CCRN Advanced Practice: Master
Hemodynamic and Multisystem Critical
Care Exam Questions & Detailed
Explanations
Subject: Clinical Judgment - Cardiovascular & Multisystem Critical Care
Question 1: A 68-year-old patient in the ICU with cardiogenic shock is being managed with a
pulmonary artery catheter and an intra-aortic balloon pump (IABP). Upon reviewing the
hemodynamic data, the nurse notes a cardiac index of 1.8 L/min/m², an SVR of 2200
dynes/sec/cm⁻⁵, and a PCWP of 24 mmHg. The IABP augmentation wave is noted to be
occurring during the systolic upstroke of the arterial waveform. What is the most appropriate
immediate nursing action?
A) Increase the IABP inflation volume to improve coronary perfusion.
B) Immediately stop the IABP and notify the physician to adjust timing.
C) Administer a rapid fluid bolus to decrease the PCWP and improve cardiac output.
D) Titrate the vasoactive infusion to decrease the SVR and offload the left ventricle.
Correct Answer: B) Immediately stop the IABP and notify the physician to adjust timing.
Explanation: The arterial waveform description indicates that the IABP is inflating during
systole rather than diastole (early inflation). Inflation during systole increases afterload,
significantly increasing myocardial oxygen demand and potentially causing left ventricular
outflow obstruction. This is a critical timing error that can be fatal. Stopping the pump prevents
further cardiac damage until the timing can be corrected (the balloon should inflate at the
dicrotic notch, which marks the beginning of diastole). Options A, C, and D do not address the
lethal timing error.
Question 2: A patient with severe sepsis is being resuscitated according to the Surviving Sepsis
Campaign guidelines. Despite 30 mL/kg of crystalloid, the patient remains hypotensive with a
MAP of 55 mmHg. Which of the following hemodynamic profiles most accurately reflects the
transition from compensatory to uncompensated septic shock?
A) Increased CO, decreased SVR, increased SvO₂
B) Decreased CO, increased SVR, decreased SvO₂
,C) Decreased CO, decreased SVR, increased SvO₂
D) Increased CO, increased SVR, decreased SvO₂
Correct Answer: B) Decreased CO, increased SVR, decreased SvO₂
Explanation: In early septic shock, the body compensates with vasodilation (low SVR) and high
cardiac output (hyperdynamic state). As the patient progresses to uncompensated or late septic
shock, myocardial depression occurs (decreased CO), and the sympathetic nervous system
attempts to compensate through intense vasoconstriction (increased SVR). The decreased SvO₂
reflects impaired oxygen delivery relative to extraction at the tissue level, signaling severe
physiological failure.
Question 3: A 55-year-old patient is admitted following a motor vehicle accident with a
suspected T6 spinal cord injury. The patient is bradycardic (HR 48 bpm) and hypotensive (BP
80/40 mmHg). Which of the following assessment findings is most consistent with neurogenic
shock compared to hypovolemic shock?
A) Pale, cool, clammy skin
B) Warm, dry skin below the level of injury
C) Elevated systemic vascular resistance (SVR)
D) Elevated CVP and PCWP readings
Correct Answer: B) Warm, dry skin below the level of injury
Explanation: Neurogenic shock occurs due to the loss of sympathetic tone, leading to massive
vasodilation and an inability of the body to regulate temperature (poikilothermia) and
vasoconstrict in response to hypotension. This results in warm, dry skin. Conversely,
hypovolemic shock features sympathetic activation, leading to peripheral vasoconstriction,
resulting in cool, clammy skin. Neurogenic shock typically presents with low SVR, whereas
hypovolemic shock presents with high SVR.
Question 4: A patient is mechanically ventilated for ARDS. The latest ABG reveals: pH 7.22,
PaCO₂ 65 mmHg, PaO₂ 58 mmHg, HCO₃ 26 mEq/L. The ventilator settings are: Volume
Control, Vt 6 mL/kg PBW, RR 24/min, PEEP 15 cmH₂O. Which of the following is the most
appropriate next step to address the acid-base disturbance?
A) Increase the respiratory rate to 30 breaths/min.
B) Increase the tidal volume to 10 mL/kg.
C) Accept permissive hypercapnia as long as the pH is > 7.20.
, D) Decrease PEEP to 10 cmH₂O to improve venous return.
Correct Answer: C) Accept permissive hypercapnia as long as the pH is > 7.20.
Explanation: In ARDS management, protective lung ventilation (low tidal volumes) is prioritized
to prevent VILI (ventilator-induced lung injury). Permissive hypercapnia is a strategy used to
allow PaCO₂ to rise, provided the arterial pH remains at a safe level (typically > 7.20–7.25) to
prevent severe acidosis. Increasing tidal volume (Option B) increases the risk of
barotrauma/volutrauma, and increasing the rate (Option A) may lead to air trapping in a non-
compliant lung.
Question 5: A patient with a history of heart failure and recent myocardial infarction develops
an acute onset of severe dyspnea and hypotension. You suspect papillary muscle rupture. Which
hemodynamic finding is most diagnostic of this acute mitral regurgitation?
A) Elevated CVP with a flattened Y descent.
B) Large, tall V-waves on the pulmonary artery occlusion pressure (PAOP) tracing.
C) Significantly elevated SVR with a low cardiac index.
D) Narrowing pulse pressure with pulsus paradoxus.
Correct Answer: B) Large, tall V-waves on the pulmonary artery occlusion pressure (PAOP)
tracing.
Explanation: Acute papillary muscle rupture leads to acute, severe mitral regurgitation. During
ventricular systole, blood is ejected back into the left atrium, causing a sudden, massive increase
in atrial pressure. This appears as large, prominent V-waves on the PCWP/PAOP tracing. This
is a hallmark finding in acute mitral regurgitation.
Question 6: A patient with DKA is receiving an insulin infusion at 0.1 units/kg/hr. The patient's
serum glucose has dropped from 450 mg/dL to 260 mg/dL over the last 2 hours. What is the
most critical next action to prevent cerebral edema?
A) Stop the insulin infusion immediately.
B) Add dextrose (D5 1/2NS) to the IV fluids once serum glucose reaches 250 mg/dL.
C) Administer a bolus of 50% dextrose.
D) Switch to a subcutaneous insulin sliding scale.
Correct Answer: B) Add dextrose (D5 1/2NS) to the IV fluids once serum glucose reaches
250 mg/dL.
Hemodynamic and Multisystem Critical
Care Exam Questions & Detailed
Explanations
Subject: Clinical Judgment - Cardiovascular & Multisystem Critical Care
Question 1: A 68-year-old patient in the ICU with cardiogenic shock is being managed with a
pulmonary artery catheter and an intra-aortic balloon pump (IABP). Upon reviewing the
hemodynamic data, the nurse notes a cardiac index of 1.8 L/min/m², an SVR of 2200
dynes/sec/cm⁻⁵, and a PCWP of 24 mmHg. The IABP augmentation wave is noted to be
occurring during the systolic upstroke of the arterial waveform. What is the most appropriate
immediate nursing action?
A) Increase the IABP inflation volume to improve coronary perfusion.
B) Immediately stop the IABP and notify the physician to adjust timing.
C) Administer a rapid fluid bolus to decrease the PCWP and improve cardiac output.
D) Titrate the vasoactive infusion to decrease the SVR and offload the left ventricle.
Correct Answer: B) Immediately stop the IABP and notify the physician to adjust timing.
Explanation: The arterial waveform description indicates that the IABP is inflating during
systole rather than diastole (early inflation). Inflation during systole increases afterload,
significantly increasing myocardial oxygen demand and potentially causing left ventricular
outflow obstruction. This is a critical timing error that can be fatal. Stopping the pump prevents
further cardiac damage until the timing can be corrected (the balloon should inflate at the
dicrotic notch, which marks the beginning of diastole). Options A, C, and D do not address the
lethal timing error.
Question 2: A patient with severe sepsis is being resuscitated according to the Surviving Sepsis
Campaign guidelines. Despite 30 mL/kg of crystalloid, the patient remains hypotensive with a
MAP of 55 mmHg. Which of the following hemodynamic profiles most accurately reflects the
transition from compensatory to uncompensated septic shock?
A) Increased CO, decreased SVR, increased SvO₂
B) Decreased CO, increased SVR, decreased SvO₂
,C) Decreased CO, decreased SVR, increased SvO₂
D) Increased CO, increased SVR, decreased SvO₂
Correct Answer: B) Decreased CO, increased SVR, decreased SvO₂
Explanation: In early septic shock, the body compensates with vasodilation (low SVR) and high
cardiac output (hyperdynamic state). As the patient progresses to uncompensated or late septic
shock, myocardial depression occurs (decreased CO), and the sympathetic nervous system
attempts to compensate through intense vasoconstriction (increased SVR). The decreased SvO₂
reflects impaired oxygen delivery relative to extraction at the tissue level, signaling severe
physiological failure.
Question 3: A 55-year-old patient is admitted following a motor vehicle accident with a
suspected T6 spinal cord injury. The patient is bradycardic (HR 48 bpm) and hypotensive (BP
80/40 mmHg). Which of the following assessment findings is most consistent with neurogenic
shock compared to hypovolemic shock?
A) Pale, cool, clammy skin
B) Warm, dry skin below the level of injury
C) Elevated systemic vascular resistance (SVR)
D) Elevated CVP and PCWP readings
Correct Answer: B) Warm, dry skin below the level of injury
Explanation: Neurogenic shock occurs due to the loss of sympathetic tone, leading to massive
vasodilation and an inability of the body to regulate temperature (poikilothermia) and
vasoconstrict in response to hypotension. This results in warm, dry skin. Conversely,
hypovolemic shock features sympathetic activation, leading to peripheral vasoconstriction,
resulting in cool, clammy skin. Neurogenic shock typically presents with low SVR, whereas
hypovolemic shock presents with high SVR.
Question 4: A patient is mechanically ventilated for ARDS. The latest ABG reveals: pH 7.22,
PaCO₂ 65 mmHg, PaO₂ 58 mmHg, HCO₃ 26 mEq/L. The ventilator settings are: Volume
Control, Vt 6 mL/kg PBW, RR 24/min, PEEP 15 cmH₂O. Which of the following is the most
appropriate next step to address the acid-base disturbance?
A) Increase the respiratory rate to 30 breaths/min.
B) Increase the tidal volume to 10 mL/kg.
C) Accept permissive hypercapnia as long as the pH is > 7.20.
, D) Decrease PEEP to 10 cmH₂O to improve venous return.
Correct Answer: C) Accept permissive hypercapnia as long as the pH is > 7.20.
Explanation: In ARDS management, protective lung ventilation (low tidal volumes) is prioritized
to prevent VILI (ventilator-induced lung injury). Permissive hypercapnia is a strategy used to
allow PaCO₂ to rise, provided the arterial pH remains at a safe level (typically > 7.20–7.25) to
prevent severe acidosis. Increasing tidal volume (Option B) increases the risk of
barotrauma/volutrauma, and increasing the rate (Option A) may lead to air trapping in a non-
compliant lung.
Question 5: A patient with a history of heart failure and recent myocardial infarction develops
an acute onset of severe dyspnea and hypotension. You suspect papillary muscle rupture. Which
hemodynamic finding is most diagnostic of this acute mitral regurgitation?
A) Elevated CVP with a flattened Y descent.
B) Large, tall V-waves on the pulmonary artery occlusion pressure (PAOP) tracing.
C) Significantly elevated SVR with a low cardiac index.
D) Narrowing pulse pressure with pulsus paradoxus.
Correct Answer: B) Large, tall V-waves on the pulmonary artery occlusion pressure (PAOP)
tracing.
Explanation: Acute papillary muscle rupture leads to acute, severe mitral regurgitation. During
ventricular systole, blood is ejected back into the left atrium, causing a sudden, massive increase
in atrial pressure. This appears as large, prominent V-waves on the PCWP/PAOP tracing. This
is a hallmark finding in acute mitral regurgitation.
Question 6: A patient with DKA is receiving an insulin infusion at 0.1 units/kg/hr. The patient's
serum glucose has dropped from 450 mg/dL to 260 mg/dL over the last 2 hours. What is the
most critical next action to prevent cerebral edema?
A) Stop the insulin infusion immediately.
B) Add dextrose (D5 1/2NS) to the IV fluids once serum glucose reaches 250 mg/dL.
C) Administer a bolus of 50% dextrose.
D) Switch to a subcutaneous insulin sliding scale.
Correct Answer: B) Add dextrose (D5 1/2NS) to the IV fluids once serum glucose reaches
250 mg/dL.
