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PCCN · Free practice test

60 free PCCN practice questions, weighted like the exam

These 60 free PCCN practice questions follow the test-plan weights: cardiovascular gets 12, musculoskeletal 1. Tick an answer and the margin explains the keyed answer and your miss. The real exam runs 3 hours for 150 questions, 125 scored.

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The 60-question PCCN practice test

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Item 01 Endocrine (3A)

A patient with DKA has BP 94/58, HR 118, and dry mucous membranes. Which initial fluid order should the nurse anticipate?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: 0.9% saline, 1 L in 1 hour

DKA causes profound volume loss, and isotonic crystalloid (0.9% saline or a balanced solution) restores perfusion and itself lowers glucose. Half-normal saline is used later if corrected sodium is high, but it expands volume poorly at first. D5W adds glucose before it is needed, and albumin offers no advantage over crystalloid.

Your pick, A: Half-normal saline expands volume poorly and is used later if the corrected sodium is high.

Your pick, B: D5W adds glucose before it is needed and does little for volume.

Your pick, C: Albumin has no advantage over crystalloid in DKA.

Item 02 Cardiovascular (1A)

A patient with suspected NSTEMI reports 7/10 chest pressure. BP 138/84, HR 92, SpO2 96% on room air. No aspirin has been given today. The nurse should FIRST anticipate

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: chewable aspirin 162–325 mg

Aspirin chewed early reduces mortality in ACS and is given to every patient without a contraindication. Current guidelines give oxygen only when SpO2 is below 90%, because routine oxygen in normoxic patients offers no benefit. Morphine is reserved for pain unrelieved by nitrates, and furosemide is not indicated without signs of heart failure.

Your pick, A: There are no signs of heart failure or fluid overload, so a diuretic is not indicated.

Your pick, B: SpO2 is 96%; oxygen in ACS is given only when SpO2 is below 90%.

Your pick, C: Morphine is kept for pain that nitrates do not relieve; it is not the first step.

Item 03 Multisystem (4B)

A patient with pyelonephritis has BP 84/38, HR 118, T 39.1 °C, CVP 4 mm Hg, warm flushed skin, bounding pulses, and capillary refill of 1 second. These findings are MOST consistent with

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: early distributive shock

Infection with fever, a wide pulse pressure, warm flushed skin, bounding pulses, and brisk capillary refill reflects vasodilation, the warm phase of distributive septic shock. Cardiogenic shock produces cool clammy skin, crackles, and a high CVP. Hypovolemic shock causes cool skin, a narrow pulse pressure, and delayed refill, while tamponade raises CVP and narrows the pulse pressure.

Your pick, B: Hypovolemic shock causes cool skin, a narrow pulse pressure and slow capillary refill.

Your pick, C: Tamponade raises the CVP and narrows the pulse pressure.

Your pick, D: Cardiogenic shock gives cool clammy skin, crackles and a high CVP.

Item 04 Respiratory (2A)

A postoperative patient develops sudden pleuritic chest pain and dyspnea. On 4 L/min nasal cannula SpO2 is 93%. Clinical probability of PE is high, CT is 2 hours away, and bleeding risk is low. Which action should the nurse anticipate?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: start anticoagulation before the CT

When the pretest probability is high and bleeding risk is low, guidelines recommend starting therapeutic anticoagulation while awaiting imaging, because an untreated PE can extend or recur during the delay. Waiting for confirmation exposes the patient to that risk. Aspirin does not treat venous thromboembolism, and a D-dimer adds nothing when probability is already high.

Your pick, A: Aspirin does not treat venous thromboembolism.

Your pick, B: An untreated PE can extend or recur during a 2-hour wait.

Your pick, C: A D-dimer adds nothing when pretest probability is already high.

Item 05 Advocacy, caring practices, diversity, teaching (II-a)

A patient with end-stage heart failure on a milrinone infusion asks for it to be stopped. When the spouse loudly objects, the patient says, "Never mind, keep it going." The nurse's INITIAL action should be to

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: speak with the patient privately about their treatment wishes

A sudden reversal in front of a forceful family member raises concern for undue influence, so the nurse first clarifies the patient's wishes privately, then involves the provider, palliative care, or ethics as needed. Documenting and continuing accepts a possibly coerced decision. Stopping the infusion acts on a request the patient has just withdrawn, and removing the spouse is punitive without clarifying what the patient wants.

Your pick, A: Stopping the infusion acts on a request the patient has just withdrawn.

Your pick, B: Removing the spouse is punitive and does not clarify what the patient wants.

Your pick, D: Documenting and continuing accepts a decision that may have been coerced.

Item 06 Neurology (3C)

A patient went to bed normal at 2300 and woke at 0700 with left arm weakness and slurred speech. It is now 0830. NIHSS is 12, and CT shows no hemorrhage. The nurse should anticipate

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: CT angiography and perfusion to assess for thrombectomy

Last known well is 2300, which is beyond the standard thrombolysis window, but a patient with a significant deficit may still qualify for thrombectomy up to 24 hours if vascular and perfusion imaging show a large-vessel occlusion with salvageable tissue. Timing from discovery is not the onset time. Declaring the patient ineligible ignores extended-window therapy. There is no 12-hour thrombolysis window from last known well.

Your pick, A: Onset time is when the patient was last known well, not when the symptoms were found.

Your pick, B: There is no 12-hour thrombolysis window measured from last known well.

Your pick, C: Extended-window thrombectomy means the patient is not automatically out of options.

Item 07 Collaboration, systems thinking, clinical inquiry (II-b)

A febrile patient has BP 84/50 and HR 124. The attending declines to order cultures or antibiotics, and the charge nurse's call did not change the plan. The nurse's BEST next action is to

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: activate the rapid response team

Hypotension with fever and tachycardia suggests probable sepsis, and any nurse can activate the rapid response team to obtain an immediate independent evaluation when the chain of command has not resolved an unsafe plan. Documenting and monitoring alone does not protect a deteriorating patient. A grievance addresses the conflict later but does nothing for the patient now. A pharmacist cannot order antibiotics without a prescriber and is not the escalation path for a refused evaluation.

Your pick, A: Documenting and monitoring does not protect a deteriorating patient.

Your pick, B: A pharmacist cannot order antibiotics and is not the escalation path.

Your pick, D: A grievance addresses the conflict later but does nothing for the patient now.

Item 08 Endocrine (3A)

A 70-kg patient with Na+ 114 mEq/L develops a generalized seizure. Which order does the nurse anticipate?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: 3% saline 150 mL IV over 10–20 minutes

Severe symptoms such as seizures are treated with a 150 mL bolus of 3% saline over 10–20 minutes, repeated as needed until symptoms stop, aiming for a rise of about 4–6 mEq/L. A slow 24-hour infusion raises sodium too slowly for an active seizure. Isotonic saline raises sodium little and can worsen hyponatremia in SIADH. Fluid restriction and urea act over days.

Your pick, B: A slow 24-hour infusion raises sodium far too slowly during an active seizure.

Your pick, C: Fluid restriction and urea work over days, not minutes.

Your pick, D: Isotonic saline raises sodium very little and can worsen hyponatremia in SIADH.

Item 09 Cardiovascular (1A)

A patient in atrial fibrillation develops a ventricular rate of 156/min, and BP falls from 124/78 to 90/58. The drop in BP is BEST explained by

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: shortened diastolic filling time

Cardiac output equals heart rate times stroke volume; at very fast rates diastole shortens, ventricular filling falls, and stroke volume drops enough that cardiac output and BP decline, worsened by loss of the atrial kick. Afterload is not increased by tachycardia, venous return is not increased, and systole is not prolonged at rapid rates.

Your pick, A: Tachycardia does not raise systemic vascular resistance; afterload is not the reason the BP fell.

Your pick, B: Systole gets shorter, not longer, as the heart rate rises.

Your pick, C: Rapid AF lowers effective filling; venous return does not increase.

Item 10 Multisystem (4B)

A lethargic patient is found with empty oxycodone and acetaminophen bottles. RR 6, SpO2 86% on room air, pinpoint pupils; ABG pH 7.22, PaCO2 68 mm Hg. The acetaminophen level is pending. While ventilating with a bag-valve mask, the nurse's PRIORITY is to give

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: IV naloxone

The acute threat is opioid-induced hypoventilation with respiratory acidosis, and naloxone rapidly restores ventilation, often avoiding intubation. Acetylcysteine is important but not time-critical in the first minutes and can start once the airway is managed. Charcoal in an obtunded patient without a protected airway risks aspiration, and bicarbonate does not correct an acidosis caused by retained CO2.

Your pick, A: Bicarbonate does not correct an acidosis caused by retained CO2.

Your pick, C: Charcoal in an obtunded patient without a protected airway risks aspiration.

Your pick, D: Acetylcysteine matters but is not time-critical in the first minutes.

Item 11 Respiratory (2A)

A patient is admitted with a COPD exacerbation, increased purulent sputum, RR 26/min, SpO2 89% on 2 L, and pH 7.37. Which corticosteroid order should the nurse anticipate?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: prednisone 40 mg daily for 5 days

GOLD recommends a short course of systemic corticosteroid, prednisone 40 mg daily for 5 days, which speeds recovery with fewer adverse effects than longer courses. High-dose IV methylprednisolone for 14 days increases hyperglycemia and infection without added benefit. Montelukast is an asthma controller with no role in COPD exacerbations. Inhaled corticosteroid monotherapy is not recommended in COPD and does not treat an acute exacerbation.

Your pick, A: Inhaled corticosteroid alone does not treat an acute exacerbation.

Your pick, C: A high-dose 14-day IV course adds hyperglycemia and infection without extra benefit.

Your pick, D: Montelukast is an asthma controller and has no role in a COPD exacerbation.

Item 12 Endocrine (3A)

A patient who took prednisone 20 mg daily for a year stopped it abruptly a week ago. BP is 78/44 despite 2 L of crystalloid. Na+ is 128 mEq/L, K+ 5.6 mEq/L, and glucose 58 mg/dL. Which order should the nurse anticipate FIRST?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: hydrocortisone 100 mg IV

Refractory hypotension, hyponatremia, hyperkalemia, and hypoglycemia after abrupt steroid withdrawal indicate adrenal crisis, which is treated at once with hydrocortisone 100 mg IV along with dextrose and fluids. A cortisol level can be drawn but must never delay treatment. Vasopressors do not work well without cortisol, and at high doses hydrocortisone already provides mineralocorticoid effect, so oral fludrocortisone is unnecessary and too slow.

Your pick, A: A cortisol level can be drawn, but it must never delay the steroid.

Your pick, C: Vasopressors work poorly without cortisol, so steroids must not be held.

Your pick, D: High-dose hydrocortisone already covers mineralocorticoid needs, and an oral drug is too slow.

Item 13 Cardiovascular (1A)

Three hours after catheter ablation for atrial fibrillation, a patient becomes restless. BP falls from 122/76 to 80/62, HR 124, and neck veins are distended. The nurse should MOST suspect

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: cardiac tamponade

Transseptal puncture and catheter manipulation can perforate the heart, and hypotension with tachycardia, narrowed pulse pressure, and distended neck veins indicates tamponade needing urgent echocardiography and pericardiocentesis. Retroperitoneal bleeding lowers venous pressure rather than distending neck veins, a vasovagal reaction causes bradycardia, and recurrent AF would appear as an irregular rhythm.

Your pick, A: A vasovagal reaction causes bradycardia, not a heart rate of 124.

Your pick, B: Retroperitoneal bleeding causes hypovolemia, which flattens the neck veins instead of distending them.

Your pick, D: Recurrent AF can drop the BP but would not explain the distended neck veins.

Item 14 Advocacy, caring practices, diversity, teaching (II-a)

A patient with end-stage heart failure has chosen comfort-focused care and has an implantable cardioverter-defibrillator that is still active. The patient asks whether the device will shock them while they are dying. The nurse's BEST action is to

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: arrange deactivation of the ICD's shock therapy

Turning off shock therapy is ethically the same as withdrawing any unwanted treatment and prevents painful shocks as arrhythmias develop near death. Shock and pacing functions are programmed separately, so pacing can continue if needed. ICDs often fire repeatedly during dying, so reassurance otherwise is false, and deactivation is done noninvasively by reprogramming, or with a magnet in urgent situations.

Your pick, B: Shock and pacing are programmed separately, so pacing can continue.

Your pick, C: Deactivation is done by reprogramming, or with a magnet urgently, not by surgery.

Your pick, D: ICDs often fire repeatedly during dying, so this reassurance is false.

Item 15 Neurology (3C)

A patient in status epilepticus has not responded to lorazepam 4 mg IV. The patient had an inferior MI 3 days ago, HR 52, BP 98/60. Which second-line agent is MOST appropriate?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: levetiracetam 60 mg/kg IV

Levetiracetam at a full loading dose (60 mg/kg, maximum 4,500 mg) has minimal cardiovascular effects, making it preferred with bradycardia and borderline BP after MI. Fosphenytoin and phenytoin can cause hypotension, bradycardia and dysrhythmias. A 500 mg dose is far below an effective loading dose.

Your pick, B: 500 mg is far below an effective loading dose for status epilepticus.

Your pick, C: Fosphenytoin can cause hypotension, bradycardia and dysrhythmias in this patient.

Your pick, D: Phenytoin carries the same cardiovascular risks and adds infusion-site toxicity.

Item 16 Endocrine (3A)

Six hours after transsphenoidal pituitary surgery, an alert patient has urine output 280 mL/h for 3 hours, urine specific gravity 1.002, Na+ 152 mEq/L, and BP 128/76. The nurse anticipates

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: desmopressin with free-water replacement

Dilute polyuria with hypernatremia after pituitary surgery is central diabetes insipidus, treated with desmopressin and replacement of the free-water deficit. A large isotonic bolus is not needed in a hemodynamically stable patient and does not correct the free-water deficit. Fluid restriction would worsen the hypernatremia. Thiazides and sodium restriction are used for nephrogenic, not central, diabetes insipidus.

Your pick, A: Fluid restriction would worsen the hypernatremia.

Your pick, C: Thiazides and sodium restriction are for nephrogenic, not central, DI.

Your pick, D: A stable patient does not need a large isotonic bolus, and it does not replace free water.

Item 17 Multisystem (4B)

Five minutes after IM epinephrine for anaphylaxis, a patient still has wheezing, BP 78/40, and HR 132. The nurse should anticipate

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: repeating IM epinephrine 0.5 mg

Persistent hypotension and bronchospasm after the first dose indicate that anaphylaxis is not controlled, and IM epinephrine can be repeated every 5–15 minutes along with IV fluids. Antihistamines and corticosteroids are adjuncts that do not reverse shock or airway compromise. A cooling blanket has no role.

Your pick, A: A cooling blanket has no role in anaphylaxis.

Your pick, B: Steroids are adjuncts with a slow onset and do not treat shock.

Your pick, C: Diphenhydramine is an adjunct and does not reverse shock or bronchospasm.

Item 18 Cardiovascular (1A)

On day 7 of an IV heparin infusion, a patient's platelet count has fallen from 240,000 to 96,000/mm³, and a new left leg DVT is found. Which action should the nurse anticipate?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: Stop all heparin and start argatroban

A 50% platelet fall 5–10 days into heparin with new thrombosis strongly suggests heparin-induced thrombocytopenia, so all heparin, including flushes, is stopped and a non-heparin anticoagulant such as argatroban is started. Enoxaparin cross-reacts with the HIT antibodies. Prophylactic platelet transfusion can fuel thrombosis, and warfarin is not started until platelets recover because it can cause venous limb gangrene.

Your pick, A: Warfarin is not started until platelets recover, and the heparin must stop now, not in 5 days.

Your pick, C: Platelet transfusion in HIT can feed more thrombosis and is not given for prophylaxis.

Your pick, D: Enoxaparin cross-reacts with HIT antibodies, so switching to it continues the problem.

Item 19 Collaboration, systems thinking, clinical inquiry (II-b)

A study reports that a new fall-prevention program changed the fall rate with a relative risk of 0.85 (95% CI 0.62–1.17). How should the nurse interpret this result?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: The effect is not statistically significant

A 95% confidence interval for a relative risk that includes 1.0 means the data are compatible with no effect, so the result is not statistically significant. Reading 0.85 as a proven 15% reduction, or calling it significant because it is below 1, ignores the interval. The interval spans both benefit and harm, so it does not show increased risk either.

Your pick, A: The interval spans both benefit and harm, so it does not show increased risk.

Your pick, B: An RR below 1 is not significant when the interval crosses 1.

Your pick, C: Calling 0.85 a proven 15% reduction ignores the confidence interval.

Item 20 Respiratory (2A)

A patient with severe asthma remains tight after albuterol, ipratropium, and IV methylprednisolone. SpO2 is 90%, RR 30/min. The nurse should anticipate

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: IV magnesium sulfate 2 g over 20 minutes

IV magnesium sulfate relaxes bronchial smooth muscle and is recommended for severe exacerbations not responding to initial therapy. Antihistamines do not relieve asthma bronchospasm. Montelukast is a controller with no role as rescue therapy. Nebulized acetylcysteine can itself trigger bronchospasm.

Your pick, A: Antihistamines do not relieve asthma bronchospasm.

Your pick, C: Nebulized acetylcysteine can itself trigger bronchospasm.

Your pick, D: Montelukast is a maintenance controller, not a rescue drug.

Item 21 Hematology, immunology, oncology (3B)

A patient with newly diagnosed ALL (WBC 85,000/mm³, bulky mediastinal mass, LDH 850 units/L, uric acid 9.2 mg/dL, normal G6PD) starts induction tomorrow. Which TLS prophylaxis is BEST?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: IV hydration plus rasburicase

High tumor burden with baseline hyperuricemia places the patient at high risk for tumor lysis, and guidelines recommend aggressive IV hydration plus rasburicase, which rapidly breaks down existing uric acid, once G6PD deficiency is excluded. Oral hydration with allopurinol is intermediate-risk prophylaxis and does not clear uric acid already present. Urine alkalinization is no longer recommended because it promotes calcium phosphate precipitation. Routine diuretics are not prophylaxis.

Your pick, B: Oral hydration with allopurinol is for intermediate risk and does not clear uric acid already present.

Your pick, C: Urine alkalinization is no longer recommended because it promotes calcium phosphate deposits.

Your pick, D: Routine diuretics are not TLS prophylaxis.

Item 22 Advocacy, caring practices, diversity, teaching (II-a)

The nurse notices that bilingual housekeeping staff are routinely used to interpret medical updates for patients with limited English proficiency on the unit. Which action BEST addresses this practice?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: Raise the concern with the unit manager as a patient safety issue

Using untrained bilingual staff violates language-access requirements and risks serious errors, so the nurse escalates the system problem to leadership so qualified interpreters are used. A glossary does not make staff qualified interpreters. A waiver does not remove the obligation to offer a qualified interpreter, and documenting names records the unsafe practice without correcting it.

Your pick, A: Documenting names records the unsafe practice without fixing it.

Your pick, B: A waiver does not remove the duty to offer a qualified interpreter.

Your pick, D: A glossary does not make housekeeping staff qualified interpreters.

Item 23 Cardiovascular (1A)

After 48 hours of IV furosemide for decompensated heart failure, a patient has lost 4 kg and breathes more easily. Creatinine has risen from 1.2 to 1.6 mg/dL. BP is 108/68, urine output 1,800 mL/24 h, lactate 1.1 mmol/L. The nurse should expect to

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: continue IV diuresis and trend labs

A small creatinine rise during effective decongestion, with stable BP, normal lactate and good urine output, reflects hemodynamic change rather than kidney injury, so IV diuresis continues with monitoring. Stopping diuretics and giving saline brings back the congestion. Low-dose dopamine has no proven renal benefit, and switching to an oral agent before decongestion is complete invites readmission.

Your pick, B: Switching to oral therapy before decongestion is finished raises the risk of readmission.

Your pick, C: Stopping diuresis and giving saline would bring the congestion back.

Your pick, D: Low-dose dopamine has no proven kidney benefit in heart failure.

Item 24 Multisystem (4B)

A patient in alcohol withdrawal has received lorazepam 2 mg, 4 mg and 8 mg IV over 90 minutes, yet the CIWA-Ar score remains above 20 with HR 132 and agitation. The nurse should anticipate

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: ICU transfer for refractory withdrawal

Persistent severe symptoms despite escalating benzodiazepine doses signal benzodiazepine-resistant withdrawal and risk of delirium tremens; ICU-level care allows phenobarbital or continuous infusions with airway monitoring. An oral agent is too slow for uncontrolled withdrawal. Haloperidol lowers the seizure threshold and does not treat withdrawal, and holding treatment lets symptoms worsen.

Your pick, A: Holding treatment lets withdrawal progress toward seizures and delirium tremens.

Your pick, B: An oral agent is too slow for uncontrolled withdrawal.

Your pick, D: Haloperidol lowers the seizure threshold and does not treat withdrawal.

Item 25 Neurology (3C)

A 78-year-old patient with mild cognitive impairment is admitted after a hip repair. Which intervention is MOST effective in preventing delirium?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: early mobility with glasses and hearing aids

Multicomponent non-pharmacologic measures such as early mobility, sensory aids, orientation and sleep promotion reduce delirium. Benzodiazepines increase delirium risk. Prolonged bed rest and constant lighting disrupt sleep and orientation. Routine antipsychotics do not prevent delirium and are not recommended.

Your pick, B: Routine antipsychotics do not prevent delirium and are not recommended.

Your pick, C: Benzodiazepines increase the risk of delirium.

Your pick, D: Bed rest and constant lighting disrupt sleep and orientation.

Item 26 Hematology, immunology, oncology (3B)

During plasmapheresis for Guillain-Barré syndrome, a patient reports tingling around the mouth and fingertips and has muscle cramps. What is the MOST likely cause?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: Citrate-induced hypocalcemia

Citrate is used as the anticoagulant in the circuit and binds ionized calcium, causing perioral and fingertip paresthesias and cramps; slowing the rate or giving calcium relieves them. Hypokalemia causes weakness and dysrhythmias without perioral tingling. Anaphylaxis causes hives, wheezing, and hypotension, and hypovolemia causes dizziness and hypotension.

Your pick, A: Hypovolemia causes dizziness and hypotension, not paresthesias.

Your pick, B: Hypokalemia causes weakness and dysrhythmias, not perioral tingling.

Your pick, C: Anaphylaxis causes hives, wheezing and hypotension.

Item 27 Respiratory (2A)

A patient with a right chest tube for a pneumothorax is repositioned, and the tubing separates from the drainage unit. The nurse's FIRST action is to

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: submerge the tube end in sterile water

Placing the open tube end 2 to 3 cm under sterile water creates an immediate water seal that stops air entering the pleural space while a new system is set up. Clamping can cause a tension pneumothorax if air continues to leak from the lung. Waiting for the provider leaves an open pathway for air. An occlusive dressing over a tube still in place does not seal the open tube end.

Your pick, A: Clamping can cause a tension pneumothorax if air is still leaking from the lung.

Your pick, B: Waiting at the bedside leaves an open path for air into the pleural space.

Your pick, D: A dressing over the insertion site does not seal the open end of the tube.

Item 28 Cardiovascular (1A)

A patient with hypertensive encephalopathy has BP 230/130 (MAP about 163 mm Hg). An IV nicardipine infusion is started. Which target for the first hour is appropriate?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: a MAP of about 122 mm Hg

In a hypertensive emergency without a compelling condition, MAP is lowered by no more than 25% in the first hour (163 × 0.75 ≈ 122), then toward 160/100 over the next 2–6 hours. A MAP of 82 is a 50% drop, and a BP of 120/80 or an SBP below 140 within the first hour risks cerebral, coronary and renal ischemia because autoregulation has shifted upward. Rapid lowering to a fixed systolic target in the first hour is reserved for compelling conditions such as aortic dissection, severe preeclampsia or pheochromocytoma crisis.

Your pick, A: A MAP of 82 is a 50% drop and risks cerebral, coronary and renal ischemia.

Your pick, B: Normalizing the BP within the first hour is too fast when autoregulation has shifted upward.

Your pick, C: A fast systolic target in the first hour is reserved for compelling conditions such as aortic dissection, which this patient does not have.

Item 29 Multisystem (4B)

A sacral wound has full-thickness skin loss with visible subcutaneous fat and some slough that does not obscure the wound bed. No bone, tendon, or muscle is visible. How should the nurse stage this pressure injury?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: stage 3

Full-thickness loss exposing fat, but not fascia, muscle, tendon, or bone, is stage 3; slough may be present as long as it does not hide the depth. Stage 2 is partial-thickness loss with no visible fat, stage 4 exposes deeper structures, and unstageable applies only when slough or eschar covers the base so the depth cannot be judged.

Your pick, A: Stage 2 is partial-thickness loss with no visible fat.

Your pick, C: Stage 4 exposes bone, tendon or muscle, which are not visible here.

Your pick, D: Unstageable applies only when slough or eschar hides the wound base.

Item 30 Gastrointestinal (3D)

A patient with cirrhosis is vomiting blood. Hb is 6.8 g/dL, BP 94/58, HR 118. Octreotide has been started, and endoscopy is planned. Which additional order should the nurse anticipate?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: IV ceftriaxone

Prophylactic antibiotics such as ceftriaxone reduce infection, rebleeding, and death in cirrhotic patients with GI bleeding. Transfusion follows a restrictive goal of about 7–8 g/dL, because higher targets raise portal pressure and rebleeding. Large crystalloid boluses have the same effect, and nonselective beta-blockers are withheld in acute bleeding with hypotension.

Your pick, B: Large saline boluses also raise portal pressure and rebleeding.

Your pick, C: A hemoglobin target of 10 raises portal pressure and rebleeding; the target is about 7–8.

Your pick, D: Nonselective beta-blockers are held during acute bleeding with hypotension.

Item 31 Advocacy, caring practices, diversity, teaching (II-a)

An older patient who speaks only Tagalog has become quiet and withdrawn 2 days after admission for pneumonia. The daughter says the patient is "just being respectful to the doctors." The nurse's BEST action is to

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: screen for delirium with the CAM using an interpreter

A change from baseline to quiet withdrawal is the classic picture of hypoactive delirium, the most often missed subtype, so the nurse screens with a validated tool through a qualified interpreter. Attributing the change to cultural deference or depression without screening can miss a reversible cause such as hypoxia or infection. Waiting overnight delays the evaluation.

Your pick, B: Labeling it depression without screening for delirium can miss hypoxia or infection.

Your pick, C: Accepting cultural deference without screening can miss a reversible cause.

Your pick, D: Waiting overnight delays the evaluation.

Item 32 Collaboration, systems thinking, clinical inquiry (II-b)

Nurses on a telemetry unit report that most cardiac monitor alarms are nonactionable, and a recent near-miss involved a delayed response to a true VT alarm. Which intervention is MOST likely to reduce alarm fatigue safely?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: Customizing alarm limits to each patient's baseline

Default limits generate frequent nonactionable alarms; customizing parameters to each patient, along with daily electrode changes, cuts false alarms so true ones stand out. Lowering the volume or silencing alarms reduces noise by hiding true alarms, the very failure behind the near-miss. Restricting response to the assigned nurse delays response when that nurse is busy.

Your pick, A: Limiting response to the assigned nurse delays response when that nurse is busy.

Your pick, B: Lowering the volume hides true alarms, the failure behind the near-miss.

Your pick, C: Silencing arrhythmia alarms would hide true VT alarms.

Item 33 Cardiovascular (1A)

Two hours after carotid endarterectomy, a patient has a rapidly enlarging neck swelling at the incision, new stridor, and difficulty swallowing. The nurse's PRIORITY action is to

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: call for emergency airway support

An expanding neck hematoma with stridor threatens the airway and requires immediate airway support and surgical evacuation. Firm pressure on the neck can occlude the carotid artery and dislodge emboli. Ice and positioning are too slow for an evolving airway emergency, and BP control does not relieve airway compression.

Your pick, A: Ice and head elevation are too slow for an airway that is closing.

Your pick, B: Controlling the BP does not relieve compression of the airway.

Your pick, C: Firm pressure on the carotid incision can compress the artery and dislodge emboli.

Item 34 Respiratory (2A)

A patient with ARDS is ventilated at 380 mL (6 mL/kg predicted body weight), PEEP 12 cm H2O, FiO2 0.60. Plateau pressure is 32 cm H2O; pH 7.34, PaCO2 50 mm Hg. Which adjustment should the nurse anticipate?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: reduce the tidal volume to about 320 mL

Six mL/kg PBW is a starting point, not a floor: if the plateau pressure stays above 30 cm H2O, the tidal volume is reduced in 1 mL/kg steps down to 4 mL/kg, accepting a higher PaCO2. Keeping 380 mL leaves the plateau above the safe limit. Increasing the PEEP raises the plateau pressure further. A larger tidal volume increases overdistension.

Your pick, A: 6 mL/kg is a starting point; the plateau pressure decides whether it is low enough.

Your pick, B: A larger tidal volume adds overdistension to lungs that are already overstretched.

Your pick, C: More PEEP raises the plateau pressure further.

Item 35 Gastrointestinal (3D)

A patient with acute pancreatitis has no gallstones on ultrasound and no alcohol use. Triglycerides are 2,400 mg/dL and glucose is 310 mg/dL. Which therapy should the nurse anticipate?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: IV regular insulin infusion

In hypertriglyceridemia-induced pancreatitis with hyperglycemia, an IV insulin infusion activates lipoprotein lipase and lowers triglycerides rapidly, with dextrose added as glucose falls. Lipid emulsion would add to the triglyceride load. ERCP is indicated for gallstone pancreatitis with cholangitis or obstruction, and prophylactic antibiotics are not recommended in acute pancreatitis.

Your pick, A: ERCP is for gallstone pancreatitis, and there are no gallstones.

Your pick, B: Lipid emulsion would add to the triglyceride load.

Your pick, D: Prophylactic antibiotics are not recommended in acute pancreatitis.

Item 36 Neurology (3C)

A patient's 1-minute generalized seizure has stopped, and the patient is now postictal. Point-of-care glucose is 35 mg/dL, and a peripheral IV is in place. Which action should the nurse take FIRST?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: give 25 g of 50% dextrose IV

Severe hypoglycemia is the likely cause of the seizure, and IV dextrose corrects it within minutes when access is available. A postictal patient cannot safely swallow, so oral glucose risks aspiration. IM glucagon is the option without IV access and acts more slowly, and lorazepam is not indicated because the seizure has stopped and the trigger is metabolic.

Your pick, A: IM glucagon is for when there is no IV access, and it acts more slowly.

Your pick, B: A postictal patient cannot swallow safely, so oral glucose risks aspiration.

Your pick, D: The seizure has stopped and its trigger is metabolic, so lorazepam is not indicated.

Item 37 Multisystem (4B)

One day after a laparoscopic colectomy, a patient has new abdominal distension, HR 124, BP 98/60, pH 7.21, HCO3 14 mEq/L, and lactate 6.2 mmol/L. Which action is the PRIORITY?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: notify the surgeon for urgent evaluation

Tachycardia, borderline hypotension, abdominal distension, and a high-lactate metabolic acidosis after abdominal surgery suggest intra-abdominal hemorrhage, ischemia, or leak, which needs urgent surgical evaluation. Bicarbonate is not indicated at a pH above 7.0 and does not treat the hypoperfusion. More opioid would mask the evolving picture, and a nasogastric tube does not address the cause of shock.

Your pick, B: More opioid would mask a worsening surgical picture.

Your pick, C: Bicarbonate is not indicated at this pH and does not treat the hypoperfusion.

Your pick, D: A nasogastric tube does not address the cause of the shock.

Item 38 Cardiovascular (1A)

A 19-year-old athlete is resuscitated after collapsing during practice. A relative died suddenly at age 30. The ECG shows marked LVH voltage with deep narrow Q waves in the lateral leads. The MOST likely cause is:

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is a leading cause of sudden cardiac death in young athletes, and a family history of sudden death with LVH voltage and deep septal Q waves strongly suggests it. Arrhythmogenic RV cardiomyopathy also causes exercise-related arrest but shows T-wave inversion in V1–V3 and epsilon waves rather than LVH. Commotio cordis requires a blow to the chest, and myocarditis would usually follow a viral illness without familial sudden death.

Your pick, A: Commotio cordis needs a blow to the chest and does not cause LVH or familial deaths.

Your pick, B: Myocarditis usually follows a viral illness and does not explain LVH or a family history of sudden death.

Your pick, C: Arrhythmogenic RV cardiomyopathy shows right precordial T-wave inversion and epsilon waves rather than LVH voltage.

Item 39 Advocacy, caring practices, diversity, teaching (II-a)

A patient discharged after a prolonged ICU stay needs tracheostomy care, insulin injections, and wound dressing changes at home. The spouse is anxious about managing all three. Which plan BEST supports a safe transition?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: Supervised practice of each skill before discharge plus home health visits

Several complex new skills need supervised hands-on practice with return demonstration, and home health nursing reinforces them in the home during the high-risk early period. Written instructions and videos do not verify competence. A single demonstration is insufficient for an anxious learner, and a visit at 2 weeks provides no early support.

Your pick, A: Videos do not check competence, and a 2-week visit gives no early support.

Your pick, B: One demonstration is not enough for an anxious learner with three new skills.

Your pick, D: Written instructions do not confirm the spouse can do the skills.

Item 40 Gastrointestinal (3D)

A patient with cirrhosis has confusion, asterixis, and agitation. Which medication order should the nurse question?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: lorazepam 2 mg IV every 4 hours as needed

Benzodiazepines are metabolized by the liver, accumulate in cirrhosis, and can precipitate or worsen hepatic encephalopathy, so a PRN lorazepam order for agitation should be questioned. Lactulose titrated to bowel movements and rifaximin are first-line therapies that lower ammonia production and absorption. Thiamine is appropriate in patients with cirrhosis at risk for deficiency, especially with alcohol use.

Your pick, A: Lactulose titrated to bowel movements is first-line therapy.

Your pick, C: Rifaximin is first-line therapy for hepatic encephalopathy.

Your pick, D: Thiamine is appropriate for patients with cirrhosis at risk of deficiency.

Item 41 Respiratory (2A)

A patient with pulmonary arterial hypertension who takes sildenafil daily develops chest pain. Which order should the nurse question?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: sublingual nitroglycerin 0.4 mg

Nitrates are contraindicated within 24 hours of a PDE-5 inhibitor such as sildenafil (48 hours for tadalafil) because the combination causes profound hypotension, which is especially dangerous with pulmonary hypertension and right ventricular dependence on preload. Aspirin, a prompt 12-lead ECG, and oxygen to correct hypoxemia are appropriate for chest pain.

Your pick, A: Aspirin is appropriate for suspected ACS.

Your pick, B: A 12-lead ECG within 10 minutes is standard for chest pain.

Your pick, D: Oxygen to correct hypoxemia is appropriate in pulmonary hypertension.

Item 42 Collaboration, systems thinking, clinical inquiry (II-b)

A telemetry unit has repeated missed medication doses around shift change. The manager plans to issue written warnings to the nurses involved. Which alternative is MOST likely to reduce the errors?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: Analyze the handoff process and redesign it with staff

Recurrent errors at the same point in the workflow point to a system problem, so a just-culture response analyzes the process, such as medication times that overlap handoff, and redesigns it with frontline staff. Retraining assumes a knowledge gap the pattern does not suggest. Public error counts and counseling, verbal or written, are punitive, discourage reporting, and leave the cause in place.

Your pick, B: Posting error counts is punitive and discourages reporting.

Your pick, C: Retraining assumes a knowledge gap that the pattern does not suggest.

Your pick, D: Verbal counseling is still punitive and leaves the cause in place.

Item 43 Cardiovascular (1A)

Two hours after femoral PCI, a patient on a heparin infusion has a firm 5-cm swelling at the puncture site with stable vital signs. The nurse's FIRST action should be to

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: apply manual pressure above the site

A developing hematoma is controlled first by firm manual pressure just proximal to the puncture site, followed by distal pulse checks and provider notification. Stopping anticoagulation needs an order and does not stop bleeding already in progress, marking alone delays treatment, and sandbags do not provide reliable hemostasis.

Your pick, A: Stopping heparin needs an order and does not stop the bleeding that is already happening.

Your pick, C: Marking the edges is useful later, but waiting an hour lets the hematoma keep growing.

Your pick, D: Sandbags do not give reliable hemostasis and are no substitute for manual pressure.

Item 44 Multisystem (4B)

A patient with a crush injury to the calf has CK rising from 1,200 to 45,000 U/L over 8 hours, dark tea-colored urine, urine output 25 mL/h, and potassium 5.1 mEq/L without ECG changes. The nurse should anticipate

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: isotonic fluids to urine output 200–300 mL/h

Aggressive isotonic fluids dilute myoglobin and flush it through the tubules, aiming for urine output of about 200–300 mL/h to prevent pigment-induced acute kidney injury. Routine urine alkalinization with bicarbonate has not been shown to improve outcomes and can worsen hypocalcemia. Loop diuretics reduce volume without clearing myoglobin, and restricting fluids speeds kidney injury, which makes hyperkalemia worse.

Your pick, A: Restricting fluids speeds kidney injury, which makes hyperkalemia worse.

Your pick, C: A loop diuretic lowers volume without clearing myoglobin.

Your pick, D: Routine urine alkalinization has not improved outcomes and can worsen hypocalcemia.

Item 45 Gastrointestinal (3D)

A patient with acetaminophen-induced acute liver failure has a GCS that falls from 14 to 8 over 6 hours. BP rises from 118/70 to 164/68, and HR falls to 54. Glucose is 110 mg/dL. Which complication is MOST likely?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: cerebral edema

Cerebral edema is a leading cause of death in acute liver failure, and a falling GCS with widening pulse pressure and bradycardia suggests rising intracranial pressure that needs urgent ICU and transplant evaluation. Hypoglycemia is common but excluded by a glucose of 110 mg/dL. Sepsis causes hypotension and tachycardia, and hepatorenal syndrome causes oliguria rather than a Cushing response.

Your pick, B: A glucose of 110 rules out hypoglycemia.

Your pick, C: Hepatorenal syndrome causes oliguria, not a falling GCS with bradycardia.

Your pick, D: Sepsis causes hypotension and tachycardia, not a Cushing response.

Item 46 Behavioral and psychosocial (4C)

A patient 3 days after admission for NSTEMI is anxious, reports a sense of doom, and asks to go home. HR 104, BP 142/88, RR 22, SpO2 97% on room air. The nurse's FIRST action is to

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: assess for chest pain and obtain a 12-lead ECG

In a patient recovering from acute coronary syndrome, new anxiety, restlessness, and a sense of impending doom may signal recurrent ischemia or a dysrhythmia, so a physiologic cause is excluded first. An anxiolytic or breathing techniques are reasonable only after ischemia has been ruled out. Discussing the risks of leaving addresses the request but not the possible cardiac cause of the behavior.

Your pick, B: An anxiolytic before assessment could mask recurrent ischemia.

Your pick, C: Breathing techniques are reasonable only after a cardiac cause is excluded.

Your pick, D: Talking about leaving addresses the request but not the possible cardiac cause.

Item 47 Advocacy, caring practices, diversity, teaching (II-a)

A patient with end-stage COPD has a documented goal of comfort care and a do-not-intubate order. ABG shows pH 7.18 and PaCO2 68 mm Hg. The patient is somnolent but breathing calmly without grimacing. The nurse's BEST action is to

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: continue comfort measures and support the family

With comfort-focused goals, interventions are chosen for their effect on symptoms, not laboratory values, and this patient shows no distress. BiPAP can relieve dyspnea in some DNI patients, but on a calm patient it adds a burdensome mask without comfort benefit. Naloxone could precipitate pain and distress, and a rapid response call escalates care the patient declined.

Your pick, A: A rapid response call escalates care the patient has declined.

Your pick, C: BiPAP on a calm patient adds a burdensome mask with no comfort benefit.

Your pick, D: Naloxone could trigger pain and distress in a patient receiving comfort care.

Item 48 Cardiovascular (1A)

One day after TAVR, a patient has HR 36, dizziness, and P waves that bear no relationship to the QRS complexes. The MOST likely cause is:

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: prosthesis injury to the conduction system

The aortic valve lies next to the AV node and left bundle, and pressure from the prosthesis commonly causes new bundle branch or complete heart block after TAVR, sometimes requiring a permanent pacemaker. A vasovagal response causes sinus bradycardia rather than AV dissociation. Hypokalemia causes tachydysrhythmias and U waves, and sedation effects would have resolved and would not dissociate P waves from QRS complexes.

Your pick, A: Hypokalemia tends to cause tachydysrhythmias and U waves, not AV dissociation.

Your pick, C: Sedation would have worn off by the next day and does not dissociate P waves from QRS complexes.

Your pick, D: A vasovagal response slows the sinus rate but keeps P waves linked to the QRS.

Item 49 Renal (3E)

An obtunded patient is admitted from home with a serum sodium of 112 mEq/L, and the duration of the hyponatremia is unknown. What is the MAXIMUM safe rise in serum sodium over the first 24 hours?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: 8 mEq/L

Hyponatremia of unknown duration is treated as chronic, and brain cells have adapted by losing osmoles, so raising sodium by more than 8 mEq/L in 24 hours risks osmotic demyelination. Severe symptoms still justify a small 3% saline bolus to raise sodium 4–6 mEq/L quickly, but within that daily limit. Twelve mEq/L exceeds the 8–10 mEq/L daily limit used for chronic hyponatremia.

Your pick, A: 20 mEq/L in 24 hours carries a high risk of osmotic demyelination.

Your pick, C: 16 mEq/L in 24 hours is far above the safe limit.

Your pick, D: 12 mEq/L in 24 hours exceeds the 8–10 mEq/L daily limit for chronic hyponatremia and raises the risk of osmotic demyelination.

Item 50 Respiratory (2A)

A patient who takes alprazolam daily is found with an empty bottle. The patient is drowsy but arousable, RR 10/min, SpO2 91% on room air. The nurse's PRIORITY action is to

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: maintain the airway and support ventilation

Management of benzodiazepine overdose is primarily supportive: airway protection, oxygenation, and ventilation come first. Flumazenil can precipitate withdrawal seizures in patients with chronic benzodiazepine use and is not given routinely. Oral activated charcoal is unsafe in a drowsy patient without a protected airway. Gastric lavage is not recommended and increases aspiration risk.

Your pick, A: Flumazenil can trigger withdrawal seizures in someone who takes a benzodiazepine every day.

Your pick, C: Oral charcoal is unsafe in a drowsy patient whose airway is not protected.

Your pick, D: Gastric lavage is not recommended and raises the risk of aspiration.

Item 51 Multisystem (4B)

A patient with pneumonia and septic shock develops oozing from IV sites and the nasogastric tube. Platelets have fallen from 198,000 to 48,000/mm³, fibrinogen is 90 mg/dL, INR 2.2, and D-dimer is markedly elevated. The patient receives subcutaneous heparin prophylaxis. The MOST LIKELY cause is

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: disseminated intravascular coagulation

Sepsis with falling platelets and fibrinogen, a prolonged INR, high D-dimer and diffuse bleeding is consumptive coagulopathy (DIC). HIT is tempting because of the heparin, but it causes thrombosis rather than bleeding and leaves fibrinogen and INR normal. TTP causes hemolytic anemia with schistocytes and a normal INR, and vitamin K deficiency prolongs the INR without consuming platelets or fibrinogen.

Your pick, A: Vitamin K deficiency prolongs the INR but does not consume platelets or fibrinogen.

Your pick, B: TTP causes hemolysis with schistocytes and a normal INR.

Your pick, D: HIT causes clotting rather than bleeding and leaves fibrinogen and INR normal.

Item 52 Cardiovascular (1A)

A stable patient has atrial fibrillation of unknown duration and has not been anticoagulated. The team wants to perform cardioversion today. Which test should be done FIRST?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: Transesophageal echocardiogram

Atrial fibrillation of 48 hours or more (or unknown duration) requires either 3 weeks of anticoagulation or a transesophageal echocardiogram to exclude left atrial appendage thrombus before cardioversion. Transthoracic imaging cannot reliably see the appendage. Starting heparin does not dissolve an existing clot, so cardioversion without imaging risks stroke.

Your pick, A: A transthoracic echo cannot reliably see the left atrial appendage.

Your pick, B: Starting heparin does not dissolve a clot that may already be there.

Your pick, D: A stress test looks for ischemia and says nothing about atrial thrombus.

Item 53 Renal (3E)

A patient receiving hemodialysis at 0800 has morning medications due at 0700. Which medication should the nurse hold until after dialysis?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: lisinopril

Antihypertensives such as lisinopril are commonly held before hemodialysis because they add to the fall in blood pressure caused by fluid removal and can precipitate intradialytic hypotension. Sevelamer is a phosphate binder taken with meals. Levothyroxine and pantoprazole do not cause hypotension and can be given as scheduled.

Your pick, B: Sevelamer is a phosphate binder taken with meals.

Your pick, C: Levothyroxine does not cause hypotension and can be given as scheduled.

Your pick, D: Pantoprazole does not affect BP during dialysis.

Item 54 Collaboration, systems thinking, clinical inquiry (II-b)

A patient with an eGFR of 25 mL/min/1.73 m² is scheduled for a contrast-enhanced CT this afternoon, and no prevention orders are in place. The nurse's BEST action is to

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, B: ask the provider about IV isotonic hydration

Risk of contrast-associated AKI is concentrated in patients with an eGFR below 30, and IV isotonic hydration is the only recommended preventive measure. N-acetylcysteine and sodium bicarbonate have not shown benefit over saline and are no longer recommended. Extra oral fluids alone are not adequate prophylaxis for a high-risk patient.

Your pick, A: Sodium bicarbonate has shown no benefit over saline and is no longer recommended.

Your pick, C: Extra oral fluids alone are not adequate prophylaxis for a high-risk patient.

Your pick, D: N-acetylcysteine has shown no benefit over saline and is no longer recommended.

Item 55 Behavioral and psychosocial (4C)

An 80-year-old patient with Alzheimer disease admitted 3 days ago no longer recognizes the spouse and is drowsy one hour and restless the next. The spouse says confusion at home had been stable for 2 years. Which finding BEST indicates delirium?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: fluctuating attention that began over days

Delirium is defined by acute onset over hours to days with fluctuating attention and level of consciousness, which distinguishes it from the slow, steady progression of dementia and warrants a search for reversible causes. Gradual memory loss over 2 years describes the underlying dementia. Evening worsening (sundowning) occurs in dementia without delirium. Difficulty recognizing family can occur in either condition and is not specific.

Your pick, A: Evening worsening, or sundowning, happens in dementia without delirium.

Your pick, B: Gradual memory loss over 2 years describes the underlying dementia.

Your pick, D: Trouble recognizing family can happen in either condition and is not specific.

Item 56 Advocacy, caring practices, diversity, teaching (II-a)

A patient with limited English proficiency will self-inject enoxaparin at home after a DVT. A qualified interpreter is present for teaching. Which finding BEST shows the patient is ready to self-administer?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, A: The patient injects a dose correctly as the nurse observes

For a psychomotor skill, the best evidence of learning is a correct return demonstration. Nodding and saying "yes" often reflect politeness rather than ability, and the interpreter's impression is not evidence of the patient's skill. A video in the patient's language provides information but does not show the patient can perform the injection.

Your pick, B: Nodding and saying yes often reflect politeness rather than ability.

Your pick, C: The interpreter's impression does not show the patient can do the injection.

Your pick, D: Watching a video gives information but does not show performance.

Item 57 Respiratory (2A)

On day 3 of IV antibiotics for community-acquired pneumonia, which finding BEST indicates readiness to switch to oral therapy?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: clinically stable and able to swallow

The switch to oral antibiotics is based on clinical stability, such as being afebrile with stable vital signs and oxygenation, plus the ability to take and absorb oral medication. The WBC count may lag behind clinical improvement. Radiographic clearing takes weeks, and a fixed IV course is not required once the patient is stable.

Your pick, A: No fixed IV course is needed once the patient is stable.

Your pick, B: Radiographic clearing takes weeks and is not the criterion.

Your pick, C: The WBC count can lag behind clinical improvement.

Item 58 Multisystem (4B)

A patient had a PICC placed 5 days ago for IV antibiotics, which finished yesterday. The patient now takes all medications by mouth. Which action BEST prevents a central line–associated bloodstream infection?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, D: ask the provider to remove the PICC

The strongest CLABSI prevention is removing a line as soon as it is no longer needed, and this PICC has no remaining indication. Heparin flushes maintain patency but do not reduce infection. Transparent dressings are changed every 7 days or when soiled, because daily changes add manipulation. Routine surveillance cultures do not prevent infection.

Your pick, A: Routine surveillance cultures do not prevent infection.

Your pick, B: Transparent dressings are changed every 7 days or when soiled; daily changes add handling.

Your pick, C: Heparin flushes keep the line patent but do not lower infection risk.

Item 59 Cardiovascular (1A)

Norepinephrine is infusing through a forearm peripheral IV. The nurse finds the skin around the site cool, blanched, and firm. After stopping the infusion, which action should the nurse anticipate?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: local phentolamine infiltration

Norepinephrine extravasation causes intense local vasoconstriction and tissue necrosis; the infusion is stopped, residual drug aspirated, and phentolamine (an alpha-blocker) is infiltrated into the area. Restarting or resuming at the same site continues the injury, and ice worsens vasoconstriction.

Your pick, A: Restarting at the injured site continues the tissue damage.

Your pick, B: Resuming the drip through the same IV keeps the drug going into the tissue.

Your pick, D: Ice makes the vasoconstriction worse and does nothing to reverse the injury.

Item 60 Musculoskeletal (4A)

A patient with severe osteoporosis develops sudden midthoracic back pain after reaching for an object. Which finding requires IMMEDIATE notification of the provider?

Tick one box. The rationale is written here once you answer.

Right.Not the keyed answer.

Keyed answer, C: new bilateral leg weakness and urinary retention

New bilateral leg weakness with urinary retention suggests spinal cord compression from a retropulsed vertebral fragment, a surgical emergency. Point tenderness over the spinous process and pain that increases with upright posture are expected with a vertebral compression fracture. Gradual height loss reflects chronic osteoporotic collapse rather than an acute emergency.

Your pick, A: Point tenderness over the spinous process is expected with a compression fracture.

Your pick, B: Pain that worsens upright is expected with a vertebral compression fracture.

Your pick, D: Gradual height loss reflects chronic osteoporotic collapse, not an acute emergency.

Score sheet

You answered 0 and got 0 right.

Answer a few items and the sheet ranks your weakest system by points lost.

For scale: the real exam pass line is 82 of the 125 scored questions. This set is practice, not a calibrated score.

Keys: 1 to 4 tick an answer, the arrow keys move between items.

Map

How the 60 map to the 12 test-plan areas

Each of the 12 test-plan areas gets its share of the 60 by its exam weight, and every area has at least 1 item. Clinical Judgment holds 48 of the 60 (80%), the same share it has on the exam; the two caring and ethics areas hold the other 12.

The 60 items by test-plan area, heaviest first
Test-plan areaChip in the quizExam weightItems here
Cardiovascular (1A)Cardiovascular20%12
Multisystem (4B)Multisystem15%9
Respiratory (2A)Respiratory14%8
Advocacy, caring practices, diversity, teaching (II-a)Caring & advocacy11%7
Collaboration, systems thinking, clinical inquiry (II-b)Collaboration & systems9%5
Neurology (3C)Neuro & behavioral7%4
Gastrointestinal (3D)Endo · GI · Renal7%4
Endocrine (3A)Endo · GI · Renal6%4
Renal (3E)Endo · GI · Renal4%2
Hematology, immunology, oncology (3B)Endo · GI · Renal3%2
Behavioral and psychosocial (4C)Neuro & behavioral3%2
Musculoskeletal (4A)Endo · GI · Renal2%1
Total7 chips101%60

Weights from the AACN test plan for exams taken on or after February 6, 2024; AACN rounds each area, so they add up to 101%. With 60 slots one item is 1.7% of the set, so the small areas sit one item above or below their weight.

The chips group the areas into seven study domains. Gastrointestinal, endocrine, renal, hematology and musculoskeletal share one chip, Endo · GI · Renal, because none of them is big enough to drill alone: together they are 22% of the exam.

Margin

Using the rationale margin

The margin is where the 60 items earn their keep. Each one carries the keyed answer, the reason it beats the other three, and a note on every wrong option, so a miss tells you which misconception picked it.

  1. Commit before you read

    Tick an answer before you look at the margin. A guess you had to make is information; a rationale you read first is not.

  2. Read the note on your pick

    The line under your wrong answer names what made it look right: the wrong mechanism, the right drug at the wrong moment, an assessment skipped. That line is the thing to fix, not the fact in the keyed answer.

  3. Let the score sheet rank the misses

    After the last item the sheet multiplies your misses by exam weight. Two cardiovascular misses outrank three musculoskeletal ones, and the sheet says so.

  4. Rerun one chip, cold

    A day later, run only the chip that leaked. Getting it right the second time from memory of the rationale is the point; getting it right from memory of the letter is not.

Format

What a real PCCN item looks like

Every PCCN item is multiple choice: a stem and four options, one best answer. There is no select-all-that-apply, so practise picking one. Most stems are a short adult vignette: a moment in the stay, a few findings with raw vital signs, then the question. The exam covers adult patients only, and AACN is moving to generic drug names only, though some questions may still show trade names during the switch.

Expect one capitalised cue word, FIRST, BEST, INITIAL or MOST LIKELY, and expect two options that are both reasonable care. The cue decides between them. 37 of our 60 carry one, and the rationale says why the other sensible option comes second.

The real exam, next to this one

Real exam

150 questions, 125 scored

Time

3 hours

Pass line

82 of 125 scored

Result

A result on screen right after the exam, and a detailed score report by email within 24 hours

Sources: PCCN exam handbook, AACN exam statistics. Checked October 2026.

That is 72 seconds an item. Run all 60 here at exam pace and you need about 72 minutes. The clock is generous; what decides the result is accuracy on the heavy systems.

Triage

What to drill first

Cardiovascular, multisystem and respiratory first: 49% of the exam and 29 of these 60, and any miss there costs more than a perfect run of the light areas. The cardiovascular guide and the respiratory guide each carry 12 more items. Then caring and ethics (12 here), with endocrine, GI, renal and neurology; the study guide has the full order, week by week.

Keep drilling the heavy three

The app sorts the same practice bank by body system, so cardiovascular, multisystem and respiratory can get a few items every shift until the exam.

Get the PCCN appBack to the questions

Free vs paid

Free and paid PCCN practice questions

The exam is set by AACN Certification Corporation, the certification arm of the American Association of Critical-Care Nurses, and its scored items are not published, so every practice question anywhere is written by someone else. What separates sources is whether they follow the current plan and explain the answer.

Free and paid PCCN practice, compared
SourceWhat you getWhat to check
This practice test60 items across all 12 areas, a rationale for every option, free, no accountNot a predictor: 60 untimed items cannot forecast a 150-item exam
AACN's own practice examPaid, sold by the association behind the examPrice, length and access period on AACN's site before you buy
Quizlet decksFree flashcards made by other usersThe date: many predate the 2024 plan and still carry the old format or outdated answers
Review books and appsLarge banks, usually with explanationsThe edition year and whether it says it follows the 2024 test plan

AACN sells its own practice exam; no prep product is required. A "PCCN test bank" sold as the real exam questions is mislabelled practice at best. For the full exam rules, start with how the PCCN exam works or the AACN exam handbook.

Summary

Before you close the sheet

The short version

  • 60 items, weighted like the plan; cardiovascular, multisystem and respiratory are 29 of them.
  • Tick first, then read the note under your wrong pick: it names the mistake.
  • The real exam is 150 questions, 125 scored, about 72 seconds an item; pace is rarely the problem.
  • The pass line is 82 of 125 scored, a raw count. Our score sheet is practice, not a forecast.
  • Study order: the heavy three, then caring and ethics, then the rest of the study guide.
FAQ

Questions nurses ask

Is this PCCN practice test free?

Yes. All 60 questions and every rationale are on this page, with no account and no sign-up. Pick a chip to drill one system or run the whole set; the score sheet is built in your browser and is gone when you close the tab.

How many questions are on the PCCN exam?

150 multiple-choice questions, 125 scored and 25 unscored, in 3 hours. That format applies to exams taken on or after February 6, 2024; older guides that say 125 items in 2.5 hours describe the previous exam.

Are these the real PCCN exam questions?

No. They are original practice items written to the current test plan and checked against current guidance. They match the format, one best answer from four options, and the weighting by area. The scored exam items are not published.

What score do you need to pass the PCCN?

82 of the 125 scored questions, set by a modified-Angoff standard-setting panel, effective January 31, 2024. It is a raw count of scored items, so do not turn your result on this page into a pass or fail.

Is the PCCN hard to pass?

It is a real filter. 70.1% of first-time candidates passed in 2025 (3,321 tested), after 68.2% in 2024 and 70.3% in 2023. The three heavy systems hold about half the scored items, so that is where a miss costs most, and why this test gives them the most items.

Are PCCN questions basic nursing questions?

No. They assume RN basics and test progressive care judgment: what to do first for an adult who is moderately stable and could get worse. Expect rhythm changes, post-procedure patients, sepsis screening and family dilemmas rather than fundamentals.

Are PCCN Quizlet decks worth using?

For quick recall of terms, yes. For exam practice, check the date first: most user decks carry no rationales, and many were built before the 2024 test plan.

How do you get your PCCN?

You need a current, unencumbered U.S. RN or APRN license and 1,750 hours of direct care of acutely ill adults in the previous 2 years, with 875 of them in the most recent year, or at least 2,000 hours of direct care of acutely ill adults in the previous 5 years, with 144 of them in the most recent year. You apply to AACN Certification Corporation and test at a PSI test center or by PSI live remote proctoring. The PCCN requirements page covers the hours in detail.

Next

Your biggest leak is the next thing to study

Run its chip again tomorrow, cold. The app keeps the same body systems and the same margin rationales, so the heavy areas get worked on shifts when you have ten minutes, not three hours.

Get the PCCN appBack to the questions