8 mm Hg, the Surviving Sepsis
Campaign guidelines recommend initial fluid resuscitation (30 mL/kg crystalloid) before titrating
vasopressors. Fluid bolus is first-line to increase preload. Vasopressors are added if fluid refractory.
Lactate is important but not the first action.
💫ANSWER✔️✔️: B. Administer a 500 mL bolus of isotonic crystalloid.
---
**Question 2**
A nurse is caring for a client who is mechanically ventilated in pressure control mode. The set inspiratory
pressure is 20 cm H₂O, PEEP 5 cm H₂O, rate 12 breaths/min. The client’s exhaled tidal volume is 350 mL
(ideal body weight 70 kg). Which of the following actions should the nurse take?
A. Increase the inspiratory pressure to 25 cm H₂O.
,B. Decrease the respiratory rate to 10 breaths/min.
C. Notify the provider because tidal volume is low (should be 6-8 mL/kg ideal body weight).
D. Suction the client for possible mucus plug.
💫RATIONALE✔️✔️: Ideal tidal volume for ARDS/lung protection is 6-8 mL/kg ideal body weight. For a 70
kg patient, target VT = 420-560 mL. The current VT of 350 mL is low. The nurse should first assess for
causes (mucus plug, bronchospasm, pneumothorax, inadequate driving pressure). Notify provider after
assessment. Option D is a possible immediate action, but notifying provider after assessment is
appropriate. However, the best answer is to increase inspiratory pressure (A) if no obstruction. But
suction first? Hmm. Given options, A is direct but suction may be needed. I’ll choose A as the likely
order.
💫ANSWER✔️✔️: A. Increase the inspiratory pressure to 25 cm H₂O.
---
**Question 3**
A nurse is caring for a client following a cardiac arrest with return of spontaneous circulation (ROSC).
The client is intubated and has a Glasgow Coma Scale (GCS) score of 6. Which of the following targeted
temperature management (TTM) orders should the nurse anticipate?
A. Maintain core temperature at 37.5°C for 72 hours.
B. Cool the client to 32-36°C for at least 24 hours.
C. Induce fever to 38.5°C to promote neurological recovery.
D. No temperature management is needed because the client is comatose.
💫RATIONALE✔️✔️: Post-cardiac arrest guidelines recommend targeted temperature management (32-
36°C) for at least 24 hours in comatose survivors to reduce neurological injury. Fever is harmful.
Normothermia is not as protective.
💫ANSWER✔️✔️: B. Cool the client to 32-36°C for at least 24 hours.
---
**Question 4**
,A nurse is assessing a client with acute respiratory distress syndrome (ARDS) who is on a ventilator. The
client’s PaO₂ is 55 mm Hg on FiO₂ 0.8, PEEP 10 cm H₂O. Which of the following is the most appropriate
next intervention?
A. Increase FiO₂ to 1.0.
B. Increase PEEP to 15 cm H₂O.
C. Prone the client.
D. Administer a neuromuscular blocking agent.
💫RATIONALE✔️✔️: In moderate to severe ARDS (PaO₂/FiO₂ ratio = 55/0.8 = 68.75, severe), prone
positioning has been shown to reduce mortality (PROSEVA trial) by improving ventilation-perfusion
matching. Increasing PEEP and FiO₂ are also options, but prone positioning is a powerful rescue therapy.
Neuromuscular blockers may be used but not first after failed PEEP/FiO₂.
💫ANSWER✔️✔️: C. Prone the client.
---
**Question 5**
A nurse is caring for a client with a pulmonary artery catheter (Swan-Ganz). The following hemodynamic
values are obtained: cardiac output (CO) 3.0 L/min, cardiac index (CI) 1.6 L/min/m², pulmonary artery
wedge pressure (PAWP) 20 mm Hg, systemic vascular resistance (SVR) 1600 dynes·sec·cm⁻⁵. Which of
the following conditions is most likely?
A. Cardiogenic shock
B. Hypovolemic shock
C. Distributive shock (septic)
D. Obstructive shock (pulmonary embolism)
💫RATIONALE✔️✔️: Low CI (<2.2) with high PAWP (>18) and high SVR (>1200) indicates cardiogenic shock
(pump failure with congestion). Hypovolemic shock would have low PAWP. Distributive shock has low
SVR. Obstructive shock (PE, tamponade) has variable PAWP (high in tamponade, low in PE) but not
typically high SVR.
💫ANSWER✔️✔️: A. Cardiogenic shock
, ---
**Question 6**
A nurse is caring for a client who has a traumatic brain injury (TBI) with an intracranial pressure (ICP)
monitor. The ICP is 22 mm Hg, cerebral perfusion pressure (CPP) is 55 mm Hg, and mean arterial
pressure (MAP) is 77 mm Hg. Which of the following actions should the nurse take first?
A. Administer mannitol 0.5 g/kg IV.
B. Elevate the head of the bed to 30 degrees.
C. Increase the rate of norepinephrine to raise MAP.
D. Hyperventilate the client to a PaCO₂ of 28 mm Hg.
💫RATIONALE✔️✔️: CPP = MAP – ICP. Normal CPP is 60-70 mm Hg. Current CPP 55 is low. ICP 22 is
elevated (>20). First-line interventions: elevate HOB 30°, ensure no jugular compression, and optimize
MAP. Hyperventilation (D) is a temporizing measure but not first due to cerebral ischemia risk. Mannitol
if refractory. Raising MAP with vasopressors is correct but elevating HOB is non-invasive first. The BEST
first step is B.
💫ANSWER✔️✔️: B. Elevate the head of the bed to 30 degrees.
---
**Question 7**
A nurse is caring for a client with acute coronary syndrome (ACS) who develops sudden severe dyspnea,
hypotension (80/50 mm Hg), and jugular venous distention. A bedside echocardiogram reveals a new
interventricular septal defect. Which of the following is the priority intervention?
A. Administer nitroglycerin IV.
B. Insert an intra-aortic balloon pump (IABP).
C. Give furosemide 40 mg IV.
D. Prepare for emergency surgical repair.
💫RATIONALE✔️✔️: Ventricular septal rupture after MI causes acute left-to-right shunt, pulmonary
edema, and cardiogenic shock. IABP is a bridge to surgery to reduce afterload and improve coronary
