Adult CCRN Certification Review
The initial certification for the Adult Critical Care Nurses (CCRN) Examination is offered by the AACN Certification Corporation. The computer-based test is taken as part of the CCRN certification.
Candidates are given three hours to complete 150 multiple-choice questions. Candidates do not have to have a BSN, but they do have to have an up-to-date RN license that is valid in the United States and free of any impediment. Candidates must meet all of the necessary eligibility requirements before taking this exam. After passing the exam, candidates receive a wall certificate and wallet card. Candidates that do not pass may appeal or take the test again.
There are no particular technical abilities needed to meet assessment eligibility, but it is important to understand physiology and how to handle situations which require monitors or ventilators. Comprehending these matters will aid candidates in comprehension of the items tested. Knowing about these tools will help when reading case studies.
The subject areas of the Adult CCRN Certification Exam include:
- 80% Clinical Judgment, which includes:
- 32% Cardiovascular
- 17% Pulmonary
- 4% Endocrine
- 3% Hematology and Immunology
- 5% Neurology
- 6% Gastrointestinal
- 5% Renal
- 8% Multisystem
20% Professional Caring and Ethical Practice, which includes:
- 2% Advocacy and Moral Agency
- 4% Caring Practices
- 4% Collaboration
- 2% Systems Thinking
- 2% Response to Diversity
- 2% Clinical Inquiry
- 4% Facilitation of Learning
CCRN Review Fulminant Pulmonary Edema
CCRN Practice Questions
1. Your patient was transferred to Coronary Care from the Medical-Surgical floor. Your patient has a pulmonary artery catheter inserted and is in septic shock. The best way to check your patient’s right-sided afterload is by measuring:
A. Left ventricular stroke work
B. Systemic vascular resistance
C. Right ventricular stroke work
D. Pulmonary vascular resistance
2. Twenty-four hours after coronary artery bypass graft surgery, your patient becomes increasingly agitated and confused. His blood pressure is difficult to auscultate. His heart rate is 130 beats/minute. His respirations are 28 breaths/minute. When auscultating his breath sounds, you find new crackles one-third up in both lung fields. Your patient’s pulmonary artery wedge pressure is 22 mm/Hg. Based on these findings, you suspect:
B. Cardiac tamponade
C. Myocardial infarction
D. Pulmonary edema
3. Identify the electrolyte imbalance most likely to affect a patient with Crohn’s disease:
4. An adolescent patient with asthma has the following arterial blood gas (ABG) results: pH 7.36; PaO2 81 mm Hg; PaCO2 52 mm Hg; and HCO3- 29 mEq/L. Choose the condition you suspect from reviewing her ABG results:
A. Respiratory alkalosis, uncompensated
B. Respiratory acidosis, compensated
C. Metabolic acidosis, compensated
D. Metabolic alkalosis, uncompensated
5. Your patient’s diagnosis is respiratory failure. Which arterial blood gas (ABG) values should you expect?
A. pH 7.3, PaO2 60 mm/Hg, PaO2 50 mm/Hg, HCO3- 26 mEq/L
B. pH 7.5, PaCO2 30 mm/Hg, PaO2 60 mm/Hg, HCO3- 24 mEq/L
C. pH 7.3, PaCO2 20 mm/Hg, PaO2 80 mm/Hg, HCO3- 16 mEq/L
D. pH 7.4, PaCO2 50 mm/Hg, PaO2 70 mm/Hg, HCO3- 26 mEq/L
6. Your patient is on a mechanical ventilator for ongoing pulmonary problems. His arterial blood gas (ABG) results are: pH 7.50; PaCO2 25 mm/Hg; PaO2 88 mm/Hg; and HCO3- 24 mEq/L. The ventilator is set in assist-control mode with a rate of 14 breaths/minute, tidal volume of 500 ml, and oxygen at 50%. Based on the patient’s ABG results, which intervention is correct?
A. Decrease the rate
B. Increase the oxygen
C. Increase the tidal volume
D. Add positive end-expiratory pressure (PEEP)
7. You are treating a patient who weighs 60 kg and has a history of chronic obstructive pulmonary disease. The patient is placed on the following ventilator settings for weaning: FiO2 0.40; tidal volume 600 cc; intermittent mandatory ventilation (IMV) 8 breaths/minute; positive end expiratory pressure 5 cm water pressure; pressure support 10 cm H2O. Twenty minutes after the ventilator changes have been made, you assess the patient and notice diaphoresis and labored breathing. The patient’s vital signs are: Heart rate 160 beats/minute; blood pressure 160/90 mm/Hg; and temperature 99°F. Choose the factor that correlates with the patient’s clinical condition:
A. Low FiO2
B. High tidal volume
C. Low tidal volume
D. IMV setting
8. Your patient with a pulmonary embolism has been receiving heparin by continuous I.V. infusion for 12 hours. Select the patient’s benchmark that indicates when you should notify the physician:
A. Prothrombin time is 125 seconds
B. Partial thromboplastin time is 30 seconds
C. Platelets are 250,000/microliters
D. D-dimer assay is negative
9. You are assessing a patient with a closed head injury, who has an intracranial pressure sensor inserted. Select the reading that would trigger you to notify a physician:
A. A rise to 20 mm/Hg that immediately decreases to 10 mm/Hg
B. A rise to 23 mm/Hg that is sustained for at least 10 minutes
C. A rise to 15 mm/Hg (while suctioning the patient’s endotracheal tube) that returns to 8 mm/Hg after the procedure
D. A rise to 12 mm/Hg that is sustained for at least 15 minutes
10. You are caring for a patient in the oliguric stage of renal failure. His serum potassium level is 5.5 mEq/L. The patient’s electrocardiogram might show:
A. Shortened Q-T interval and peaked T-waves
B. Depressed S-T segments
C. Prolonged Q-T interval
D. Presence of U-waves
Answers & Explanations
1. D: Pulmonary vascular resistance
Pulmonary vascular resistance measures the right ventricle’s resistance to ejection. Afterload is the force against which a ventricle contracts. Determine right-sided afterload by measuring resistance to ejection from the right ventricle. To assess right-sided afterload, measure pulmonary vascular resistance. Left and right ventricular stroke work measure the effort of each ventricle per stroke. Systemic vascular resistance measures the resistance to ejection from the left ventricle.
2. D: Pulmonary edema
Pulmonary edema is swelling from accumulated fluid in the extravascular spaces of the lungs, and is a common complication of cardiac disorders. Your patient shows signs of pulmonary edema. His elevated pulmonary artery wedge pressures indicate your patient may have left-sided heart failure, which commonly leads to pulmonary edema. In hypovolemia, pulmonary artery wedge pressure decreases, and the lungs are clear. In cardiac tamponade, all pulmonary artery pressures increase until they reach the same pressure throughout, and the lungs are clear. An uncomplicated myocardial infarction does not change pulmonary artery pressures, and the lungs are clear.
3. D: Hypomagnesemia
Crohn’s disease is a type of autoimmune inflammatory bowel disease (IBD) that affects mostly the ileum and colon. However, the Crohn’s patient may also have edema, redness, and dysfunction in the mouth, esophagus, and stomach. The Crohn’s patient cannot absorb magnesium through the lower GI tract. Closely monitor your patient for hypomagnesemia. By contrast, potassium is affected by upper GI tract problems, such as vomiting.
4. B: Respiratory acidosis, compensated
Her pH is in the low normal range, but her carbon dioxide and bicarbonate levels are abnormal. Asthma creates poor air movement for your patient. Her retained CO2 suggests acidosis, as her body compensates for the poor movement of air by increasing the bicarbonate levels. The pH value within the normal range suggests compensated respiratory acidosis. If your patient’s pH was elevated, respiratory alkalosis would be a reasonable suspicion. Metabolic acidosis does not produce an elevated bicarbonate level. If her condition was uncompensated metabolic alkalosis, then her pH would be greater than 7.45.
5. A: pH 7.3, PaO2 60 mm/Hg, PaO2 50 mm/Hg, HCO3- 26 mEq/L
Respiratory acidosis frequently accompanies respiratory failure. Normal ABG values are PaO2 less than 60 mm/Hg and PaCO2 50 mm/Hg or more. Option b indicates respiratory alkalosis. Option c indicates metabolic acidosis. Option d indicates compensated respiratory acidosis.
6. A: Decrease the rate
The patient’s ABG results indicate respiratory alkalosis, which is corrected by retaining more carbon dioxide (CO2). Changing the mode to intermittent mandatory ventilation, decreasing the rate, or decreasing the tidal volume may accomplish this. The oxygen level is within normal limits, so do not adjust it. Adding PEEP would increase gas diffusion, not decrease CO2 levels.
7. D: IMV setting
IMV is frequently used for weaning clients from mechanical ventilation and usually works well. The disadvantage of IMV is that it increases the work of breathing. A patient with chronic lung disease typically cannot handle the increased work of breathing and will begin to show signs of respiratory distress shortly after being placed on IMV. Pressure support is a ventilatory parameter that can be increased to decrease the work of breathing; it may need to be increased in this situation, rather than returning the patient to the assist control mode. Since this patient weighs 60 kg and tidal volume is calculated at 10 to 15 cc per 1 kg of body weight, a tidal volume of 600 cc is appropriate. An FiO2 of 0.40 is adequate for a patient with chronic disease. If the FiO2 is too high, the hypoxic drive is suppressed, and the patient will not attempt spontaneous breathing.
8. B: Partial thromboplastin time is 30 seconds
The goal of heparin therapy is to maintain the patient’s partial thromboplastin time (PTT) at 1½ times the normal control. In this case, notify the physician because the PTT is too low. The prothrombin time is used to regulate warfarin (Coumadin) therapy. Platelets are not evaluated during heparin treatment. The d-dimer assay is appropriate for diagnosing disseminated intravascular coagulation (DIC).
9. B: A rise to 23 mm/Hg that is sustained for at least 10 minutes
ICP normally ranges from 0 to 10 mm/Hg with an upper limit of 15 mm/Hg. A rise in ICP (greater than 15 mm/Hg) sustained over 10 minutes should be reported to the physician immediately. Rises in ICP with suctioning are normal, and the physician should be notified only if the ICP does not return to normal after the procedure.
10. A: Shortened Q-T interval and peaked T-waves
Hyperkalemia can shorten the Q-T interval and cause peaked T-waves and ventricular arrhythmias. Depressed S-T segments are seen with hypertrophy or as an adverse effect of digoxin (Lanoxin). A prolonged Q-T interval is seen with hypocalcemia, and U-waves are seen with hypokalemia.