Adult CCRN Exam | Barron's CCRN Review Book - Complete Solution Guide Page 1
Adult CCRN Exam / Barron's CCRN Review Book
Complete Solution Guide — 200 Questions with Detailed Rationales
Critical Care Registered Nurse Certification • Aligned with current AACN CCRN Examination Standards
• Clinical Judgment (80%) + Professional Caring & Ethical Practice (20%)
Instructions to the Candidate:
1. This exam contains 200 multiple-choice questions organized into 8 sections aligned with the AACN Adult CCRN
Examination Content Outline.
2. Each question has four options (A–D) with ONE correct answer.
3. Cognitive level distribution: ~30% recall, ~50% application, ~20% analysis.
4. Approximately 80% of items are scenario-based; 20% are direct recall of critical care concepts and protocols.
5. Each question includes a detailed rationale with critical care nursing-specific reasoning (why the correct option is
right and why distractors are wrong, including pathophysiological basis, hemodynamic principles, pharmacological
mechanisms, evidence-based guidelines, and AACN Synergy Model application).
6. Suggested time: 3.5 hours (approx. 1 minute per question, with rationales reviewed afterward).
Section 1: Cardiovascular System
Q1: A 58-year-old male presents with substernal chest pressure radiating to the left arm, diaphoresis, and
dyspnea. The ECG shows ST-segment elevation in leads II, III, and aVF. Which coronary artery is most
likely occluded?
A. Left anterior descending (LAD)
B. Right coronary artery (RCA) [CORRECT]
C. Circumflex artery
D. Left main coronary artery
Correct Answer: B — Right coronary artery (RCA)
Rationale:
ST elevation in leads II, III, and aVF indicates inferior wall MI, most commonly caused by occlusion of the right coronary
artery (RCA). The LAD supplies the anterior wall (V1-V4), the circumflex supplies the lateral wall (I, aVL, V5-V6), and
left main occlusion causes widespread ST changes. Early recognition guides emergent PCI activation.
Q2: A patient with STEMI is receiving IV nitroglycerin for chest pain. BP drops from 118/72 to 78/42.
What is the PRIORITY nursing action?
A. Increase nitroglycerin rate
B. Decrease nitroglycerin rate and administer IV fluid bolus [CORRECT]
C. Administer metoprolol IV push
D. Reposition the patient to semi-Fowler's
Correct Answer: B — Decrease nitroglycerin rate and administer IV fluid bolus
Rationale:
Hypotension is the most common adverse effect of IV nitroglycerin due to venodilation reducing preload. Priority action
is to decrease the nitroglycerin rate and administer an IV fluid bolus to restore preload and BP. Beta-blockers are
Aligned with current AACN CCRN Examination Standards 200 Questions | Complete Solution with Verified Rationales
,Adult CCRN Exam | Barron's CCRN Review Book - Complete Solution Guide Page 2
contraindicated in hypotension. Increasing nitroglycerin would worsen hypotension. The patient should be supine, not
semi-Fowler's.
Q3: A patient with acute decompensated heart failure has a PAOP of 24 mmHg, CI of 1.8 L/min/m², and
SVR of 1800 dynes/sec/cm⁵. Which vasoactive medication regimen is MOST appropriate?
A. Norepinephrine and furosemide
B. Dobutamine and nitroprusside [CORRECT]
C. Vasopressin and hydrocortisone
D. Epinephrine and albumin
Correct Answer: B — Dobutamine and nitroprusside
Rationale:
This profile shows high preload (PAOP 24), low cardiac output (CI 1.8), and high afterload (SVR 1800) - classic
cardiogenic shock/acute decompensated HF. Dobutamine provides inotropic support to improve CO/CI while
nitroprusside reduces afterload (SVR). Norepinephrine would worsen afterload. Vasopressin is for vasodilatory shock.
The goal is to optimize preload, augment contractility, and reduce afterload.
Q4: A patient with heart failure has an S3 heart sound, JVD to the angle of the jaw, bilateral crackles, and
2+ pitting edema. These findings are MOST consistent with:
A. Left-sided heart failure only
B. Right-sided heart failure only
C. Biventricular heart failure [CORRECT]
D. Cardiac tamponade
Correct Answer: C — Biventricular heart failure
Rationale:
S3 and bilateral crackles indicate left ventricular failure (pulmonary congestion), while JVD and pitting edema indicate
right ventricular failure (systemic congestion). Combined findings are diagnostic of biventricular (congestive) heart
failure. Cardiac tamponade presents with Beck's triad (muffled heart tones, hypotension, JVD) and pulsus paradoxus.
Q5: Which ECG finding is the strongest indicator of impending ventricular fibrillation in a patient with
acute MI?
A. Frequent PVCs
B. R-on-T phenomenon [CORRECT]
C. First-degree AV block
D. Atrial fibrillation
Correct Answer: B — R-on-T phenomenon
Rationale:
R-on-T phenomenon occurs when a premature ventricular contraction (PVC) falls on the T wave of the preceding beat
during the vulnerable repolarization period, which can trigger ventricular fibrillation (VF). It is a critical warning sign
requiring immediate intervention. Frequent PVCs alone are less ominous. First-degree AV block and atrial fibrillation are
not typically precursors to VF.
Aligned with current AACN CCRN Examination Standards 200 Questions | Complete Solution with Verified Rationales
,Adult CCRN Exam | Barron's CCRN Review Book - Complete Solution Guide Page 3
Q6: A patient with heart failure has a BNP of 1,800 pg/mL. The patient is receiving IV furosemide. Which
finding BEST indicates that treatment is effective?
A. Urine output of 50 mL/hr
B. Decrease in BNP to 600 pg/mL after 24 hours [CORRECT]
C. Increase in body weight
D. Decrease in serum sodium
Correct Answer: B — Decrease in BNP to 600 pg/mL after 24 hours
Rationale:
BNP is released from ventricles in response to stretch/overload. A declining BNP indicates reduced wall stress and
improved heart failure status. BNP <100 rules out HF, >400 supports HF diagnosis, and >1,000 indicates significant
decompensation. While urine output is important, BNP directly reflects cardiac status. Weight gain and hyponatremia
would indicate worsening HF.
Q7: A patient is receiving an IV heparin infusion for NSTEMI. The aPTT is 110 seconds (control 30). The
patient has melena. What is the PRIORITY action?
A. Increase heparin rate
B. Decrease heparin rate or discontinue and notify provider [CORRECT]
C. Administer vitamin K
D. Continue current rate
Correct Answer: B — Decrease heparin rate or discontinue and notify provider
Rationale:
Active GI bleeding (melena) with prolonged aPTT (110 sec) indicates heparin-induced bleeding complication. Priority
action is to decrease/discontinue the heparin infusion and notify the provider. Protamine sulfate (not vitamin K) reverses
heparin. Vitamin K reverses warfarin. Continuing or increasing heparin would worsen bleeding.
Q8: A patient with acute MI develops a new systolic murmur at the apex, loud P2, and sudden pulmonary
edema 4 days after admission. What complication should the nurse suspect?
A. Ventricular septal rupture
B. Papillary muscle rupture with acute mitral regurgitation [CORRECT]
C. Aortic dissection
D. Pericarditis
Correct Answer: B — Papillary muscle rupture with acute mitral regurgitation
Rationale:
Acute severe mitral regurgitation from papillary muscle rupture (typically 2-7 days post-MI) presents with a new apical
systolic murmur, pulmonary edema, and cardiogenic shock. The posteromedial papillary muscle has single blood supply
(RCA/PDA) making it more vulnerable. VSD presents with a harsh holosystolic murmur at the lower left sternal border.
Both require emergent surgical intervention.
Q9: Which rhythm requires immediate synchronized cardioversion per ACLS guidelines?
A. Stable supraventricular tachycardia
B. Unstable atrial fibrillation with hypotension [CORRECT]
C. Sinus tachycardia
D. First-degree AV block
Correct Answer: B — Unstable atrial fibrillation with hypotension
Rationale:
Synchronized cardioversion is indicated for unstable tachyarrhythmias (with signs of poor perfusion: hypotension, altered
mental status, chest pain, acute heart failure). Unstable atrial fibrillation with hypotension requires immediate
Aligned with current AACN CCRN Examination Standards 200 Questions | Complete Solution with Verified Rationales
, Adult CCRN Exam | Barron's CCRN Review Book - Complete Solution Guide Page 4
synchronized cardioversion. Stable SVT can be treated with vagal maneuvers or adenosine. Sinus tachycardia treatment
targets the underlying cause. First-degree AV block requires no treatment.
Q10: A patient has a heart rate of 40 bpm, BP 88/50, and complains of dizziness. The ECG shows a wide
QRS (>0.12 sec) with no P waves. What is the appropriate intervention?
A. Administer adenosine 6 mg IV push
B. Apply transcutaneous pacemaker pads and prepare for transvenous pacing [CORRECT]
C. Administer amiodarone 150 mg IV
D. Administer atropine 1 mg IV push
Correct Answer: B — Apply transcutaneous pacemaker pads and prepare for transvenous pacing
Rationale:
Wide-complex bradycardia with unstable hemodynamics (hypotension, dizziness) indicates high-grade AV block below
the bundle of His. Atropine is less likely to be effective for infranodal blocks (Mobitz II, third-degree with wide QRS).
Transcutaneous pacing is the immediate intervention while preparing for transvenous pacing. Adenosine and amiodarone
are inappropriate for bradycardia.
Q11: A patient with a pulmonary artery catheter has a PAOP waveform showing large a waves and large v
waves. These findings are MOST consistent with:
A. Mitral stenosis and mitral regurgitation [CORRECT]
B. Mitral regurgitation only
C. Mitral stenosis only
D. Aortic stenosis
Correct Answer: A — Mitral stenosis and mitral regurgitation
Rationale:
Large a waves indicate increased resistance to atrial emptying (mitral stenosis), and large v waves indicate regurgitant
backflow into the atrium (mitral regurgitation). Combined findings suggest both MS and MR. Large a waves alone occur
in MS, mitral atresia, or complete heart block. Large v waves alone occur in MR, VSD, or heart failure. Interpretation
guides diagnosis and treatment.
Q12: A patient has a CVP of 2 mmHg, BP 84/50, HR 120, and dry mucous membranes. Which intervention
should the nurse anticipate?
A. Administer IV furosemide
B. Administer IV fluid bolus (250-500 mL crystalloid) [CORRECT]
C. Start norepinephrine infusion
D. Administer IV nitroglycerin
Correct Answer: B — Administer IV fluid bolus (250-500 mL crystalloid)
Rationale:
Low CVP (2 mmHg) with hypotension and tachycardia indicates hypovolemia. The appropriate intervention is an IV
fluid bolus (250-500 mL crystalloid) to restore preload and improve cardiac output. Furosemide and nitroglycerin would
worsen hypovolemia. Norepinephrine may be added if fluids are insufficient. Fluid responsiveness should be assessed
before vasopressors.
Aligned with current AACN CCRN Examination Standards 200 Questions | Complete Solution with Verified Rationales
Adult CCRN Exam / Barron's CCRN Review Book
Complete Solution Guide — 200 Questions with Detailed Rationales
Critical Care Registered Nurse Certification • Aligned with current AACN CCRN Examination Standards
• Clinical Judgment (80%) + Professional Caring & Ethical Practice (20%)
Instructions to the Candidate:
1. This exam contains 200 multiple-choice questions organized into 8 sections aligned with the AACN Adult CCRN
Examination Content Outline.
2. Each question has four options (A–D) with ONE correct answer.
3. Cognitive level distribution: ~30% recall, ~50% application, ~20% analysis.
4. Approximately 80% of items are scenario-based; 20% are direct recall of critical care concepts and protocols.
5. Each question includes a detailed rationale with critical care nursing-specific reasoning (why the correct option is
right and why distractors are wrong, including pathophysiological basis, hemodynamic principles, pharmacological
mechanisms, evidence-based guidelines, and AACN Synergy Model application).
6. Suggested time: 3.5 hours (approx. 1 minute per question, with rationales reviewed afterward).
Section 1: Cardiovascular System
Q1: A 58-year-old male presents with substernal chest pressure radiating to the left arm, diaphoresis, and
dyspnea. The ECG shows ST-segment elevation in leads II, III, and aVF. Which coronary artery is most
likely occluded?
A. Left anterior descending (LAD)
B. Right coronary artery (RCA) [CORRECT]
C. Circumflex artery
D. Left main coronary artery
Correct Answer: B — Right coronary artery (RCA)
Rationale:
ST elevation in leads II, III, and aVF indicates inferior wall MI, most commonly caused by occlusion of the right coronary
artery (RCA). The LAD supplies the anterior wall (V1-V4), the circumflex supplies the lateral wall (I, aVL, V5-V6), and
left main occlusion causes widespread ST changes. Early recognition guides emergent PCI activation.
Q2: A patient with STEMI is receiving IV nitroglycerin for chest pain. BP drops from 118/72 to 78/42.
What is the PRIORITY nursing action?
A. Increase nitroglycerin rate
B. Decrease nitroglycerin rate and administer IV fluid bolus [CORRECT]
C. Administer metoprolol IV push
D. Reposition the patient to semi-Fowler's
Correct Answer: B — Decrease nitroglycerin rate and administer IV fluid bolus
Rationale:
Hypotension is the most common adverse effect of IV nitroglycerin due to venodilation reducing preload. Priority action
is to decrease the nitroglycerin rate and administer an IV fluid bolus to restore preload and BP. Beta-blockers are
Aligned with current AACN CCRN Examination Standards 200 Questions | Complete Solution with Verified Rationales
,Adult CCRN Exam | Barron's CCRN Review Book - Complete Solution Guide Page 2
contraindicated in hypotension. Increasing nitroglycerin would worsen hypotension. The patient should be supine, not
semi-Fowler's.
Q3: A patient with acute decompensated heart failure has a PAOP of 24 mmHg, CI of 1.8 L/min/m², and
SVR of 1800 dynes/sec/cm⁵. Which vasoactive medication regimen is MOST appropriate?
A. Norepinephrine and furosemide
B. Dobutamine and nitroprusside [CORRECT]
C. Vasopressin and hydrocortisone
D. Epinephrine and albumin
Correct Answer: B — Dobutamine and nitroprusside
Rationale:
This profile shows high preload (PAOP 24), low cardiac output (CI 1.8), and high afterload (SVR 1800) - classic
cardiogenic shock/acute decompensated HF. Dobutamine provides inotropic support to improve CO/CI while
nitroprusside reduces afterload (SVR). Norepinephrine would worsen afterload. Vasopressin is for vasodilatory shock.
The goal is to optimize preload, augment contractility, and reduce afterload.
Q4: A patient with heart failure has an S3 heart sound, JVD to the angle of the jaw, bilateral crackles, and
2+ pitting edema. These findings are MOST consistent with:
A. Left-sided heart failure only
B. Right-sided heart failure only
C. Biventricular heart failure [CORRECT]
D. Cardiac tamponade
Correct Answer: C — Biventricular heart failure
Rationale:
S3 and bilateral crackles indicate left ventricular failure (pulmonary congestion), while JVD and pitting edema indicate
right ventricular failure (systemic congestion). Combined findings are diagnostic of biventricular (congestive) heart
failure. Cardiac tamponade presents with Beck's triad (muffled heart tones, hypotension, JVD) and pulsus paradoxus.
Q5: Which ECG finding is the strongest indicator of impending ventricular fibrillation in a patient with
acute MI?
A. Frequent PVCs
B. R-on-T phenomenon [CORRECT]
C. First-degree AV block
D. Atrial fibrillation
Correct Answer: B — R-on-T phenomenon
Rationale:
R-on-T phenomenon occurs when a premature ventricular contraction (PVC) falls on the T wave of the preceding beat
during the vulnerable repolarization period, which can trigger ventricular fibrillation (VF). It is a critical warning sign
requiring immediate intervention. Frequent PVCs alone are less ominous. First-degree AV block and atrial fibrillation are
not typically precursors to VF.
Aligned with current AACN CCRN Examination Standards 200 Questions | Complete Solution with Verified Rationales
,Adult CCRN Exam | Barron's CCRN Review Book - Complete Solution Guide Page 3
Q6: A patient with heart failure has a BNP of 1,800 pg/mL. The patient is receiving IV furosemide. Which
finding BEST indicates that treatment is effective?
A. Urine output of 50 mL/hr
B. Decrease in BNP to 600 pg/mL after 24 hours [CORRECT]
C. Increase in body weight
D. Decrease in serum sodium
Correct Answer: B — Decrease in BNP to 600 pg/mL after 24 hours
Rationale:
BNP is released from ventricles in response to stretch/overload. A declining BNP indicates reduced wall stress and
improved heart failure status. BNP <100 rules out HF, >400 supports HF diagnosis, and >1,000 indicates significant
decompensation. While urine output is important, BNP directly reflects cardiac status. Weight gain and hyponatremia
would indicate worsening HF.
Q7: A patient is receiving an IV heparin infusion for NSTEMI. The aPTT is 110 seconds (control 30). The
patient has melena. What is the PRIORITY action?
A. Increase heparin rate
B. Decrease heparin rate or discontinue and notify provider [CORRECT]
C. Administer vitamin K
D. Continue current rate
Correct Answer: B — Decrease heparin rate or discontinue and notify provider
Rationale:
Active GI bleeding (melena) with prolonged aPTT (110 sec) indicates heparin-induced bleeding complication. Priority
action is to decrease/discontinue the heparin infusion and notify the provider. Protamine sulfate (not vitamin K) reverses
heparin. Vitamin K reverses warfarin. Continuing or increasing heparin would worsen bleeding.
Q8: A patient with acute MI develops a new systolic murmur at the apex, loud P2, and sudden pulmonary
edema 4 days after admission. What complication should the nurse suspect?
A. Ventricular septal rupture
B. Papillary muscle rupture with acute mitral regurgitation [CORRECT]
C. Aortic dissection
D. Pericarditis
Correct Answer: B — Papillary muscle rupture with acute mitral regurgitation
Rationale:
Acute severe mitral regurgitation from papillary muscle rupture (typically 2-7 days post-MI) presents with a new apical
systolic murmur, pulmonary edema, and cardiogenic shock. The posteromedial papillary muscle has single blood supply
(RCA/PDA) making it more vulnerable. VSD presents with a harsh holosystolic murmur at the lower left sternal border.
Both require emergent surgical intervention.
Q9: Which rhythm requires immediate synchronized cardioversion per ACLS guidelines?
A. Stable supraventricular tachycardia
B. Unstable atrial fibrillation with hypotension [CORRECT]
C. Sinus tachycardia
D. First-degree AV block
Correct Answer: B — Unstable atrial fibrillation with hypotension
Rationale:
Synchronized cardioversion is indicated for unstable tachyarrhythmias (with signs of poor perfusion: hypotension, altered
mental status, chest pain, acute heart failure). Unstable atrial fibrillation with hypotension requires immediate
Aligned with current AACN CCRN Examination Standards 200 Questions | Complete Solution with Verified Rationales
, Adult CCRN Exam | Barron's CCRN Review Book - Complete Solution Guide Page 4
synchronized cardioversion. Stable SVT can be treated with vagal maneuvers or adenosine. Sinus tachycardia treatment
targets the underlying cause. First-degree AV block requires no treatment.
Q10: A patient has a heart rate of 40 bpm, BP 88/50, and complains of dizziness. The ECG shows a wide
QRS (>0.12 sec) with no P waves. What is the appropriate intervention?
A. Administer adenosine 6 mg IV push
B. Apply transcutaneous pacemaker pads and prepare for transvenous pacing [CORRECT]
C. Administer amiodarone 150 mg IV
D. Administer atropine 1 mg IV push
Correct Answer: B — Apply transcutaneous pacemaker pads and prepare for transvenous pacing
Rationale:
Wide-complex bradycardia with unstable hemodynamics (hypotension, dizziness) indicates high-grade AV block below
the bundle of His. Atropine is less likely to be effective for infranodal blocks (Mobitz II, third-degree with wide QRS).
Transcutaneous pacing is the immediate intervention while preparing for transvenous pacing. Adenosine and amiodarone
are inappropriate for bradycardia.
Q11: A patient with a pulmonary artery catheter has a PAOP waveform showing large a waves and large v
waves. These findings are MOST consistent with:
A. Mitral stenosis and mitral regurgitation [CORRECT]
B. Mitral regurgitation only
C. Mitral stenosis only
D. Aortic stenosis
Correct Answer: A — Mitral stenosis and mitral regurgitation
Rationale:
Large a waves indicate increased resistance to atrial emptying (mitral stenosis), and large v waves indicate regurgitant
backflow into the atrium (mitral regurgitation). Combined findings suggest both MS and MR. Large a waves alone occur
in MS, mitral atresia, or complete heart block. Large v waves alone occur in MR, VSD, or heart failure. Interpretation
guides diagnosis and treatment.
Q12: A patient has a CVP of 2 mmHg, BP 84/50, HR 120, and dry mucous membranes. Which intervention
should the nurse anticipate?
A. Administer IV furosemide
B. Administer IV fluid bolus (250-500 mL crystalloid) [CORRECT]
C. Start norepinephrine infusion
D. Administer IV nitroglycerin
Correct Answer: B — Administer IV fluid bolus (250-500 mL crystalloid)
Rationale:
Low CVP (2 mmHg) with hypotension and tachycardia indicates hypovolemia. The appropriate intervention is an IV
fluid bolus (250-500 mL crystalloid) to restore preload and improve cardiac output. Furosemide and nitroglycerin would
worsen hypovolemia. Norepinephrine may be added if fluids are insufficient. Fluid responsiveness should be assessed
before vasopressors.
Aligned with current AACN CCRN Examination Standards 200 Questions | Complete Solution with Verified Rationales
