Adult CCRN Certification
Examination: Advanced Clinical
Judgment Practice Question Bank —
150 High-Complexity Multiple-Choice
Questions with Evidence-Based
Rationales Aligned to the 2026 AACN
Test Plan
Table of Contents
1. Cardiovascular (Questions 1–30)
2. Respiratory (Questions 31–60)
3. Endocrine/Hematology/Gastrointestinal/Renal & Genitourinary/Integumentary (Questions 61–
95)
4. Musculoskeletal/Neurological/Behavioral & Psychosocial (Questions 96–125)
5. Multisystem (Questions 126–140)
6. Professional Caring and Ethical Practice (Questions 141–150)
SECTION 1: CARDIOVASCULAR (Questions 1–30)
🟢 1. A patient in the ICU develops sudden onset chest pain, diaphoresis, and ST-segment elevation in
leads II, III, and aVF. Which coronary artery is MOST LIKELY occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
🔴 Correct Answer: C
Rationale: Leads II, III, and aVF are inferior leads. The right coronary artery (RCA) supplies the inferior
wall of the left ventricle in approximately 80% of individuals (right-dominant circulation). ST elevation in
,these leads indicates an inferior wall myocardial infarction, most commonly due to RCA occlusion. The
LAD supplies the anterior wall, and the circumflex supplies the lateral wall. This pattern is a classic CCRN
exam presentation of inferior MI.
🟢 2. A patient with acute decompensated heart failure has a pulmonary artery wedge pressure
(PAWP) of 22 mmHg. Which intervention is the PRIORITY?
A. Administer IV furosemide
B. Initiate dobutamine infusion
C. Place the patient in Trendelenburg position
D. Administer 500 mL normal saline bolus
🔴 Correct Answer: A
Rationale: A PAWP of 22 mmHg (normal 6–12 mmHg) indicates elevated left ventricular filling pressures
consistent with volume overload in heart failure. IV loop diuretics (furosemide) are the first-line
intervention to reduce preload and pulmonary congestion. Dobutamine is an inotrope used for low
cardiac output, not first-line for volume overload. Trendelenburg would worsen pulmonary congestion.
Fluid bolus would exacerbate the condition.
🟢 3. A patient with a temporary transvenous pacemaker has a pacing spike followed by a QRS complex
but no preceding P wave. This rhythm indicates:
A. Failure to capture
B. Failure to sense
C. Ventricular pacing
D. Atrial fibrillation
🔴 Correct Answer: C
Rationale: A pacing spike followed by a QRS without a preceding P wave indicates ventricular pacing. In
ventricular pacing, the pacing lead is positioned in the right ventricle, and the spike initiates ventricular
depolarization directly. Failure to capture would show a pacing spike with no subsequent QRS. Failure to
sense would show inappropriate pacing spikes. Atrial fibrillation would show irregularly irregular R-R
intervals without pacing spikes.
🟢 4. A patient is admitted with acute decompensated heart failure. The physician orders nesiritide
(Natrecor) for volume overload refractory to loop diuretics. The nurse should closely monitor for
which side effect?
A. Hypokalemia
B. Hypotension
C. Ventricular dysrhythmia
D. Nausea/vomiting
,🔴 Correct Answer: B
Rationale: Nesiritide is a recombinant B-type natriuretic peptide that causes vasodilation, leading to
reduced preload and afterload. The most significant adverse effect is hypotension. Patients should have
frequent blood pressure monitoring during infusion. Hypokalemia is associated with loop diuretics, not
nesiritide. This is a classic CCRN pharmacology question.
🟢 5. Which of the following physiologic changes occurs as a direct result of cardiogenic shock?
A. Increase in capacitance
B. Increase in afterload
C. Decrease in preload
D. Decrease in SVR
🔴 Correct Answer: B
Rationale: Cardiogenic shock results from pump failure, leading to decreased cardiac output and
compensatory vasoconstriction. This vasoconstriction increases systemic vascular resistance (SVR) and
afterload. Preload may be elevated or normal depending on the cause. Capacitance (venous pooling)
decreases as the body attempts to maintain preload. Decreased SVR is characteristic of distributive
shock, not cardiogenic.
🟢 6. A patient with an acute anterior wall myocardial infarction develops a new holosystolic murmur
at the apex, pulmonary edema, and hypotension. The MOST LIKELY complication is:
A. Papillary muscle rupture
B. Ventricular septal defect
C. Left ventricular free wall rupture
D. Pericardial tamponade
🔴 Correct Answer: B
Rationale: A new holosystolic murmur at the apex (or left sternal border) with pulmonary edema and
hypotension after an anterior MI suggests a ventricular septal defect (VSD). The anterior wall is supplied
by the LAD, and septal rupture creates a left-to-right shunt. Papillary muscle rupture typically produces a
murmur of mitral regurgitation and is more common with inferior MI. Free wall rupture leads to
tamponade and pulseless electrical activity.
🟢 7. A patient has a CVP of 16 mmHg and a PAWP of 8 mmHg. This hemodynamic pattern is MOST
consistent with:
A. Left ventricular failure
B. Right ventricular failure
, C. Cardiogenic shock
D. Hypovolemic shock
🔴 Correct Answer: B
Rationale: Elevated CVP (normal 2–6 mmHg) with normal PAWP indicates right ventricular failure or
increased right-sided pressures. In right ventricular failure, the right ventricle cannot effectively pump
blood forward, causing backup into the systemic venous system (elevated CVP). Left ventricular function
remains adequate (normal PAWP). Left ventricular failure would show elevated PAWP. Cardiogenic
shock typically shows elevated PAWP and low cardiac index.
🟢 8. A patient on continuous cardiac monitoring develops a rhythm showing no P waves, an irregularly
irregular ventricular rate, and fibrillatory baseline activity. The PRIORITY intervention is:
A. Administer adenosine 6 mg IV push
B. Synchronized cardioversion at 100 joules
C. Assess the patient for hemodynamic stability
D. Initiate CPR immediately
🔴 Correct Answer: C
Rationale: The rhythm described is atrial fibrillation (AF). The first step in management is always to
assess the patient's hemodynamic stability. If the patient is stable, rate control and anticoagulation are
considered. If unstable (hypotension, altered mental status, chest pain, acute heart failure),
synchronized cardioversion is indicated. Adenosine is ineffective for AF. CPR is not indicated for a
patient with a pulse.
🟢 9. After cardiac surgery, a patient who is a Jehovah's Witness has an HCT of 18% and accumulated
chest-tube drainage of 1800 cc in the first 3 hours. The MOST appropriate action would be to:
A. Begin continuous-circuit autotransfusion
B. Administer donated directed PRBCs
C. Administer donated autologous whole blood
D. Administer 500 cc of albumin
🔴 Correct Answer: A
Rationale: For Jehovah's Witness patients who refuse blood products, continuous-circuit
autotransfusion (cell salvage) is an acceptable method to recover and reinfuse the patient's own blood
lost from the surgical site. This respects the patient's religious beliefs while addressing blood loss.
Donated PRBCs and autologous blood are unacceptable to Jehovah's Witnesses. Albumin does not
replace red blood cell mass.
Examination: Advanced Clinical
Judgment Practice Question Bank —
150 High-Complexity Multiple-Choice
Questions with Evidence-Based
Rationales Aligned to the 2026 AACN
Test Plan
Table of Contents
1. Cardiovascular (Questions 1–30)
2. Respiratory (Questions 31–60)
3. Endocrine/Hematology/Gastrointestinal/Renal & Genitourinary/Integumentary (Questions 61–
95)
4. Musculoskeletal/Neurological/Behavioral & Psychosocial (Questions 96–125)
5. Multisystem (Questions 126–140)
6. Professional Caring and Ethical Practice (Questions 141–150)
SECTION 1: CARDIOVASCULAR (Questions 1–30)
🟢 1. A patient in the ICU develops sudden onset chest pain, diaphoresis, and ST-segment elevation in
leads II, III, and aVF. Which coronary artery is MOST LIKELY occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
🔴 Correct Answer: C
Rationale: Leads II, III, and aVF are inferior leads. The right coronary artery (RCA) supplies the inferior
wall of the left ventricle in approximately 80% of individuals (right-dominant circulation). ST elevation in
,these leads indicates an inferior wall myocardial infarction, most commonly due to RCA occlusion. The
LAD supplies the anterior wall, and the circumflex supplies the lateral wall. This pattern is a classic CCRN
exam presentation of inferior MI.
🟢 2. A patient with acute decompensated heart failure has a pulmonary artery wedge pressure
(PAWP) of 22 mmHg. Which intervention is the PRIORITY?
A. Administer IV furosemide
B. Initiate dobutamine infusion
C. Place the patient in Trendelenburg position
D. Administer 500 mL normal saline bolus
🔴 Correct Answer: A
Rationale: A PAWP of 22 mmHg (normal 6–12 mmHg) indicates elevated left ventricular filling pressures
consistent with volume overload in heart failure. IV loop diuretics (furosemide) are the first-line
intervention to reduce preload and pulmonary congestion. Dobutamine is an inotrope used for low
cardiac output, not first-line for volume overload. Trendelenburg would worsen pulmonary congestion.
Fluid bolus would exacerbate the condition.
🟢 3. A patient with a temporary transvenous pacemaker has a pacing spike followed by a QRS complex
but no preceding P wave. This rhythm indicates:
A. Failure to capture
B. Failure to sense
C. Ventricular pacing
D. Atrial fibrillation
🔴 Correct Answer: C
Rationale: A pacing spike followed by a QRS without a preceding P wave indicates ventricular pacing. In
ventricular pacing, the pacing lead is positioned in the right ventricle, and the spike initiates ventricular
depolarization directly. Failure to capture would show a pacing spike with no subsequent QRS. Failure to
sense would show inappropriate pacing spikes. Atrial fibrillation would show irregularly irregular R-R
intervals without pacing spikes.
🟢 4. A patient is admitted with acute decompensated heart failure. The physician orders nesiritide
(Natrecor) for volume overload refractory to loop diuretics. The nurse should closely monitor for
which side effect?
A. Hypokalemia
B. Hypotension
C. Ventricular dysrhythmia
D. Nausea/vomiting
,🔴 Correct Answer: B
Rationale: Nesiritide is a recombinant B-type natriuretic peptide that causes vasodilation, leading to
reduced preload and afterload. The most significant adverse effect is hypotension. Patients should have
frequent blood pressure monitoring during infusion. Hypokalemia is associated with loop diuretics, not
nesiritide. This is a classic CCRN pharmacology question.
🟢 5. Which of the following physiologic changes occurs as a direct result of cardiogenic shock?
A. Increase in capacitance
B. Increase in afterload
C. Decrease in preload
D. Decrease in SVR
🔴 Correct Answer: B
Rationale: Cardiogenic shock results from pump failure, leading to decreased cardiac output and
compensatory vasoconstriction. This vasoconstriction increases systemic vascular resistance (SVR) and
afterload. Preload may be elevated or normal depending on the cause. Capacitance (venous pooling)
decreases as the body attempts to maintain preload. Decreased SVR is characteristic of distributive
shock, not cardiogenic.
🟢 6. A patient with an acute anterior wall myocardial infarction develops a new holosystolic murmur
at the apex, pulmonary edema, and hypotension. The MOST LIKELY complication is:
A. Papillary muscle rupture
B. Ventricular septal defect
C. Left ventricular free wall rupture
D. Pericardial tamponade
🔴 Correct Answer: B
Rationale: A new holosystolic murmur at the apex (or left sternal border) with pulmonary edema and
hypotension after an anterior MI suggests a ventricular septal defect (VSD). The anterior wall is supplied
by the LAD, and septal rupture creates a left-to-right shunt. Papillary muscle rupture typically produces a
murmur of mitral regurgitation and is more common with inferior MI. Free wall rupture leads to
tamponade and pulseless electrical activity.
🟢 7. A patient has a CVP of 16 mmHg and a PAWP of 8 mmHg. This hemodynamic pattern is MOST
consistent with:
A. Left ventricular failure
B. Right ventricular failure
, C. Cardiogenic shock
D. Hypovolemic shock
🔴 Correct Answer: B
Rationale: Elevated CVP (normal 2–6 mmHg) with normal PAWP indicates right ventricular failure or
increased right-sided pressures. In right ventricular failure, the right ventricle cannot effectively pump
blood forward, causing backup into the systemic venous system (elevated CVP). Left ventricular function
remains adequate (normal PAWP). Left ventricular failure would show elevated PAWP. Cardiogenic
shock typically shows elevated PAWP and low cardiac index.
🟢 8. A patient on continuous cardiac monitoring develops a rhythm showing no P waves, an irregularly
irregular ventricular rate, and fibrillatory baseline activity. The PRIORITY intervention is:
A. Administer adenosine 6 mg IV push
B. Synchronized cardioversion at 100 joules
C. Assess the patient for hemodynamic stability
D. Initiate CPR immediately
🔴 Correct Answer: C
Rationale: The rhythm described is atrial fibrillation (AF). The first step in management is always to
assess the patient's hemodynamic stability. If the patient is stable, rate control and anticoagulation are
considered. If unstable (hypotension, altered mental status, chest pain, acute heart failure),
synchronized cardioversion is indicated. Adenosine is ineffective for AF. CPR is not indicated for a
patient with a pulse.
🟢 9. After cardiac surgery, a patient who is a Jehovah's Witness has an HCT of 18% and accumulated
chest-tube drainage of 1800 cc in the first 3 hours. The MOST appropriate action would be to:
A. Begin continuous-circuit autotransfusion
B. Administer donated directed PRBCs
C. Administer donated autologous whole blood
D. Administer 500 cc of albumin
🔴 Correct Answer: A
Rationale: For Jehovah's Witness patients who refuse blood products, continuous-circuit
autotransfusion (cell salvage) is an acceptable method to recover and reinfuse the patient's own blood
lost from the surgical site. This respects the patient's religious beliefs while addressing blood loss.
Donated PRBCs and autologous blood are unacceptable to Jehovah's Witnesses. Albumin does not
replace red blood cell mass.
