CRITICAL CARE
MASTERY: ADVANCED
MEDICAL NURSING
EXAMINATION
77 Practice Questions with Exhaustive,
Evidence-Based Rationales
Designed for CCRN Certification Preparation and Graduate-Level Curricula.
I. Advanced Cardiovascular & Hemodynamic Management (Q1–Q15)
Question Number Question Answer and Detailed
Rationale
Q1 A 68-year-old patient presents Answer: Initiation of
with suspected Cardiogenic Dobutamine infusion.
Shock. Hemodynamic Rationale: The patient’s
monitoring reveals a Cardiac hemodynamic profile defines a
Index (CI) of 1.9 L/min/m$^2$ severe state of primary pump
and a Pulmonary Capillary failure. The Cardiac Index (CI)
Wedge Pressure (PCWP) of 24 is critically low (normal range is
mm Hg. Which pharmacological 2.5–4.0 L/min/m$^2$ ),
intervention is the priority? indicating inadequate tissue
perfusion. Simultaneously, the
Pulmonary Capillary Wedge
Pressure (PCWP) is
significantly elevated at 24 mm
Hg (normal 8–12 mm Hg; >18
mm Hg suggests severe Left
Ventricular (LV) failure). This
combination—low output with
high filling pressures—is
characteristic of advanced
Cardiogenic Shock, often
described as a "wet and cold"
profile. The immediate
therapeutic goal is to increase
,Question Number Question Answer and Detailed
Rationale
myocardial contractility and
decrease the afterload against
which the failing ventricle must
pump. Dobutamine is the agent
of choice because it is a
positive inotrope, primarily
acting as a beta-1 agonist,
which dramatically increases
contractility (inotropic effect).
Additionally, it provides a
degree of peripheral
vasodilation (reducing systemic
vascular resistance, or
afterload), further easing the
workload on the struggling LV.
Administering crystalloids or
volume expanders would be
severely detrimental, as the
high PCWP confirms severe
volume overload, risking flash
pulmonary edema and further
respiratory compromise.
Vasoconstrictors like
Norepinephrine are typically
avoided in initial management
unless profound hypotension
(MAP < 60 mmHg) requires
immediate systemic vascular
tone support, as they increase
afterload, which will worsen the
LV’s performance. The ability to
link specific abnormal
hemodynamic values (low CI,
high PCWP) to the most
appropriate pharmacological
class (inodilator vs.
vasoconstrictor) is central to
advanced clinical
decision-making.
Q2 The nurse notes a patient Answer: Right Ventricular
receiving mechanical ventilation (RV) failure, severe tricuspid
has a Central Venous Pressure regurgitation, or increased
(CVP) reading that consistently intrathoracic pressure
peaks at 18 mm Hg. The secondary to mechanical
PCWP is 10 mm Hg. What is ventilation. Rationale: A CVP
,Question Number Question Answer and Detailed
Rationale
the most likely cause of this of 18 mm Hg is significantly
isolated finding? elevated (normal 2–5 mm Hg) ,
reflecting high pressure in the
right atrium and increased RV
preload. In contrast, the PCWP
is normal at 10 mm Hg , which
accurately estimates the Left
Ventricular filling pressure. This
hemodynamic dissociation,
where the right-sided pressure
is high but the left-sided
pressure is normal, rules out
generalized hypervolemia or
global biventricular failure.
Instead, it suggests a primary
pathology affecting the right
heart’s ability to handle volume
or outflow. Potential causes
include acute RV infarct,
massive pulmonary embolism
(Obstructive Shock), or severe
pulmonary hypertension, all of
which elevate RV afterload and
subsequently RV preload.
Furthermore, Positive
End-Expiratory Pressure
(PEEP) utilized in mechanical
ventilation significantly
increases intrathoracic
pressure, which impedes
venous return to the right heart,
leading to a falsely or genuinely
elevated CVP reading without
necessarily influencing the
left-sided PCWP to the same
degree. The advanced nurse
must evaluate the clinical
context (e.g., history of PE,
right heart strain on ECG, or
high ventilator settings) before
determining the need for
targeted RV afterload reduction
or volume management.
Q3 A patient on telemetry exhibits Answer: Preparation for
a ventricular rate of 140 bpm, immediate synchronized
, Question Number Question Answer and Detailed
Rationale
no discernable P waves, and cardioversion. Rationale: The
wide, bizarre QRS complexes electrocardiogram
(> 0.12 seconds). The patient is findings—wide QRS, fast rate
diaphoretic and has a blood (140 bpm), absence of P
pressure of 85/50 mm Hg. waves—are highly
What is the priority nursing characteristic of Ventricular
intervention? Tachycardia (VT) or
wide-complex Tachycardia with
aberrancy. Crucially, the patient
exhibits signs of hemodynamic
instability: profound
hypotension (85/50 mmHg) and
poor peripheral perfusion
(diaphoresis). Low cardiac
output due to a critically fast,
inefficient ventricular rhythm
combined with severe signs of
low perfusion constitutes a
medical emergency. For
unstable VT, delaying treatment
increases the risk of
progression to ventricular
fibrillation and cardiac arrest.
Immediate electrical
cardioversion, synchronized to
the R-wave, is the definitive,
life-saving intervention.
Pharmacological interventions
(like Amiodarone or lidocaine)
are reserved for stable
wide-complex tachycardias.
While Atropine is used for
symptomatic bradycardia , it is
inappropriate here, and
defibrillation (unsynchronized
shock) is reserved only for
pulseless rhythms.
Q4 A 55-year-old patient Answer: Suggests
recovering from septic shock sepsis-induced myocardial
shows a trend of decreasing depression; next step is
Cardiac Index (CI) (now 2.1 introducing a positive
L/min/m$^2$) despite inotrope (e.g., Dobutamine).
maintaining a Mean Arterial Rationale: This clinical
Pressure (MAP) of 68 mm Hg scenario involves differentiating
with Norepinephrine. The between persistent distributive
MASTERY: ADVANCED
MEDICAL NURSING
EXAMINATION
77 Practice Questions with Exhaustive,
Evidence-Based Rationales
Designed for CCRN Certification Preparation and Graduate-Level Curricula.
I. Advanced Cardiovascular & Hemodynamic Management (Q1–Q15)
Question Number Question Answer and Detailed
Rationale
Q1 A 68-year-old patient presents Answer: Initiation of
with suspected Cardiogenic Dobutamine infusion.
Shock. Hemodynamic Rationale: The patient’s
monitoring reveals a Cardiac hemodynamic profile defines a
Index (CI) of 1.9 L/min/m$^2$ severe state of primary pump
and a Pulmonary Capillary failure. The Cardiac Index (CI)
Wedge Pressure (PCWP) of 24 is critically low (normal range is
mm Hg. Which pharmacological 2.5–4.0 L/min/m$^2$ ),
intervention is the priority? indicating inadequate tissue
perfusion. Simultaneously, the
Pulmonary Capillary Wedge
Pressure (PCWP) is
significantly elevated at 24 mm
Hg (normal 8–12 mm Hg; >18
mm Hg suggests severe Left
Ventricular (LV) failure). This
combination—low output with
high filling pressures—is
characteristic of advanced
Cardiogenic Shock, often
described as a "wet and cold"
profile. The immediate
therapeutic goal is to increase
,Question Number Question Answer and Detailed
Rationale
myocardial contractility and
decrease the afterload against
which the failing ventricle must
pump. Dobutamine is the agent
of choice because it is a
positive inotrope, primarily
acting as a beta-1 agonist,
which dramatically increases
contractility (inotropic effect).
Additionally, it provides a
degree of peripheral
vasodilation (reducing systemic
vascular resistance, or
afterload), further easing the
workload on the struggling LV.
Administering crystalloids or
volume expanders would be
severely detrimental, as the
high PCWP confirms severe
volume overload, risking flash
pulmonary edema and further
respiratory compromise.
Vasoconstrictors like
Norepinephrine are typically
avoided in initial management
unless profound hypotension
(MAP < 60 mmHg) requires
immediate systemic vascular
tone support, as they increase
afterload, which will worsen the
LV’s performance. The ability to
link specific abnormal
hemodynamic values (low CI,
high PCWP) to the most
appropriate pharmacological
class (inodilator vs.
vasoconstrictor) is central to
advanced clinical
decision-making.
Q2 The nurse notes a patient Answer: Right Ventricular
receiving mechanical ventilation (RV) failure, severe tricuspid
has a Central Venous Pressure regurgitation, or increased
(CVP) reading that consistently intrathoracic pressure
peaks at 18 mm Hg. The secondary to mechanical
PCWP is 10 mm Hg. What is ventilation. Rationale: A CVP
,Question Number Question Answer and Detailed
Rationale
the most likely cause of this of 18 mm Hg is significantly
isolated finding? elevated (normal 2–5 mm Hg) ,
reflecting high pressure in the
right atrium and increased RV
preload. In contrast, the PCWP
is normal at 10 mm Hg , which
accurately estimates the Left
Ventricular filling pressure. This
hemodynamic dissociation,
where the right-sided pressure
is high but the left-sided
pressure is normal, rules out
generalized hypervolemia or
global biventricular failure.
Instead, it suggests a primary
pathology affecting the right
heart’s ability to handle volume
or outflow. Potential causes
include acute RV infarct,
massive pulmonary embolism
(Obstructive Shock), or severe
pulmonary hypertension, all of
which elevate RV afterload and
subsequently RV preload.
Furthermore, Positive
End-Expiratory Pressure
(PEEP) utilized in mechanical
ventilation significantly
increases intrathoracic
pressure, which impedes
venous return to the right heart,
leading to a falsely or genuinely
elevated CVP reading without
necessarily influencing the
left-sided PCWP to the same
degree. The advanced nurse
must evaluate the clinical
context (e.g., history of PE,
right heart strain on ECG, or
high ventilator settings) before
determining the need for
targeted RV afterload reduction
or volume management.
Q3 A patient on telemetry exhibits Answer: Preparation for
a ventricular rate of 140 bpm, immediate synchronized
, Question Number Question Answer and Detailed
Rationale
no discernable P waves, and cardioversion. Rationale: The
wide, bizarre QRS complexes electrocardiogram
(> 0.12 seconds). The patient is findings—wide QRS, fast rate
diaphoretic and has a blood (140 bpm), absence of P
pressure of 85/50 mm Hg. waves—are highly
What is the priority nursing characteristic of Ventricular
intervention? Tachycardia (VT) or
wide-complex Tachycardia with
aberrancy. Crucially, the patient
exhibits signs of hemodynamic
instability: profound
hypotension (85/50 mmHg) and
poor peripheral perfusion
(diaphoresis). Low cardiac
output due to a critically fast,
inefficient ventricular rhythm
combined with severe signs of
low perfusion constitutes a
medical emergency. For
unstable VT, delaying treatment
increases the risk of
progression to ventricular
fibrillation and cardiac arrest.
Immediate electrical
cardioversion, synchronized to
the R-wave, is the definitive,
life-saving intervention.
Pharmacological interventions
(like Amiodarone or lidocaine)
are reserved for stable
wide-complex tachycardias.
While Atropine is used for
symptomatic bradycardia , it is
inappropriate here, and
defibrillation (unsynchronized
shock) is reserved only for
pulseless rhythms.
Q4 A 55-year-old patient Answer: Suggests
recovering from septic shock sepsis-induced myocardial
shows a trend of decreasing depression; next step is
Cardiac Index (CI) (now 2.1 introducing a positive
L/min/m$^2$) despite inotrope (e.g., Dobutamine).
maintaining a Mean Arterial Rationale: This clinical
Pressure (MAP) of 68 mm Hg scenario involves differentiating
with Norepinephrine. The between persistent distributive
