CCRN (Adult) Critical Care Nursing Exam — All Questions

A patient on a medical unit has a temperature of 38.9 °C, a respiratory rate of 26/min, a heart rate of 118/min and new confusion. Sepsis is suspected, and antibiotics are ordered. Which sequence reflects the Surviving Sepsis Campaign 2026 guideline?

• a.Give the antibiotic now and draw cultures once the fever has broken
• b.Draw blood cultures promptly, ideally before the first antibiotic✓
• c.Hold the antibiotic until culture results identify the organism
• d.Draw cultures only if the patient is still febrile after 24 hours

The 2026 guideline recommends collecting blood cultures as soon as possible and ideally before antimicrobials are given, without letting cultures delay treatment. Drawing cultures after antibiotics lowers their yield, and waiting for results or for 24 hours of fever delays therapy in a potentially time-critical infection.

A 54-year-old in septic shock is receiving norepinephrine. Which initial mean arterial pressure target does the Surviving Sepsis Campaign 2026 guideline recommend for this patient?

• a.55 mm Hg
• b.85 mm Hg
• c.75 mm Hg
• d.65 mm Hg✓

The 2026 guideline recommends an initial MAP target of 65 mm Hg over higher targets in adults with septic shock (with a lower 60–65 mm Hg range suggested for patients aged 65 or older, which does not apply here). A MAP of 55 is below the recommended floor, and 75 or 85 mm Hg requires more vasopressor without shown benefit.

A patient in septic shock remains hypotensive after initial crystalloid resuscitation. Which vasopressor does the Surviving Sepsis Campaign recommend as first-line in most adults?

• a.Norepinephrine✓
• b.Vasopressin
• c.Phenylephrine
• d.Dopamine

Both the 2021 and 2026 Surviving Sepsis Campaign guidelines name norepinephrine as the first-line vasopressor in septic shock (recommended over dopamine, and suggested over vasopressin). Vasopressin is added when MAP remains inadequate on norepinephrine, not used first. Phenylephrine is not the recommended first-line agent.

For initial fluid resuscitation of an adult with sepsis-induced hypoperfusion, which fluid does the Surviving Sepsis Campaign 2026 guideline suggest?

• a.Hydroxyethyl starch
• b.A balanced crystalloid✓
• c.5% dextrose in water
• d.0.9% sodium chloride

The 2026 guideline suggests balanced crystalloids over 0.9% saline for initial resuscitation. Dextrose 5% in water distributes into all body water and does little for intravascular volume, and starches are not recommended for resuscitation in sepsis.

After an initial crystalloid bolus, the team is unsure whether a patient with septic shock will benefit from more fluid. Which approach to guiding further fluid does the Surviving Sepsis Campaign 2026 suggest?

• a.Daily weight compared with admission weight
• b.A single central venous pressure reading
• c.Dynamic measures such as a passive leg raise✓
• d.Blood pressure response to one bolus alone

The 2026 guideline suggests using dynamic measures to guide initial fluid resuscitation, such as the response of stroke volume or pulse pressure to a passive leg raise or fluid challenge, over physical examination or static measures alone. A single CVP value and a daily weight are static, and blood pressure alone is a less reliable marker of fluid responsiveness.

A hospital is choosing a screening tool to identify acutely ill ward patients at risk of sepsis. Which approach does the Surviving Sepsis Campaign 2026 guideline recommend?

• a.NEWS, NEWS2, MEWS or SIRS rather than qSOFA✓
• b.Screening only after cultures return positive
• c.qSOFA as the single screening tool
• d.Lactate testing only when hypotension appears

The 2026 guideline recommends using NEWS, NEWS2, MEWS or SIRS over qSOFA for acutely ill hospital patients, because qSOFA used alone misses many patients. Waiting for hypotension or positive cultures defeats the purpose of early screening.

A patient with confirmed septic shock has just been recognized on the unit. How soon should antimicrobials be given, according to the Surviving Sepsis Campaign?

• a.Within 3 hours of recognition
• b.After the lactate level has been repeated
• c.Within 6 hours of recognition
• d.Immediately, ideally within 1 hour✓

For septic shock, both the 2021 and 2026 Surviving Sepsis Campaign guidelines recommend giving antimicrobials immediately, ideally within 1 hour of recognition, because delay is most strongly linked to death in shock. Three- or six-hour windows and waiting for a repeat lactate introduce avoidable delay.

Minutes after starting an IV antibiotic, a patient develops hives, wheezing, throat tightness and a blood pressure of 76/40 mm Hg. The infusion has been stopped. What is the first-line drug and route?

• a.Diphenhydramine by IV push
• b.Nebulized albuterol treatment
• c.Methylprednisolone by IV push
• d.Epinephrine IM into the thigh✓

The World Allergy Organization guidance names intramuscular epinephrine into the vastus lateralis (0.01 mg/kg, maximum 0.5 mg in adults, repeated every 5–15 minutes as needed) as first-line treatment. Antihistamines, glucocorticoids and inhaled beta-agonists are second-line, and inhaled bronchodilators are not an alternative to repeated epinephrine.

When assessing a burn, the nurse finds white, leathery skin that is numb to touch. How should this burn be classified?

• a.Full-thickness✓
• b.Superficial
• c.Superficial partial-thickness
• d.Partial-thickness

MedlinePlus describes full-thickness burns as affecting the deep layers of skin with white or blackened skin that may be numb. Superficial burns cause pain and redness of the outer layer only, and partial-thickness burns are painful, red and blistered because nerve endings remain.

A patient found down for many hours has dark tea-colored urine. The dipstick is strongly positive for blood, but microscopy shows almost no red cells. The creatine kinase is 48,000 U/L. What do these findings indicate?

• a.Myoglobinuria from rhabdomyolysis✓
• b.Hemolytic transfusion reaction
• c.Hematuria from a kidney stone
• d.Bilirubinuria from liver failure

A urine dipstick reacts to the heme in both hemoglobin and myoglobin, so a strongly positive test with few red cells points to myoglobin; tea-colored urine and a creatine kinase far above five times normal confirm rhabdomyolysis. A stone causes red cells on microscopy. There has been no transfusion. Bilirubin does not produce a positive blood reaction.

A patient with a large aspirin overdose is breathing rapidly and deeply, is alert, and has a mixed respiratory alkalosis and anion-gap metabolic acidosis. The team is considering sedation for an agitated moment. Why is this approach concerning?

• a.Sedation will speed aspirin absorption from the gut
• b.Reduced ventilation lets CO2 rise and worsens the acidemia✓
• c.Sedatives bind salicylate and inactivate treatment
• d.Rapid breathing in salicylate toxicity is harmful

The Cureus 2025 review warns that intubation or chemical restraint should be avoided if possible, because apnea or reduced ventilation raises carbon dioxide, lowers pH, shifts salicylate into tissues and worsens toxicity; if intubation is unavoidable, ventilation must match the patient's high minute ventilation. The patient's rapid breathing is compensation, not the harm. Sedatives do not change gut absorption or inactivate a treatment.

A patient who overdosed on a calcium channel blocker is hypotensive and has evidence of myocardial dysfunction. Which therapies are first-line in the 2017 expert consensus?

• a.IV atropine followed by a beta-blocker infusion
• b.Activated charcoal alone with observation
• c.IV calcium and high-dose insulin, plus a vasopressor✓
• d.IV nitroglycerin combined with a loop diuretic

The Critical Care Medicine 2017 consensus lists IV calcium, high-dose insulin therapy (with myocardial dysfunction) and norepinephrine or epinephrine among first-line treatments for CCB poisoning. A beta-blocker would further depress the heart, charcoal is decontamination rather than hemodynamic treatment for a symptomatic patient, and vasodilators with diuretics would worsen hypotension.

Four hours after swallowing a large amount of acetaminophen, a patient says she feels fine and wants to leave. What should the nurse understand?

• a.Acetaminophen toxicity mainly damages the kidneys within the first hour
• b.Treatment is only needed once jaundice or confusion develops
• c.Absence of symptoms at four hours rules out significant toxicity
• d.Symptoms can be delayed 12 hours or more; early antidote matters✓

MedlinePlus notes that symptoms may not occur until 12 or more hours after ingestion, that N-acetylcysteine is the antidote, and that treatment within 8 hours gives a very good chance of recovery, while a large untreated overdose can cause liver failure. Feeling well early is expected and not reassuring. The liver, not the kidney, is the main target, and waiting for jaundice means waiting for liver injury.

After several days of continuous nasogastric suction, a patient's ABG shows pH 7.52, PaCO2 47 mm Hg and HCO3 36 mEq/L. How should the nurse interpret this?

• a.Respiratory alkalosis with renal compensation
• b.Metabolic alkalosis, partly compensated✓
• c.Respiratory acidosis with metabolic compensation
• d.Metabolic acidosis with respiratory compensation

The pH is high and the bicarbonate is high, so the primary problem is metabolic alkalosis; loss of gastric acid and chloride through suction or vomiting is a classic cause (hypochloremic alkalosis). The PaCO2 is slightly raised as the lungs compensate. A respiratory alkalosis would show a low PaCO2, and both acidosis options require a low pH.

A hemorrhaging trauma patient arrives cold and acidotic with prolonged clotting times. Which combination does the team call the 'lethal triad'?

• a.Hypotension, bradycardia and hypoxemia
• b.Tachycardia, fever and leukocytosis
• c.Hypothermia, acidosis and coagulopathy✓
• d.Hyperkalemia, hypocalcemia and hypoglycemia

Initial trauma management aims to prevent the lethal triad of acidosis, coagulopathy and hypothermia, each of which worsens the others and drives death from exsanguination; some authors add hypocalcemia to make a 'lethal diamond'. The other combinations are not the lethal triad.

A patient with severe trauma and major bleeding is receiving a massive transfusion. In the PROPPR trial, what did a 1:1:1 ratio of plasma, platelets and red cells achieve compared with 1:1:2?

• a.A higher rate of transfusion-related lung injury and thrombosis in the 1:1:1 group
• b.More patients reached hemostasis, with fewer deaths from exsanguination at 24 hours✓
• c.No difference in any outcome, so the ratio does not matter in massive bleeding
• d.Significantly lower 30-day all-cause mortality with no difference in bleeding deaths

PROPPR found no significant difference in 24-hour or 30-day all-cause mortality, but more patients in the 1:1:1 group achieved hemostasis and fewer died from exsanguination by 24 hours, without an increase in complications. So it did not lower 30-day mortality, did not increase lung injury or thrombosis, and did show a difference in bleeding outcomes.

A severely malnourished patient started on enteral nutrition two days ago now has new weakness and a falling serum phosphorus. What is the most likely explanation?

• a.Tube feeding intolerance
• b.Hypervolemic hyponatremia
• c.Refeeding syndrome✓
• d.Adrenal insufficiency

The 2020 ASPEN consensus, as used in the 2026 Nutrients study, defines refeeding syndrome as a fall in serum phosphorus, potassium and/or magnesium within five days of starting or substantially increasing nutrition, with hypophosphatemia the hallmark. Feeding intolerance causes gastrointestinal symptoms, not falling phosphorus, and neither hyponatremia nor adrenal insufficiency explains the timing and the phosphorus drop.

The daughter of an ICU patient with advanced heart failure asks whether accepting palliative care means stopping all treatment for the heart. Which reply is accurate?

• a.Palliative care requires a do-not-resuscitate order
• b.Palliative care can be given alongside disease treatment✓
• c.Palliative care begins only after all treatment has stopped
• d.Palliative care is reserved for the final days of a person's life

The National Institute on Aging explains that palliative care can begin as early as diagnosis and can occur alongside other treatment for the disease; hospice is the form used when disease-directed treatment is stopped. It is not limited to the final days, and it does not require a DNR order.