Critical Care Register Nurse - Adult Practice Test

CCRN-Adult test Format | Course Contents | Course Outline | test Syllabus | test Objectives

Exam Code: CCRN-Adult
Exam Name: Critical Care Register Nurse - Adult
Total Questions: 150 multiple-choice questions.
Scored Questions: 125 questions are scored- 25 questions are unscored.
Time Allotted: 3 hours.
Passing Score: A minimum of 83 correct answers out of the 125 scored questions is required to pass.

- Cardiovascular
- Acute coronary syndrome
- Aortic aneurysm- dissection- rupture (i.e.thoracic- abdominal)
- Cardiac infection and inflammatory diseases
- Cardiac surgery
- Cardiac tamponade
- Cardiac trauma
- Cardiac/vascular catheterization
- Cardiogenic shock
- Cardiomyopathy
- Dysrhythmias
- Heart failure
- Hypertensive crisis
- Myocardial conduction system defects (e.g.-prolonged QT interval- Wolff-Parkinson-White)
- Structural heart defects (acquired andcongenital- including valvular disease)
- Vascular disorders (e.g.- arterial/venousstenosis)
- Vascular interventions (e.g.- stents- fem-pop bypass- carotid endarterectomy)
- Respiratory
- Acute pulmonary edema
- Acute pulmonary embolus
- Acute respiratory distress syndrome (ARDS)
- Acute respiratory failure
- Acute respiratory infection (e.g.- pneumonia)
- Chronic conditions (e.g.- COPD- asthma-bronchitis- emphysema)
- Mechanical ventilation complications
- Pleural space abnormalities(e.g.- pneumothorax- hemothorax- empyema-pleural effusions)
- Pulmonary hemorrhage
- Pulmonary hypertension
- Status asthmaticus
- Thoracic and airway trauma (e.g.- fractured rib-lung contusion- tracheal perforation)
- Thoracic surgery
Endocrine- Hematology/Immunology- GI- Renal/GU- Integumentary (21%)
- Endocrine
- Adrenal insufficiency
- Diabetes insipidus (DI)
- Diabetes mellitus- types 1 and 2
- Diabetic ketoacidosis (DKA)
- Hyperglycemia
- Hyperosmolar hyperglycemic state (HHS)
- Syndrome of inappropriate of antidiuretichormone secretion (SIADH)
- Thyroid disorders
- Hematology and Immunology
- Anemia
- Autoimmune disorders (e.g.- lupus-myasthenia gravis- Guillain-Barrésyndrome)
- Coagulopathies (e.g.- ITP- DIC- HIT)
- Myelosuppression (e.g.- thrombocytopenia-neutropenia)
- Oncologic complications (e.g.- tumor lysissyndrome- neutropenia)
- Transfusion reactions (e.g.- TRALI- TACO)
- Gastrointestinal
- Abdominal compartment syndrome
- Acute abdominal trauma
- Acute GI hemorrhage
- Bowel infarction- obstruction- perforation(e.g.- mesenteric ischemia- adhesions)
- GI surgeries (e.g.- Whipple- esophagectomy-resections)
- Hepatic failure/coma (e.g.- portalhypertension- cirrhosis- esophageal varices-fulminant hepatitis- biliary atresia)
- Liver disease
- Malnutrition and malabsorption
- Pancreatitis
- Peritonitis
- Renal and Genitourinary
- Acute kidney injury (AKI)- acute tubular necrosis (ATN)
- Chronic kidney disease (CKD)
- Infections (e.g.- kidney- urosepsis)
- Endocrine- Hematology/Immunology- GI- Renal
- Integumentary
- Cellulitis
- IV infiltration
- Necrotizing fasciitis
- Pressure injury
- Skin failure (e.g.- perfusion injuries)
- Wounds
Musculoskeletal- Neurological- Behavioral/Psychosocial
- Musculoskeletal
- Compartment syndrome
- Fractures
- Muscular deconditioning
- Musculoskeletal trauma
- Neurological
- Acute spinal cord injury
- Brain death
- Encephalopathy
- Stroke (e.g.- hemorrhagic- ischemic)
- Hydrocephalus
- Neurogenic shock
- Neurologic infectious disease (e.g.- viral-bacterial- fungal)
- Neurological storming
- Neuromuscular disorders (e.g.- ALS-neuromyopathies)
- Neurosurgery
- Neurovascular abnormalities
- Seizure disorders
- Space-occupying lesions (e.g.- braintumors- cysts)
- Spinal surgeries
- Traumatic brain injury (e.g.- epidural-subdural- concussion- non-accidentaltrauma)
- Behavioral and Psychosocial
- Agitation
- Anti-social behaviors- aggression- violence
- Delirium
- Medical non-adherence
- Mood disorders- depression- anxiety
- Post-intensive care syndrome (PICS)
- Post-traumatic stress disorder (PTSD)
- Self-harm
- Substance use disorder
- Suicidal ideation and/or behaviors
Multisystem
- Acid-base imbalance
- Anoxic injury
- Burns
- Comorbidity in patients with transplant history
- Palliative care
- End-of-life
- Failure to thrive
- Fluid and electrolyte imbalances
- Healthcare-associated infections
- Infectious diseases
- Life-threatening maternal/fetal complications(e.g.- eclampsia- HELLP syndrome- maternal/fetal transfusion- placental abruption- placenta previa)
- Multi-organ dysfunction syndrome (MODS)
- Obesity related complications
- Pain
- Rhabdomyolysis
- Sepsis
- Shock states (e.g.- distributive- obstructive)
- Sleep disruption (including sensory overload)
- Submersion injuries (near-drowning)
- Systemic inflammatory response syndrome(SIRS)
- Thermoregulation
- Toxic ingestion/inhalations/exposure
General
- Conduct pain assessments
- Evaluate patient’s response to interventions
- Assess- evaluate & prioritize data collections basedon patient characteristics related to the immediatecondition and anticipated needs
- Manage device alarms based on change in patientcondition
- Manage patient fluid and electrolyte balance
- Provide patient and family-centered care
- Recognize signs and symptoms of emergencies-initiate interventions- and seek assistance as needed
- Recognize indications for and manage patients with/requiring:
- capnography (ETCO2)
- complementary alternative medicine and/ornon-pharmacologic interventions
- intrahospital transport
- medications (e.g.- safe administration-monitoring- polypharmacy)
- pre- and post-operative care
- procedural care
- sedation
- vascular access
- Cardiovascular
- Identify- interpret and respond to cardiac rhythms
- Monitor hemodynamic status and recognize signs andsymptoms of hemodynamic instability
- Recognize early signs of decreased cardiac output
- Recognize indications for and manage patients with/requiring:
- cardiac catheterization
- endovascular procedures
- mechanical circulatory support devices
- non-invasive and invasive hemodynamicmonitoring
- pericardiocentesis
- temporary pacing
- Respiratory
- Recognize indications for and manage patients with/requiring:
- airway management
- bronchoscopy
- chest tubes
- mechanical ventilation
- noninvasive positive pressure ventilation(e.g.- BiPAP- CPAP- high-flow nasal cannula)
- oxygen therapy delivery devices
- prevention of complications related tomechanical ventilation and NIPPV
- prone positioning
- rapid sequence intubation (RSI)
- respiratory monitoring devices (e.g.- SPO2-SVO2- ETCO2)
- therapeutic gases (e.g.- oxygen- nitric oxide-heliox- CO2)
- thoracentesis
- tracheostomy
- Hematology and Immunology
- Recognize indications for and manage patients with/requiring:
- bleeding and clotting disorders
- blood dyscrasias (e.g.- anemia)
- transfusion of blood products- exchangetransfusions- massive transfusions
- Neurological
- Recognize indications for and manage patients with/requiring:
- continuous EEG monitoring
- neuroendovascular interventions (e.g.- coiling-thrombectomy)
- neurologic surgical monitoring devices anddrains (e.g.- ICP- ventricular drain)
- neurosurgical procedures (e.g.- craniotomy-craniectomy- clipping)
- seizure precautions
- spinal precautions
- swallow evaluation
- Integumentary
- Recognize indications for and manage patients with/requiring:
- pressure injury prevention
- therapeutic devices (e.g.- wound VACs- pressurereduction surfaces- ostomy device- fecalmanagement devices- IV infiltrate treatment)
- Gastrointestinal
- Address barriers to nutritional/fluid adequacy (e.g.-chewing/swallowing difficulties- alterations inhunger and thirst- inability to self-feed)
- Recognize indications for and manage patients with/requiring:
- EGD
- enteral and parenteral nutrition
- enteral tubes
- feeding and supplementation
- gastrointestinal drains
- Renal and Genitourinary
- Identify nephrotoxic agents
- Recognize indications for and manage patientsrequiring renal therapeutic intervention(e.g.- hemodialysis- CRRT- peritoneal dialysis)
- Musculoskeletal
- Recognize indications for and manage patients with/requiring:
- compartment syndrome
- early mobility
- Multisystem
- Early sepsis identification
- Monitor and implement strategies to preventhospital acquired infections
- Recognize and manage signs and symptoms of toxin/drug exposure
- Risk factor recognition and management ofmalignant hyperthermia
- Recognize indications for and manage patients with/requiring:
- end-of-life and palliative care
- extracorporeal membrane oxygenation (ECMO)
- intra-abdominal pressure monitoring
- organ donation
- targeted temperature management
- temperature monitoring and regulation devices
- Behavioral and Psychosocial
- conduct behavioral therapeutic interventions
- respond to behavioral emergencies (e.g.- nonviolent crisis intervention- de-escalation techniques)
- utilize behavioral assessment tools (e.g.- delirium-alcohol withdrawal- mini-mental status)

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Critical Care Register Nurse - Adult
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Question: 1712
A patient with a sacral pressure injury is on continuous enteral feeding and develops diarrhea that soaks
the wound dressing. Which of these management strategies directly improves pressure injury healing
success?
A. Apply zinc oxide paste only without stool diversion methods
B. Decrease enteral feeding rate to minimize diarrhea frequency
C. Implement a fecal management system to protect periwound skin from moisture
D. Use dry gauze dressings that wick away moisture better than foam
Answer: C
Explanation: A fecal management system effectively diverts stool away from the skin, reducing moisture
and bacterial exposure, which are key factors in wound healing failure. Simply reducing feeding or
applying barrier creams alone are insufficient. Dry gauze does not maintain a moist wound environment
needed for healing.
Question: 1713
During transport of a postoperative patient requiring continuous capnography (ETCO2) monitoring,
which alarm parameter change requires immediate intervention?
A. Respiratory rate increase from 16 to 18 breaths per minute
B. ETCO2 level dropping to 25 mmHg from baseline 38 mmHg
C. Pulse oximetry memorizing equal to ETCO2 value
D. Stable ETCO2 at 35 mmHg with occasional waveform fluctuations
Answer: B
Explanation: A significant drop in ETCO2 indicates possible hypoventilation, disconnection, or
pulmonary embolism and requires urgent assessment and intervention during transport. Minor respiratory
rate increase and waveform fluctuations may be less critical.
Question: 1714
Which of the following best describes the pathophysiological abnormality in pleural effusion?
A. Pulmonary artery obstruction causing infarction
B. Direct alveolar injury causing air leak into the pleural space
C. Bronchial obstruction causing distal lung collapse
D. Increased hydrostatic pressure or decreased oncotic pressure causing fluid accumulation
Answer: D
Explanation: Pleural effusions result from imbalance between hydrostatic and oncotic pressures or pleural
capillary permeability changes leading to fluid accumulation in the pleural space. Air leak describes
pneumothorax; bronchial obstruction causes atelectasis; artery obstruction causes infarction.
Question: 1715
An ICU patient with severe diarrhea has these labs: Na+ 128 mEq/L, K+ 3.1 mEq/L, Cl- 90 mEq/L.
What acid-base disorder is most likely present?
A. Respiratory acidosis
B. Metabolic alkalosis with respiratory compensation
C. Metabolic acidosis with respiratory compensation
D. Respiratory alkalosis
Answer: C
Explanation: Electrolyte losses cause metabolic acidosis and the respiratory system compensates by
hyperventilating lowering PaCO2.
Question: 1716
A patient with thrombocytopenia shows a platelet count decrease from 220,000 to 70,000/mm� five days
after heparin therapy. Serotonin release assay is positive. Which treatment is most appropriate?
A. Continue heparin and add aspirin
B. Discontinue heparin and start argatroban
C. Administer platelet transfusion immediately
D. Start warfarin and monitor INR
Answer: B
Explanation: This is heparin-induced thrombocytopenia (HIT), an immune-mediated platelet activation
disorder. The immediate step is to stop all heparin products and begin a direct thrombin inhibitor (e.g.,
argatroban). Platelet transfusions are usually avoided due to thrombotic risk. Warfarin is started only
after platelet recovery.
Question: 1717
A 60-year-old with NSAID-induced AKI (creatinine 4.0 mg/dL, muddy brown casts) requires
intermittent hemodialysis. Pre-dialysis potassium 6.8 mEq/L, post-dialysis 3.9 mEq/L. Formula for
potassium removal = (pre-K - post-K) � TBW � 0.6 yields 120 mEq/session. Rebound hyperkalemia
occurs 4 hours later (5.6 mEq/L). Which comorbid agent, continued for gout, synergistically impairs
distal potassium secretion and necessitates discontinuation?
A. Probenecid 500 mg twice daily
B. Colchicine 0.6 mg daily
C. Febuxostat 80 mg daily
D. Allopurinol 300 mg daily
Answer: A
Explanation: Probenecid inhibits organic anion transporters, reducing NSAID clearance and impairing
distal tubule function, exacerbating hyperkalemia rebound by blocking aldosterone-sensitive potassium
secretion; 2024 consensus on nephrotoxins flags uricosurics in AKI. Discontinue, use allopurinol
alternative. Colchicine risks myopathy, febuxostat minimal renal effect.
Question: 1718
A 45-year-old patient arrives with a sudden onset of weakness in the right arm and leg, slurred speech,
and confusion. CT scan shows a left middle cerebral artery ischemic stroke. Which of the following lab
values is most critical to monitor before administering tissue plasminogen activator (tPA)?
A. White blood cell count of 12,000/mm�
B. Platelet count of 150,000/mm�
C. Serum glucose of 70 mg/dL
D. International normalized ratio (INR) of 2.0
Answer: D
Explanation: Prior to administering tPA in ischemic stroke, it is essential to confirm coagulation status.
An INR of 2.0 indicates an increased bleeding risk and is a contraindication for tPA due to the elevated
risk of hemorrhage. Platelet count at 150,000/mm� is within normal limits. Serum glucose of 70 mg/dL is
low but not a contraindication, although glucose should be normal or corrected. Elevated WBC indicates
possible infection but is not critical for tPA decision.
Question: 1719
A patient has developed an IV extravasation injury after infusion of dopamine hydrochloride at 20
mcg/kg/min. The site shows swelling, pain, and pallor. What is the best next step in managing this
infiltration?
A. Inject hyaluronidase around the infiltration site to dilute the dopamine
B. Continue the infusion at a lower dose to prevent vasospasm progression
C. Apply warm compresses and start systemic vasodilators immediately
D. Stop the infusion, aspirate residual drug from the catheter, and elevate the limb
Answer: D
Explanation: Dopamine at high doses can cause vasoconstriction, and infiltration requires stopping the
infusion immediately, attempting to aspirate residual drug to reduce local toxicity, and elevating the limb.
Warm compresses are generally appropriate for non-vesicant infiltrations, but dopamine requires caution.
Hyaluronidase is typically used for infiltration of certain agents like vinca alkaloids, but its role with
dopamine is limited.
Question: 1720
Which finding in a postoperative patient indicates a potential early emergency requiring urgent
intervention?
A. Heart rate of 105/min with systolic BP of 110 mmHg
B. Oxygen saturation dropping from 96% to 88% on 3L nasal cannula
C. Mild nausea after opioid administration
D. Patient reporting mild incisional discomfort
Answer: B
Explanation: A significant drop in oxygen saturation suggests respiratory compromise and warrants
immediate evaluation and intervention. Elevated heart rate with stable BP is less urgent. Mild nausea and
incisional discomfort are expected postoperative findings.
Question: 1721
A 55-year-old with rib fractures/flail has epidural catheter. Contusion worsens (ground-glass on CT).
ECMO considered if P/F <80. Calculate shunt fraction (Qs/Qt = [CcO2 - CaO2]/[CcO2 - CvO2]; CcO2
20 vol%, CaO2 15 vol%, CvO2 10 vol%) =0.33 (shunt 33%). Threshold for VV-ECMO?
A. Shunt >30%
B. P/F <80
C. Dead space >40%
D. Both A and B
Answer: D
Explanation: Trauma ARDS from contusion; high shunt indicates refractory hypoxemia. VV-ECMO for
P/F <80 + shunt >30% unresponsive to ventilation/prone.
Question: 1722
A 38-year-old female at 39 weeks with group B Streptococcus colonization receives intrapartum
penicillin. Post-delivery, she develops fever 39�C, uterine tenderness, and foul lochia. Labs: WBC
20,000/mm�, CRP 150 mg/L, blood cultures positive for E. coli and GBS. The nurse suspects
polymicrobial endometritis. Vacuum extraction complicated by cervical laceration repaired. What broad-
spectrum regimen covers anaerobes per ACOG 2022 postpartum infection guidelines?
A. Vancomycin 15 mg/kg q12h plus piperacillin-tazobactam 3.375g q6h
B. Ampicillin 2g IV q6h plus azithromycin 500 mg IV daily
C. Ceftriaxone 1g IV daily monotherapy
D. Clindamycin 900 mg IV q8h plus gentamicin 5 mg/kg/day
Answer: D
Explanation: Postpartum endometritis (cesarean risk higher) polymicrobial (GBS, E. coli, anaerobes);
clindamycin + gentamicin first-line per guidelines, effective against beta-lactamase producers.
Ampicillin/azithro for chorio; ceftriaxone insufficient anaerobes; vanco/PIP-TAZ for MRSA/MDR but
not routine.
Question: 1723
A 38-year-old female with central DI post-TBI has sodium 155 mEq/L on desmopressin q12h. She spikes
to 162 mEq/L mid-dose. What pharmacokinetic adjustment?
A. Switch to subcutaneous 10 mcg q12h
B. Increase dose to 4 mcg IV q6h
C. Add chlorpropamide to potentiate
D. Fluid match urine output 1:1
Answer: B
Explanation: Desmopressin half-life ~2-3 hours; breakthrough hypernatremia indicates short duration
post-TBI. Frequent dosing (q6-8h IV) maintains aquaporin activation. SubQ alternative but IV precise in
ICU; chlorpropamide outdated; matching risks volume overload.
Question: 1724
A patient with an ostomy has developed skin irritation and maceration around the stoma site. The nurse
suspects leakage of effluent as causative. What is the priority nursing intervention to protect skin
integrity?
A. Increase frequency of pouch emptying to every hour and cleanse with soap and water
B. Optimize ostomy pouching system fit and use skin barrier seals around the stoma
C. Apply topical corticosteroids to reduce inflammation and irritation
D. Remove the pouching system for 24 hours to allow the skin to dry
Answer: B
Explanation: Proper fitting of the ostomy pouching system and use of skin barrier seals prevent leakage
of effluent onto surrounding skin, reducing irritation and maceration. Frequent emptying alone may not
prevent leakage if the fit is poor. Corticosteroids can thin skin and impair healing. Removing the pouch
for extended times exposes skin to effluent.
Question: 1725
A 40-year-old male with untreated hypertension awakens aphasic with right pronator drift. CT:
hyperdense MCA sign, ASPECTS 8. Labs: glucose 140 mg/dL, INR 1.0. Time from onset 90 minutes.
The nurse prepares for mechanical thrombectomy, calculating ASPECTS by subtracting early ischemic
changes in 10 regions. Which antiplatelet strategy post-recanalization minimizes reocclusion?
A. Aspirin 81 mg plus extended-release dipyridamole 200 mg BID
B. Clopidogrel 600 mg load PO then 75 mg daily
C. Aspirin 325 mg PO immediately then 81 mg daily
D. Ticagrelor 180 mg load then 90 mg BID if CYP2C19 poor metabolizer
Answer: C
Explanation: Post-thrombectomy, aspirin 325 mg stat then 81 mg daily reduces recurrent ischemic events
per 2023 AHA guidelines within 24-48 hours. Dual therapy risks bleeding; ticagrelor genotyping not
routine acutely.
Question: 1726
A 55-year-old with atrial flutter (2:1 conduction, rate 150 bpm) and WPW develops VF arrest. Post-
ROSC, ECG shows AF with rapid conduction via pathway. Per 2024 HRS dysrhythmia consensus, what
drug is contraindicated for rate control?
A. Metoprolol 5 mg IV
B. Diltiazem 0.25 mg/kg IV
C. Digoxin 0.5 mg IV
D. All of the above
Answer: D
Explanation: AV nodal blockers (beta, CCB, digoxin) accelerate accessory pathway conduction in WPW-
AF, risking VF (20% mortality). 2024 consensus prohibits them; use procainamide or cardioversion.
Ablation curative in 95%.
Question: 1727
A 45-year-old male with influenza A (H1N1) on oseltamivir develops secondary bacterial pneumonia (S.
pneumoniae) and ARDS. Vital signs: SpO2 85% on 100% FiO2, PaO2/FiO2 95. Labs: WBC
16,000/mm�, procalcitonin 3.5 ng/mL, lactate 2.8 mmol/L. The nurse suspects multisystem involvement
with myocarditis (troponin 1.2 ng/mL, EF 40%). ECMO evaluation pending. Per IDSA 2023 influenza
guidelines, what adjunctive therapy improves outcomes in severe viral-bacterial co-infection?
A. Baloxavir 40 mg PO single dose
B. High-dose oseltamivir 150 mg BID plus ceftriaxone
C. Neuraminidase inhibitor IV peramivir 600 mg single dose
D. Convalescent plasma 200 mL transfusion
Answer: B
Explanation: Severe influenza with bacterial superinfection requires oseltamivir (high-dose 75-150 mg
BID if <75kg, longer duration >5 days) + beta-lactam (ceftriaxone for pneumococcus) per guidelines,
reducing viral load/mortality. Baloxavir/peramivir alternatives but oral high-dose preferred hospitalized;
plasma investigational. Supportive (proning, steroids if ARDS).
Question: 1728
A patient post-abdominal trauma is diagnosed with bowel ischemia. What is the foremost surgical
indication?
A. Mild metabolic acidosis
B. Elevated white blood cell count
C. Abdominal pain controlled by analgesics
D. Presence of free air on abdominal X-ray
Answer: D
Explanation: Free air indicates bowel perforation, a clear surgical emergency. Leukocytosis and mild
acidosis are less definitive. Controlled pain does not exclude ischemia needing surgery.
Question: 1729
A 25-year-old female post-partum day 3 develops severe headache and seizures. MRI: posterior
reversible encephalopathy syndrome (PRES) with vasogenic edema. BP 190/100 mmHg, urine protein
2+ (prior preeclampsia). Labs: creatinine 1.1 mg/dL, uric acid 6.8 mg/dL. The nurse calculates urine
protein-creatinine ratio 0.35 g/g from spot urine. Which antihypertensive is safest for breastfeeding?
A. Nitroprusside infusion 0.3 mcg/kg/min titrated
B. Hydralazine 10 mg IV q20min up to 20 mg
C. Nifedipine XL 30 mg PO daily
D. Labetalol 20 mg IV q10min PRN SBP >160 mmHg
Answer: D
Explanation: PRES in eclampsia requires BP control; labetalol (beta-blocker) is first-line IV, category C
but preferred in lactation per ACOG 2024. Hydralazine alternative, nifedipine oral, nitroprusside
thiocyanate risk in renal impairment.
Question: 1730
A patient receiving ECMO develops active bleeding with an activated clotting time (ACT) of 180
seconds. The target ACT range is 180-220 seconds. Which action is appropriate?
A. Hold heparin and consult ECMO team for anticoagulation adjustment
B. Increase heparin to achieve ACT of 220-250 seconds
C. Continue current anticoagulation and monitor bleeding closely
D. Administer protamine sulfate immediately to reverse heparin
Answer: A
Explanation: ACT at lower target range with active bleeding necessitates holding or reducing heparin and
consulting the ECMO team for balancing bleeding and clotting risks. Increasing heparin worsens
bleeding. Immediate reversal is contraindicated without consultation. Monitoring alone risks hemorrhage
progression.
Question: 1731
A 58-year-old male with severe traumatic brain injury (TBI) from a motor vehicle collision is admitted to
the neuro-ICU with a Glasgow Coma Scale (GCS) score of 6. Continuous EEG (cEEG) monitoring is
initiated due to nonconvulsive status epilepticus (NCSE) detected on initial spot EEG, showing periodic
discharges (PDs) evolving over time with a frequency of 2 Hz. The patient's mean arterial pressure
(MAP) is 85 mmHg, and intracranial pressure (ICP) is 18 mmHg, yielding a cerebral perfusion pressure
(CPP) of 67 mmHg calculated as CPP = MAP - ICP. Quantitative EEG (qEEG) trends reveal a
suppression ratio of 25% over the last 24 hours. Which intervention is most appropriate to optimize
seizure detection and management based on accurate 2024 evidence?
A. Discontinue cEEG after 36 hours if no additional seizures are detected, as further yield is low without
risk factors
B. Continue cEEG for a minimum of 72 hours regardless of initial findings to capture linear seizure
detection increases
C. Initiate prophylactic levetiracetam at 1000 mg IV every 12 hours while maintaining cEEG for 48 hours
D. Switch to intermittent EEG spot checks every 6 hours to reduce artifact interference from ICU
equipment
Answer: B
Explanation: accurate 2024-2025 evidence from large retrospective studies indicates that seizure detection
on cEEG increases linearly for the first 36 hours in critically ill patients with TBI, but to
comprehensively capture evolving NCSE patterns, especially with PDs, monitoring should extend to at
least 72 hours for optimal detection rates, particularly in high-risk cases like low GCS. The CPP of 67
mmHg is within target (60-70 mmHg for TBI), but ongoing cEEG is essential for dynamic assessment of
cerebral function, as qEEG suppression ratios above 20% signal potential ongoing injury. Prophylactic
ASMs like levetiracetam may be considered per Neurocritical Care Society guidelines but do not replace
extended monitoring; intermittent checks miss nonconvulsive events, and early discontinuation risks
undetected seizures leading to secondary brain injury.
Question: 1732
A patient exhibits continuous cardiac output measurements of 1.8 L/min and mixed venous oxygen
saturation (SvO2) of 55%. Mean arterial pressure is 70 mmHg, heart rate 120 bpm. What is the most
appropriate interpretation of these hemodynamics?
A. High oxygen delivery with adequate cardiac output
B. Septic shock with vasoplegia
C. Low cardiac output state with increased oxygen extraction
D. Hypovolemic shock with low preload
Answer: C
Explanation: Low cardiac output (normal ~4-8 L/min) with reduced SvO2 indicates tissues extracting
more oxygen due to decreased delivery. Tachycardia is compensatory. Septic shock typically has high
SvO2 due to shunting. Hypovolemia usually lowers CVP and MAP more severely.
Question: 1733
A 60-year-old with cardiogenic shock and pulmonary edema (SCAPE) on BiPAP 12/8 cm H2O has
ABG: pH 7.29, PaO2 70 mm Hg, PaCO2 48 mm Hg, HCO3- 22 mEq/L. MAP 65 mm Hg on
norepinephrine 5 mcg/min. Per 2024 AHA, what nitroprusside dose (0.3 mcg/kg/min) calculation for 80
kg patient targets afterload reduction without cyanide toxicity?
A. Max 10 mcg/kg/min cumulative
B. 0.5-5 mcg/kg/min infusion
C. Titrate to MAP >65 mm Hg
D. Bolus 50 mcg then infuse
Answer: B
Explanation: In SCAPE with shock, nitroprusside 0.5-5 mcg/kg/min (24-400 mcg/min for 80 kg) reduces
afterload via venodilation, improving cardiac output by 25% per 2024 American Heart Association
guidelines, with monitoring for thiocyanate >10 mg/dL. Mixed acidosis/hypoxemia. Max duration <48
hours, no bolus risks hypotension, titrate to symptoms not just MAP.
Question: 1734
A 50-year-old male with alcohol use disorder presents with confusion, fever (38.2�C), and hypotension
(BP 85/55 mmHg). WBC 14,000/�L, no focal infection. He meets 3 SIRS criteria but qSOFA 1.
Procalcitonin 0.8 ng/mL, CRP 80 mg/L. After fluids, lactate normalizes. Biomarker panel shows low
sTREM-1 (<50 pg/mL). Which disposition avoids unnecessary antibiotics while addressing SIRS?
A. Discharge with close outpatient follow-up
B. Start empirical antibiotics pending cultures
C. Admit to ward for observation and serial CRP
D. ICU admission for hemodynamic monitoring
Answer: C
Explanation: Noninfectious SIRS from alcohol withdrawal (tremor, fever, tachycardia) mimics sepsis but
low procalcitonin (<0.5 ng/mL rules out bacterial, NPV 99%) and sTREM-1 (myeloid trigger, specific
for infection) differentiate. SSC 2021 (weak) suggests biomarkers to de-escalate; 2023 Eur J Clin
Microbiol meta (n=2,000) shows procal <1 + low sTREM avoids abx 70% safely. Ward safe if stable
post-fluids.
Question: 1735
A 72-year-old male with atrial fibrillation on warfarin (INR 3.2) presents with acute upper GI
hemorrhage following a fall with abdominal impact. Nasogastric tube yields 800 mL coffee-ground
emesis. Vital signs: BP 85/50 mmHg, HR 112 bpm. Labs: Hgb 8.1 g/dL, platelets 120 x 10^3/�L, BUN
45 mg/dL, creatinine 1.8 mg/dL. Endoscopy reveals bleeding duodenal ulcer (Forrest Ia) with visible
vessel, treated with epinephrine injection and hemoclips. Post-procedure, he receives 4 units FFP and 2
units PRBCs, but hypotension persists. CT abdomen shows periduodenal hematoma with extension
causing partial duodenal obstruction and rising IAP to 22 mmHg. Bladder pressure correlates with
reduced urine output (20 mL/hr) and new metabolic acidosis (pH 7.28, base excess -8). What is the
priority intervention to prevent progression to full ACS in this coagulopathic trauma-related hemorrhage?
A. Continuous veno-venous hemofiltration for lactate clearance
B. Prothrombin complex concentrate and additional endoscopic hemostasis
C. Neuromuscular blockade and sedation to reduce abdominal wall tension
D. Surgical duodenotomy with hematoma evacuation
Answer: B
Explanation: In acute GI hemorrhage complicated by trauma-induced hematoma, coagulopathy
exacerbates expansion, driving IAP elevation and ACS risk. Priority is rapid reversal with prothrombin
complex concentrate (PCC) over FFP for faster INR normalization (<1.5 target per 2024 ACG
guidelines), combined with repeat endoscopy for hemostasis to halt volume accumulation. This addresses
the bleeding source directly, preventing further pressure buildup and organ compromise (renal, acid-
base). Neuromuscular blockade temporizes wall compliance but ignores etiology; hemofiltration treats
consequence; surgical evacuation risks worsening bleed in unstable coagulopathy.
Question: 1736
A 70-year-old woman with suspected urosepsis has hypotension and an elevated lactate of 4.2 mmol/L.
Her initial serum creatinine was 1.0 mg/dL; now it is 1.8 mg/dL. Which is the best marker for early
detection of AKI in this patient?
A. Blood urea nitrogen (BUN)
B. Creatinine clearance
C. Urine output monitoring
D. Serum creatinine
Answer: C
Explanation: Urine output monitoring is the earliest and most sensitive measure of AKI in critically ill
patients. Serum creatinine and BUN lag behind real injury, and creatinine clearance requires 24-hour
urine, not practical in acute care. Urine output changes detect renal function deterioration promptly.
Question: 1737
A 55-year-old patient diagnosed with sepsis has a procalcitonin level of 15 ng/mL and is on
vasopressors. After 48 hours, procalcitonin has decreased to 2 ng/mL and hemodynamics improved. What
is the recommended action regarding antibiotics?
A. Continue antibiotics for at least 14 days regardless of procalcitonin
B. Consider antibiotic de-escalation guided by clinical improvement and procalcitonin reduction
C. Discontinue antibiotics immediately due to procalcitonin decrease
D. Increase antibiotic spectrum pending culture results
Answer: B
Explanation: Procalcitonin is a biomarker that helps guide antibiotic duration. A significant drop supports
antibiotic de-escalation if clinical status improves. Immediate discontinuation may risk relapse. Fixed-
duration therapy is not individualized.
Question: 1738
In a patient with subarachnoid hemorrhage, which clinical and laboratory finding most strongly indicates
the development of cerebral vasospasm?
A. Headache relief with pain medication and low ICP
B. Stable neurological test and normal serum sodium
C. New focal neurological deficits and transcranial Doppler mean velocity >120 cm/s
D. Increased urine output with serum creatinine elevation
Answer: C
Explanation: Vasospasm after subarachnoid hemorrhage causes new neurological deficits and elevated
cerebral blood flow velocity (>120 cm/s) on transcranial Doppler. Stable exams and symptom relief do
not indicate vasospasm. Urine output/creatinine changes are unrelated.
Question: 1739
A critically ill patient with disseminated intravascular coagulation (DIC) has platelet count of 35,000,
fibrinogen 90 mg/dL, PT prolonged, and active bleeding. What is the priority treatment?
A. Platelet transfusion only
B. Fresh frozen plasma only
C. Administration of platelet transfusion and cryoprecipitate
D. Vitamin K administration
Answer: C
Explanation: Active bleeding with low platelets and fibrinogen in DIC requires replacement of platelets
and fibrinogen (via cryoprecipitate). FFP alone does not raise fibrinogen sufficiently. Vitamin K is not
effective in DIC, a consumptive coagulopathy.
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