20 free CCRN (Adult) practice questions

Correct answer: C · Synchronized cardioversion, since the rhythm is causing instability

The 2025 AHA adult advanced life support guideline recommends synchronized cardioversion for hemodynamically unstable narrow-complex tachycardia. Hypotension, new confusion, and cool, clammy skin that began with the rhythm, in an afebrile patient who was stable minutes earlier, make the tachycardia the likely cause of the instability rather than a sign of another illness such as sepsis. The same guideline places IV diltiazem or verapamil only in stable regular narrow-complex tachycardia. Unsynchronized shock is its treatment for sustained polymorphic ventricular tachycardia, not for an organized narrow-complex rhythm with a blood pressure. A fluid bolus and 30 minutes of observation delay the electrical therapy that, in the guideline's words, unstable patients warrant. Vagal maneuvers and adenosine also have a place in regular narrow-complex tachycardia, but they are not among these choices.

Look for this next time: When a tachycardia itself is causing hypotension, altered mental status, or shock, prepare for synchronized cardioversion.

Correct answer: D · Notify the surgeon now and prepare for emergency pericardial decompression

Falling blood pressure and tachycardia with a rising CVP, diastolic pressures that are now nearly equal (CVP 18, PA diastolic 19, PAOP 18), muffled heart sounds, and distended neck veins point to cardiac tamponade. The MSD Manual describes elevated, equal diastolic pressures in all cardiac chambers and the pulmonary artery in tamponade, notes that blood collecting rapidly can cause it in small amounts, and says that when tamponade is suspected, drainage follows at once, after an echocardiogram unless even a brief delay could be life-threatening. After cardiac surgery, that means calling the surgeon now and preparing for decompression. Tamponade impairs cardiac filling, so a diuretic or a vasodilator, which lowers filling pressures further, would deepen the shock. Re-zeroing makes sense when one number looks wrong, but several findings agree here, and an hour's delay is dangerous.

Look for this next time: After cardiac surgery, hypotension with rising, nearly equal diastolic pressures calls for immediate escalation for possible tamponade.

Correct answer: C · A drop of no more than 25%, so no lower than about 165 mm Hg

The 2025 AHA/ACC high blood pressure guideline says that in a hypertensive emergency without a compelling condition, systolic pressure should fall by no more than 25% within the first hour; then, if he is stable, to below 160/100 mm Hg over the next 2 to 6 hours, and cautiously to 130 to 140 mm Hg over the following 24 to 48 hours. A 25% drop from 220 is 55, so the first-hour floor is about 165 mm Hg. A target below 140, or below 120 in aortic dissection, applies to compelling conditions, which the team has ruled out. A normal reading within the hour is what the guideline warns against: in long-standing hypertension, rapid correction can cause organ hypoperfusion because autoregulation is lost.

Look for this next time: Without a compelling condition, lower systolic pressure by no more than 25% in the first hour of a hypertensive emergency.

Correct answer: A · Lower the tidal volume toward about 360 mL, aiming for a plateau below 30

Lung-protective ventilation sets tidal volume by predicted body weight, not actual weight. The ATS 2024 ARDS guideline keeps its strong recommendation for 4 to 8 mL/kg predicted body weight with plateau pressure below 30 cm H2O, and the 2026 Surviving Sepsis Campaign guideline recommends a low tidal volume of 6 mL/kg for adults with sepsis and ARDS. Here 600 mL is 10 mL/kg of predicted weight, and 6 mL/kg is about 360 mL. The 2021 Surviving Sepsis text describes reducing toward about 6 mL/kg over 1 to 2 hours, raising the respiratory rate up to 35/min to maintain minute ventilation. Using actual weight gives about 590 mL, which is almost no change. Raising the volume, or accepting a plateau of 33, keeps the lungs above the 30 cm H2O limit.

Look for this next time: Calculate ARDS tidal volume from predicted body weight, and keep plateau pressure below 30 cm H2O.

Correct answer: D · Call for immediate needle decompression, then a chest tube, without imaging

Sudden hypotension and hypoxemia in a ventilated patient, with breath sounds absent on one side and the trachea pushed to the other, indicate tension pneumothorax, which the MSD Manual says occurs most often with positive-pressure ventilation. It is diagnosed clinically and treated at once with needle decompression, followed immediately by a chest tube; waiting for a radiograph wastes minutes while venous return to the heart fails and arrest approaches. More PEEP adds positive pressure to a chest that is already trapping air. Suctioning can clear a blocked tube, but a blocked tube does not explain the tracheal shift, and a 15-minute wait is too long. The nurse's role is to get the provider who will decompress to the bedside now.

Look for this next time: Treat suspected tension pneumothorax on the ventilator as a clinical diagnosis: decompress first and image later.

Correct answer: B · Desmopressin, with urine losses replaced and sodium tracked closely

Large volumes of very dilute urine after pituitary surgery, with a rising sodium, fit central diabetes insipidus, now also called arginine vasopressin deficiency. The MSD Manual lists hypophysectomy and pituitary tumors among its causes, says urine specific gravity is usually below 1.005, warns that dehydration can develop rapidly if urinary losses are not replaced, and names desmopressin as the treatment. Fluid restriction is the approach for SIADH, the opposite problem, and would deepen the water deficit. Hypertonic saline adds sodium to a patient whose sodium is already high. Holding fluids for 12 hours ignores losses of several hundred milliliters an hour. The 2022 renaming statement notes that withholding desmopressin from patients with central diabetes insipidus has caused serious harm.

Look for this next time: Dilute polyuria with a rising sodium after pituitary surgery suggests central DI (AVP deficiency): anticipate desmopressin and replace the losses.

Correct answer: C · Stop the unit, call the clinician/blood bank, and maintain IV access with saline via new tubing

Fever, dyspnea, back pain, and hypotension during a red-cell transfusion require immediate cessation and urgent assessment for a serious transfusion reaction. Notify the treating clinician and blood bank, support airway, breathing, and circulation, and maintain IV access with normal saline through new tubing under the local protocol; do not flush residual blood from the transfusion tubing into the patient. Send the retained unit/tubing and requested samples for investigation. Do not restart this unit in the described severe reaction. Slowing it, restarting after an antipyretic, or rapidly finishing it continues a potentially harmful exposure.

Look for this next time: For a serious suspected transfusion reaction, stop the transfusion, call for urgent assessment, maintain safe IV access, and follow blood-bank investigation instructions.

Correct answer: A · Supine, end-expiration, relaxed abdomen, zero at midaxillary line/iliac-crest level, ≤25 mL

WSACS specifies measurement at end-expiration with the patient supine and abdominal muscles relaxed, using no more than 25 mL sterile saline for the bladder technique. The zero-reference point is the midaxillary line at the level of the iliac crest. The alternatives fail because they use an elevated or unspecified position, inspiration, excessive filling volume, or a different reference point. The iliac-crest level itself is not an error when combined with the correct midaxillary reference. Consistent technique matters before interpreting the pressure.

Look for this next time: For bladder pressure, use supine end-expiration with relaxed abdominal muscles, zero at the midaxillary line at iliac-crest level, and no more than 25 mL saline.

Correct answer: A · IV gentamicin, added to her current antibiotic regimen

Her creatinine has more than doubled while her urine output falls, so kidney injury is developing. The KDIGO 2012 acute kidney injury guideline suggests not using aminoglycosides, such as gentamicin, to treat infections unless no suitable, less nephrotoxic alternative is available, and its management text calls for stopping potentially nephrotoxic drugs. With no documented reason for choosing it, the gentamicin order is the one to clarify with the prescriber before it is given. Acetaminophen as needed for fever, insulin by correction scale with glucose checks, and ondansetron as needed for nausea are not the nephrotoxic exposure this situation turns on. The question does not require staging the injury; it asks which order adds avoidable harm to failing kidneys.

Look for this next time: When kidney function is falling, question a new aminoglycoside or other nephrotoxic drug unless no safer alternative is suitable.

Correct answer: B · CPP is about 53 mm Hg: below the 60–70 target, with ICP above the 22 threshold

Cerebral perfusion pressure is mean arterial pressure minus intracranial pressure: 79 − 26 = 53 mm Hg. The Brain Trauma Foundation's fourth-edition severe TBI guidelines recommend a CPP target of 60 to 70 mm Hg and treating ICP above 22 mm Hg, so this patient has both a low CPP and an ICP that needs treatment. Adding ICP to MAP reverses the formula and produces a falsely reassuring 105. Subtracting ICP from the systolic pressure uses the wrong pressure and gives 86. The figure of 53 is right, but calling it adequate applies a threshold below the guideline's 60 to 70 target. Report both numbers, because each one calls for action.

Look for this next time: CPP equals MAP minus ICP; in severe TBI, aim for 60 to 70 mm Hg and treat ICP above 22 mm Hg.

Correct answer: D · Bring BP below 185/110 first, then keep it under 180/105 for at least 24 hours

The 2026 AHA/ASA acute ischemic stroke guideline says that patients who are otherwise eligible for IV thrombolysis should have systolic pressure lowered below 185 mm Hg and diastolic below 110 mm Hg before treatment starts, to reduce hemorrhagic complications, and that blood pressure should then be kept below 180/105 mm Hg for at least the first 24 hours. Starting first and treating the pressure later skips that pre-treatment threshold. A systolic goal below 140 is not the pre-treatment threshold, and the same guideline found that intensive lowering below 140 after thrombolysis brought no functional benefit in mild to moderate stroke. A high reading on arrival does not by itself end eligibility; the guideline's step is to lower it below 185/110 before starting.

Look for this next time: Before IV thrombolysis, bring blood pressure below 185/110 mm Hg, then keep it below 180/105 mm Hg for at least 24 hours.

Correct answer: D · Report suspected compartment syndrome now, and loosen the splint as ordered

Pain out of proportion that worsens with passive stretch raises concern for acute compartment syndrome. Palpable pulses and brisk refill do not rule it out: microvascular perfusion can fail before large-artery pulses disappear. Notify the responsible team immediately and relieve constricting material as ordered or authorized by protocol while urgent assessment and possible fasciotomy are arranged. Waiting hours, elevating the limb high, or only escalating analgesia risks delaying treatment. Pallor and absent pulses are late findings, not signs to wait for.

Look for this next time: Escalate pain out of proportion that worsens with passive stretch at once; palpable pulses do not exclude compartment syndrome.

Correct answer: A · Ask about switching her to dexmedetomidine, and start nonpharmacologic delirium measures

The 2018 SCCM PADIS guideline names benzodiazepine use as a modifiable risk factor for delirium, suggests light rather than deep sedation, and suggests propofol or dexmedetomidine over benzodiazepines in ventilated adults. The 2025 focused update suggests dexmedetomidine over propofol when light sedation or less delirium is the priority. The 2018 guideline also suggests a multicomponent nonpharmacologic approach, such as reorientation, better sleep, early mobility, and hearing and vision aids. Deeper midazolam sedation works against both the light-sedation goal and the delirium risk. The 2025 update made no recommendation for or against antipsychotics to treat ICU delirium, so the claim that the guidelines recommend haloperidol is false. The 2018 guideline notes that restraints lack studies showing benefit and carry safety concerns, including unplanned extubation and greater agitation.

Look for this next time: For delirium during a benzodiazepine infusion, address the benzodiazepine and add nonpharmacologic measures instead of deepening sedation.

Correct answer: A · Norepinephrine through a peripheral IV now, titrated to an initial MAP of about 65

The 2026 Surviving Sepsis Campaign guideline suggests starting vasopressors peripherally rather than delaying until central access is secured. It recommends norepinephrine as the first-line agent over dopamine, epinephrine, or selepressin, suggests it over vasopressin or angiotensin II, and recommends an initial MAP target of 65 mm Hg over higher targets, kept within a reasonable range of about 5 mm Hg. She is 52, so the 60 to 65 range the guideline suggests for adults 65 or older does not apply. Waiting an hour for the central line leaves her hypotensive and hypoperfused. Dopamine is not first-line, and a MAP of 75 or more is above the recommended initial target. Vasopressin is suggested as an addition when norepinephrine needs are escalating, not as the first agent.

Look for this next time: In septic shock, start norepinephrine peripherally if central access will be delayed, aiming first for a MAP of about 65 mm Hg.

Correct answer: C · Metabolic acidosis with appropriate respiratory compensation

Low pH with low bicarbonate shows primary metabolic acidosis. Winter's formula predicts PaCO2 = 1.5 × 13 + 8 ± 2, or 25.5–29.5 mm Hg. The measured 29 is within that range, so respiratory compensation is appropriate. A higher PaCO2 would suggest added respiratory acidosis; a lower one would suggest added respiratory alkalosis. The pH remains acidemic at 7.26. More generally, a pH inside the laboratory normal interval cannot by itself distinguish compensation from a mixed disorder; compare the expected response.

Look for this next time: In metabolic acidosis, compare the measured PaCO2 with (1.5 × HCO3−) + 8 ± 2 to judge whether compensation is appropriate.

Correct answer: D · Call for dantrolene and the MH cart, stop any trigger, and hyperventilate with 100% oxygen

Rising end-tidal CO2 despite more ventilation, tachycardia, rigidity, and a climbing temperature soon after a volatile anesthetic and succinylcholine point to malignant hyperthermia. MHAUS notes that the hour right after surgery is still a critical time. Its emergency steps are to stop triggering agents, get dantrolene and the MH cart while calling for help, and hyperventilate with 100% oxygen to flush volatile agents and lower ETCO2; it calls dantrolene the only currently accepted specific treatment. Cooling is part of MH care when core temperature is above 39 °C or rising fast, but a cooling blanket and a 30-minute wait leave the reaction untreated. A non-depolarizing paralytic does not treat MH, which is driven by increased calcium inside the muscle. Cultures and antibiotics chase sepsis while the crisis progresses.

Look for this next time: Suspect malignant hyperthermia when ETCO2 climbs despite more ventilation after triggering agents, and get dantrolene immediately.

Correct answer: B · Raise the directive with the team now, and help the daughter honor her mother's wishes

The ANA Code of Ethics (2025), Provision 1.4, says patients have the right to accept or refuse treatment, and that when a patient lacks capacity, an alternate decision-maker should base decisions on the patient's previously expressed wishes and known values. Nurses preserve and protect those rights. Here the wishes are written, recent, and specific, and the daughter reports no change, so the nurse brings the directive to the team at once and helps the daughter separate her grief from what her mother wanted, asking for palliative care or an ethics consultation if the conflict continues. Intubating on the agent's demand alone sets the patient's stated wishes aside. Staying out of the discussion abandons the nurse's advocacy role. Sending the daughter away removes the family involvement the Code supports and does not resolve the conflict. Surrogate and advance directive laws vary by state.

Look for this next time: When a surrogate's request conflicts with a valid advance directive, advocate for the patient's documented wishes and support the surrogate through the decision.

Correct answer: B · Invite him to stay, with a team member assigned to explain and support him

The 2025 AHA guidelines on ethics call family presence during resuscitation the recommended approach in most situations, because it can improve family members' short- and long-term psychological outcomes, and they advise robust emotional support, ideally from a team member dedicated to that task, such as a social worker or chaplain. AACN's practice alert calls family presence a recognized autonomous nursing intervention. Here the husband is calm, policy allows it, and the record shows no objection, so the nurse offers him the choice with a support person beside him. The AHA notes that interference is uncommon, so sending him out on that ground is not supported. Leaving him alone withholds the support the guideline describes, and making him wait for the outcome denies a presence the policy allows.

Look for this next time: When policy allows, offer family presence during resuscitation with a dedicated staff member to explain and support.

Correct answer: C · State the concern again using CUS, and if unresolved, go up the chain of command

AHRQ TeamSTEPPS offers two tools for this moment. CUS means stating the Concern, saying you are Uncomfortable, and then naming it a Safety issue, with a supervisor notified if the safety issue is not acknowledged. The Two-Challenge Rule asks the person raising a concern to voice it assertively at least two times and, if the outcome is still unacceptable, to take stronger action through the supervisor and up the chain of command. The nurse has raised it once, so the next step is a second, explicit challenge and, if that fails, escalation. Transferring and documenting leaves the patient in a placement the nurse judges unsafe. Asking the family to object hands the nurse's advocacy to them. A quiet, unexplained delay leaves the team unaware of the disagreement.

Look for this next time: State the unresolved safety concern clearly and escalate through the chain of command; assessment and emergency help for deterioration must not wait for a two-challenge sequence.

Correct answer: B · Use the qualified video interpreter, and invite the son to stay for support

Under the federal Section 1557 rule (45 CFR 92.201), a covered health program must offer a qualified interpreter when interpretation is needed and must not rely on an accompanying adult who is not a qualified interpreter, except as a temporary measure in an emergency or when the patient asks for that adult in private with a qualified interpreter present. Neither exception applies: this is not an emergency, a qualified interpreter is minutes away, and the patient has not asked for her son. He can still stay for support, and her nodding does not change the rule. The rule also bars relying on staff who are not qualified interpreters or qualified bilingual staff. English handouts and gestures do not give meaningful access to a consent discussion. AHRQ TeamSTEPPS also lists CUS as a way to speak up when an interpreter is needed.

Look for this next time: For consent and teaching with a patient who has limited English proficiency, use a qualified interpreter rather than family, outside narrow exceptions.