The CCRN (Critical Care Registered Nurse) is a nursing certification awarded by AACN.
AACN publishes the official exam outline, eligibility rules and fees — see AACN's official page before you book.
Twenty CCRN (Critical Care Registered Nurse) questions, with the answers hidden until you want them — covering Pathology, Management, Procedures, Pharmacology and more. They are real cards from our 1000-card deck, not the 30 on the free preview page, so you can use both. Work through them cold, then use your score below to decide what to study next. AACN publishes the official exam outline — check it for the real blueprint.
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A patient with an inferior STEMI presents with BP 82/44, JVD, and clear breath sounds. What is the priority intervention and what should be avoided?
Show answer →Right Ventricular Infarction (RVMI). Triad: Hypotension, JVD, clear lungs. Priority: Volume expansion (NS boluses) to increase RV preload and stroke volume. Avoid: Nitrates, Morphine, and Diuretics, as these reduce preload and can cause profound cardiovascular collapse. Exam Tip: RVMI is seen in ~40% of inferior MIs; always check right-sided leads (V4R).
On day 4 post-MI, a patient develops a new, loud holosystolic murmur at the left sternal border and acute heart failure. Which diagnostic finding is pathognomonic?
Show answer →Ventricular Septal Rupture (VSR). Diagnosis: Oxygen step-up (significant increase in SaO2) from the Right Atrium to the Right Ventricle or Pulmonary Artery during PA catheterization. Rationale: Oxygenated blood shunts from the high-pressure LV to the low-pressure RV. Exam Tip: Differentiate from Papillary Muscle Rupture, which has no O2 step-up and is heard at the apex.
Which hemodynamic profile (CO/CI, PAOP, and SVR) is expected in a patient experiencing cardiogenic shock following a massive anterior wall MI?
Show answer →CO/CI: Low (<2.2 L/min/m2) due to pump failure. PAOP: High (>18 mmHg) due to blood backing up into the pulmonary vasculature. SVR: High (>1400 dynes) as a compensatory mechanism to maintain MAP. Exam Tip: Cardiogenic shock is the only shock state with BOTH low CO and high PAOP. Treat with inotropes and afterload reducers (if BP tolerates).
A patient develops sudden, severe pulmonary edema and a holosystolic murmur at the apex 3 days after an RCA-occlusion MI. What is the most likely mechanical complication?
Show answer →Papillary Muscle Rupture causing Acute Mitral Regurgitation. The posteromedial papillary muscle is most vulnerable as it has a single blood supply (RCA). Presentation: Flash pulmonary edema and cardiogenic shock. Exam Tip: This is a surgical emergency. IABP therapy is often used as a bridge to surgery to reduce afterload and improve forward flow.
A patient reports pleuritic chest pain 48 hours post-STEMI that improves when leaning forward. EKG shows diffuse ST elevation and PR depression. What is the preferred treatment?
Show answer →Acute Post-MI Pericarditis. Preferred Treatment: High-dose Aspirin (e.g., 650 mg every 6-8 hours). Rationale: Standard NSAIDs (like Ibuprofen) and Steroids should be avoided in the first 7-10 days post-MI as they can impair myocardial scar formation and increase the risk of ventricular rupture. Exam Tip: Look for global EKG changes rather than territorial.
Five days after a STEMI, a patient suddenly develops PEA, JVD, and muffled heart sounds. What is the most likely cause and the immediate required procedure?
Show answer →Left Ventricular Free Wall Rupture leading to Cardiac Tamponade. This sudden death complication presents with Beck's Triad (Hypotension, JVD, Muffled heart sounds) and PEA. Immediate Action: Pericardiocentesis to relieve pressure, followed by emergency surgical repair. Exam Tip: Most common in older adults with their first MI and late or no reperfusion.
Compare the clinical significance of a new 2nd-degree Mobitz Type II heart block in an Anterior MI versus a Wenckebach (Type I) block in an Inferior MI.
Show answer →Inferior MI: Usually involves the AV node (RCA); Type I is often transient and asymptomatic. Anterior MI: Involves the Bundle of His or Purkinje fibers (LAD); Type II is high-risk for sudden progression to Complete Heart Block (CHB) and ventricular asystole. Exam Tip: Anterior MI blocks are below the node and require immediate standby or active temporary pacing.
A patient with STEMI presents to a non-PCI capable facility. Transfer to a PCI center will take 120 minutes. According to current guidelines, what is the preferred reperfusion strategy and the target time frame for administration?
Show answer →If the expected Door-to-Balloon (D2B) time at a PCI-capable center exceeds 120 minutes from first medical contact, fibrinolytic therapy is indicated unless contraindicated. The goal Door-to-Needle (D2N) time for fibrinolytics is within 30 minutes of arrival. Exam Tip: AACN emphasizes the 120-minute window for transfer. If transfer can be done such that D2B is <120 mins, PCI is superior. If not, give fibrinolytics. Always monitor for reperfusion signs: ST-segment resolution >50% within 60-90 mins, relief of chest pain, and reperfusion arrhythmias like Accelerated Idioventricular Rhythm (AIVR).
A patient with an inferior wall STEMI (leads II, III, aVF) has a BP of 88/54 mmHg and clear lung sounds. What is the priority nursing intervention and which class of medications must be strictly avoided?
Show answer →The presentation suggests Right Ventricular (RV) Infarction. Priority: Administer an IV fluid bolus (Normal Saline) to increase preload, as the RV is preload-dependent. Avoid: Nitrates, Morphine, and Diuretics. Rationale: These medications decrease preload, which can lead to profound hypotension and cardiovascular collapse in RV failure. Exam Strategy: On the CCRN, clear lungs + hypotension + inferior MI is the classic triad for RV involvement. Always check a Right-Sided EKG (V4R) to confirm.
Which absolute contraindication to fibrinolytic therapy is most likely to be tested when a patient presents with a STEMI and a history of a non-hemorrhagic stroke?
Show answer →Ischemic stroke within the last 3 months is an absolute contraindication to fibrinolytic therapy. Other absolute contraindications include: any prior intracranial hemorrhage (ICH), known structural cerebrovascular lesion (AVM), known malignant intracranial neoplasm, suspected aortic dissection, or active internal bleeding (excluding menses). Clinical Pearl: Severe uncontrolled hypertension (>180/110) at presentation is a relative contraindication, but if it cannot be controlled, it becomes a major risk for ICH. AACN often tests the distinction between absolute and relative contraindications.
A patient with NSTEMI develops refractory chest pain, a new holosystolic murmur at the apex, and acute pulmonary edema. What is the definitive management priority?
Show answer →This patient likely has acute mitral regurgitation due to papillary muscle rupture, a mechanical complication of MI. The priority is immediate stabilization (often with an Intra-Aortic Balloon Pump [IABP] to decrease afterload) followed by urgent surgical repair and/or cardiac catheterization. Rationale: Unlike STEMI, NSTEMI usually follows an ischemia-driven pathway. However, hemodynamic instability or mechanical complications (murmurs) move the patient into the Immediate Invasive category (<2 hours). Exam Tip: Distinguish between papillary muscle rupture (mitral area) and VSD (left sternal border). Both cause holosystolic murmurs.
A patient is receiving Ticagrelor (Brilinta) as part of DAPT post-PCI. What specific side effect must the nurse monitor for that is unique to this P2Y12 inhibitor and not seen with Clopidogrel?
Show answer →Dyspnea (shortness of breath) is a unique, usually self-limiting side effect of Ticagrelor, occurring in up to 15-20% of patients. It is not related to heart failure or pulmonary pathology but is thought to be mediated by adenosine. Clinical Reasoning: Ticagrelor is a reversible P2Y12 inhibitor. Unlike Clopidogrel (a prodrug), Ticagrelor does not require hepatic activation. AACN may test your ability to differentiate DAPT agents. Also, monitor for bradyarrhythmias and increased uric acid levels.
During PA catheter insertion, the waveform changes from a pressure of 25/2 to 25/11 mmHg. What anatomical location has the catheter tip reached?
Show answer →The catheter has moved from the Right Ventricle (RV) to the Pulmonary Artery (PA). Key identifier: The diastolic pressure rises (from near-zero in the RV to ~10-15 mmHg in the PA) and the dicrotic notch appears (representing pulmonic valve closure). AACN Tip: If the catheter migrates back into the RV, it creates a high risk for ventricular arrhythmias (V-tach). Immediate action: Inflate the balloon to float it forward or notify the provider to pull it back. Never leave a catheter in the RV.
A patient on 16 cmH2O PEEP requires PAWP measurement. How should the nurse obtain the most accurate reading?
Show answer →Measure PAWP at end-expiration without disconnecting the ventilator. End-expiration is when pleural pressure is closest to atmospheric pressure. Clinical Pearl: For PEEP >10 cmH2O, the PAWP may be falsely elevated if the catheter is not in West Zone 3 of the lung. Do NOT remove PEEP for measurement as it causes alveolar collapse and hemodynamic instability. AACN Strategy: PAWP should be measured at the mean of the a-wave. If the PEEP (in mmHg) is > 1/2 the PAWP, the reading may reflect airway pressure rather than left atrial pressure.
After inflating the PA catheter balloon for a wedge pressure, the patient suddenly develops hemoptysis and dyspnea. What is the priority nursing intervention?
Show answer →Suspect Pulmonary Artery Rupture. Priority: Turn the patient onto the affected side (lateral decubitus) to prevent blood from aspirating into the unaffected lung (protecting the good lung). Provide 100% oxygen and prepare for emergency intubation, potentially with a double-lumen tube. Prevention: Avoid over-inflation; never exceed the recommended balloon volume (1.5 mL) and stop inflation immediately once the waveform changes from PA to PAWP. AACN Tip: Hemoptysis after wedging is a never event requiring immediate life-saving action.
A patient with a new systolic murmur shows a PAWP waveform with large, sharp peaks occurring after the QRS complex. What is the likely cause?
Show answer →Large V-waves in the PAWP waveform, indicating Mitral Regurgitation (MR). In MR, blood flows backward into the left atrium during ventricular systole, creating a pressure spike. This can overestimate the true PAWP if not measured correctly. AACN Strategy: Distinguish V-waves from PA systolic pressure by timing—V-waves occur after the QRS (late systole). True PAWP (Left Atrial Pressure) should be measured at the mean of the a-wave (following the P-wave on EKG), not at the peak of the V-wave.
A patient with HFrEF (EF 30%) is being optimized on GDMT. What are the four pillars of therapy proven to reduce mortality in this population according to 2026 standards?
Show answer →Per 2026 guidelines, the four pillars are: 1) ARNI (Sacubitril/Valsartan preferred over ACE/ARB), 2) Evidence-based Beta-blockers (Carvedilol, Metoprolol Succinate, or Bisoprolol), 3) Mineralocorticoid Receptor Antagonists (MRA: Spironolactone or Eplerenone), and 4) SGLT2 Inhibitors (Dapagliflozin or Empagliflozin). Exam Tip: AACN emphasizes that these should be initiated early and titrated rapidly. All four classes improve survival and reduce hospitalizations.
A 45-year-old intubated patient follows commands and opens eyes to speech but cannot provide a verbal response. How should the nurse accurately document the Glasgow Coma Scale (GCS) score?
Show answer →The GCS should be documented as 10T (E4, V1t, M5). When a patient is intubated, the verbal component is scored as a 1 and the suffix T or t is added. Exam Strategy: The AACN emphasizes that you must NOT assign a verbal score higher than 1 for an intubated patient, even if they appear to be mouthing words. Always use the best response for each category. A change in GCS of ≥2 points is clinically significant and requires immediate notification to the provider.
A patient in early septic shock has a BP of 88/46, HR 115, and warm, flushed skin. What are the expected findings for Cardiac Index (CI) and Systemic Vascular Resistance (SVR)?
Show answer →In early (hyperdynamic/distributive) septic shock, the CI is typically elevated (>4.0 L/min/m2) due to compensatory tachycardia and decreased afterload. The SVR is low (<800 dynes/sec/cm-5) due to massive vasodilation from inflammatory mediators. CCRN Tip: This is the ONLY shock state with an initially high CI. If the patient transitions to late (cold) sepsis, CI will drop and SVR may rise as a terminal compensatory effort.
A patient ingested an unknown amount of acetaminophen 6 hours ago. The level returns above the treatment line on the Rumack-Matthew nomogram. What is the priority intervention and the golden window for maximum efficacy?
Show answer →Priority: Administer N-acetylcysteine (NAC). The golden window is within 8 hours of ingestion to prevent hepatotoxicity. NAC restores glutathione stores, allowing the detoxification of the toxic metabolite NAPQI. Exam Tip: If the ingestion time is unknown or >24h, the nomogram is not used; treat empirically if APAP is detectable or AST/ALT are elevated.
17–20 correct
Strong. Move to the hardest material and timed drilling rather than re-reading topics you already know.
12–16 correct
A normal mid-prep score. Work the topics you missed one at a time — the topic pages below are built for exactly that.
Under 12 correct
Early days. Go topic by topic instead of taking more mixed tests: pick your weakest area below and drill it until the questions feel routine.
Pathology questions
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Management questions
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Procedures questions
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Pharmacology questions
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Assessment questions
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Diagnostics questions
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Toxicology questions
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Try 30 free CCRN cards firstIt is 20 real question-and-answer cards from our 1000-card CCRN deck, mixed across topics so it feels like the breadth of the exam. It is not the official AACN exam and is not endorsed by AACN — for the official outline and any official practice material, go to AACN directly.
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