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CRITICAL CARE NURSING CERTIFICATION
2
Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required. The authors and the publisher of
this work have checked with sources believed to be reliable in their efforts to provide information
that is complete and generally in accord with the standards accepted at the time of publication.
However, in view of the possibility of human error or changes in medical sciences, neither the
authors nor the publisher nor any other party who has been involved in the preparation or
publication of this work warrants that the information contained herein is in every respect
accurate or complete, and they disclaim all responsibility for any errors or omissions or for the
results obtained from use of the information contained in this work. Readers are encouraged to
confirm the information contained herein with other sources. For example and in particular,
readers are advised to check the product information sheet included in the package of each drug
they plan to administer to be certain that the information contained in this work is accurate and
that changes have not been made in the recommended dose or in the contraindications for
administration. This recommendation is of particular importance in connection with new or
infrequently used drugs.
3
seventh edition
4
CRITICAL CARE NURSING CERTIFICATION
5
Preparation, Review, and Practice Exams
6
Critical Care Nursing Certification: Preparation, Review, and Practice Exams, Seventh Edition
Copyright © 2018 by McGraw-Hill Education. All rights reserved. Printed in The United States of America. Except as permitted under the
United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a
data base or retrieval system, without the prior written permission of the publisher.
Previous editions copyright © 2010, 2007 by The McGraw-Hill Companies, Inc. Copyright © 1998 by Appleton & Lange as Critical Care,
Certification: Preparation, Review, and Practice Exams. Copyright © 1993, 1991, and 1983/1984 as Critical Care, Certification Preparation
and Review and Critical Care, Certification Practice Exams.
1 2 3 4 5 6 7 8 9 LOV 22 21 20 19 18 17
ISBN 978-0-07-182676-1
MHID 0-07-182676-9
e-ISBN 978-0-07-182670-9
e-MHID 0-07-182670-X
This book was set in Adobe Garamond Pro by Cenveo® Publisher Services.
The editors were Susan Barnes and Christina M. Thomas.
The production supervisor was Catherine H. Saggese.
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McGraw-Hill Education books are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate
training programs. To contact a representative please visit the Contact Us pages at www.mhprofessional.com.
7
Dedication
To my colleagues over the years, friends, and family (especially Angie and my M&M boys): You
have given me more than I have ever deserved.
Also, to my mentors, such as Tom Ahrens, whose guidance has helped make opportunities such as
this possible.
Alexander P. Johnson, MSN, RN, ACNP-BC, CCNS, CCRN
8
Contents
Reviewers
Contributors
Preface
Acknowledgments
Test-Taking Tips
PART I. CARDIOVASCULAR
1. Cardiovascular Anatomy and Physiology
2. Diagnosis and Treatment of Cardiovascular Disorders
3. The Normal ECG
4. The 12-Lead ECG
5. Hemodynamic Monitoring
6. Acute Coronary Syndrome (Angina Pectoris and Myocardial Infarction)
7. Conduction Blocks
8. Congestive Heart Failure, Pulmonary Edema, and Hypertensive Crisis
9. Cardiogenic Shock
10. Hemorrhagic (Hypovolemic) Shock
11. Interpreting Dysrhythmias
12. Cardiomyopathies and Pericarditis
13. Treatment of Cardiac, Valvular, and Vascular Insufficiency, and Trauma
Cardiovascular Practice Exam
9
PART V. NEUROLOGY
30. Anatomy and Physiology of the Nervous System
31. Intracranial Pressure
32. Acute Head Injuries and Craniotomies
33. Stroke
34. The Vertebrae and Spinal Cord
35. Encephalopathies, Coma, and Brain Herniation
36. Meningitis, Guillain–Barré, Muscular Dystrophy, and Myasthenia Gravis
37. Seizures and Status Epilepticus
Neurology Practice Exam
PART X. BEHAVIOR
52. Behavioral and Psychologic Factors in Critical Care
Index
10
Reviewers
11
Contributors
12
Chapter 45: Diagnosis and Treatment of Acute Renal Failure
Chapter 46: Renal Trauma
13
Preface
In this edition of Critical Care Nursing Certification: Preparation, Review, and Practice Exams, we have
updated the content in light of the latest changes to the CCRN exam. However, we have honored the vision
and format of previous editions: We hope that this edition may also serve as a comprehensive critical care
reference text (using short, easy to read chapters) as well as a certification preparation book. In this edition, in
the “Editor’s Note” section, we have provided some general test-taking strategies at the beginning of each
chapter, as well as an estimated amount of questions that you will be likely to see from that chapter on the
exam. Another new addition to this edition has been answer rationales for each review question that help
provide and reinforce test-taking information, tactics, and techniques that are designed to increase success on
future exam questions.
The CCRN exam generally reflects what you see every day in your practice. A focus is placed on the 80/20
rule, and unusually encountered concepts and conditions are not emphasized on the exam. The content of the
exam is something that you will generally see in your practice. In fact, one of the best ways to study for the
exam is to use the information in this book in your clinical practice.
Best of luck on the exam. Passing the exam is a major milestone in your career and helps validate your
knowledge and commitment to your patients and your practice. To paraphrase a famous quote, “We are not
telling you it will be easy, but we can tell you it is going to be worth it.”
14
Acknowledgments
We are indebted to our friends, team members, and leaders at Northwestern Medicine–Central DuPage
Hospital. Without their patience, strength, support, and excellent care delivered daily, an endeavor such as this
may not have been possible.
15
Test-Taking Tips
The following are some general test-taking tips. Follow them as you prepare for the examinations in this text
and on the CCRN examination. They can make the difference in several points on the examination.
1. Answer all questions. Unanswered questions are counted as incorrect. Use your knowledge to rule our
incorrect answers whenever in doubt.
2. Be well rested before the examination. Get a good night’s sleep before the examination. Do not try to
“cram” on the morning of the test: You may confuse yourself if you study right before the test.
3. Have a good but light breakfast. You will be taking the test for perhaps 3 h (the exam is 150 total
questions [125 are scored] to be answered within the 3-h timeframe). Eat food that is not all
carbohydrates so that you can make it through the examination without becoming hungry or getting a
headache.
4. Do not change answers unless you are absolutely sure. Many first impressions are accurate.
5. Go through the test answer all questions. Mark on a piece of scrap paper the questions that are
difficult. Then go back and review the difficult questions. Do not be discouraged if there are many
hard questions.
6. Do not expect to answer all questions correctly. If you do not know the answer to a question, make an
educated guess and go on. Do not let it bother you that you missed a few questions. You will not have
a good perception of how you did until you get the results. However, bear in mind that in 2016, the
first time pass rate of the CCRN was 79.1%, was is very strong.
7. Achieving approximately 70% or greater on the practice examinations is often a very strong sign of
readiness and adequate preparedness for the examination. Similarly, a raw score of 87 of 125 (70%) is
what is required to pass the examination. So again, do not be discouraged by questions that may seem
challenging.
In addition, general practice trends in critical care nursing are reflected on the exam (such as the overall
decreased use of pulmonary artery catheters). However, more focused information that only reflects regional
or institutional trends are not covered, such as the technical specifications of an esophageal Doppler monitor
or stop-cock functionality. Remain mindful of this when considering “obscure” questions to anticipate.
1. Do not let the fact that other people finish early (or that you finish before others) disturb you. People
work at different rates without necessarily a difference in results.
2. If you feel thirsty or need to go to the restroom, ask permission from the monitor. Always try to
maintain your physiological status at optimal levels. An aspirin (or similar analgesic) may be in order
if a headache develops during the test.
3. Do not try to establish patterns in how the items are written (eg, “Two B’s have occurred, now some
other choice is likely”). The AACN Certification Corporation has excellent test-writing mechanisms.
Patterns in test answers, if they occur, are coincidental.
16
I
CARDIOVASCULAR
17
1
EDITORS’ NOTE
Although basic anatomy is not commonly addressed in the CCRN exam, an understanding of the principles of
anatomy may help your perception of more specific questions regarding cardiovascular concepts. The
following chapter is a brief review of key anatomic and physiologic cardiovascular concepts that should
prove useful in preparing for the test. This chapter also addresses background information on cardiovascular
concepts sometimes found on the CCRN exam. If you do not have a strong background in anatomy and
physiology, study this section closely. You may want to review the cardiovascular sections of physiology
textbooks as well.
The CCRN exam places the most emphasis on the cardiovascular component, with approximately 20% of
the test questions in this content area. While many nurses are relatively strong in cardiovascular concepts, do
not take this part of the exam lightly. The better you perform in any one area, the greater your chances of
overall success on the exam.
The heart lies in the mediastinum, above the diaphragm, surrounded on both sides by the lungs. If one looks at
a frontal (anterior) view, the heart resembles a triangle (Fig. 1-1). The base of the heart is parallel to the right
edge of the sternum, whereas the lower right point of the triangle represents the apex of the heart. The apex is
usually at the left midclavicular line at the fifth intercostal space (ICS). The average adult heart is about 5 in.
long and 3½ in. wide, about the size of an average man’s clenched fist. The heart weighs about 2 g for each
pound of ideal body weight.
18
Figure 1-1. Frontal view of the heart.
The heart is supported by a fibrous skeleton (Fig. 1-2) composed of dense connective tissue. This skeleton
connects the four valve rings (annuli) of the heart: the tricuspid, mitral, pulmonic, and aortic valves. Attached
to the superior (top) surface of this skeleton are the right and left atria, the pulmonary artery, and the aorta.
Attached to the inferior (lower) surface of the skeleton are the right and left ventricles and the mitral and
tricuspid valve cusps.
19
Figure 1-2. Fibrous skeleton of the heart (frontal view).
The heart can be studied as two parallel pumps: the right pump (right atrium and ventricle) and the left
pump (left atrium and ventricle). Each pump receives blood into its atrium. The blood flows from atria
through a one-way valve into the ventricles. From each ventricle, blood is ejected into a circulatory system.
The right ventricle ejects blood into the pulmonary circulation, while the left ventricle ejects blood into the
systemic circulation. Although there are differences between the right and left sides of the heart, the gross
anatomy of each side is similar. Structural features of each chamber are discussed below.
The heart is enclosed in a fibrous sac called the pericardium. The pericardium is composed of two layers: the
fibrous and parietal pericardia. The fibrous pericardium is the outer layer that helps support the heart. The
parietal pericardium, the inside layer, is a smooth fibrous membrane.
Next to the parietal serous layer of the pericardium is a visceral layer, which is actually the outer heart
surface. It is most often termed the “epicardium.” Between the epicardium and the parietal pericardium is 10
to 20 mL of fluid, which prevents friction during the heart’s contraction and relaxation.
The myocardium, or muscle mass of the heart, is composed of cardiac muscle, which has characteristics of
both smooth and skeletal muscles. The endocardium is the inner surface of the heart wall. It is a membranous
covering that lines all of the heart’s chambers and the valves.
Papillary muscles originate in the ventricular endocardium and attach to chordae tendineae (Fig. 1-3). The
chordae tendineae attach to the inferior surface of the tricuspid and mitral valve cusps, enabling the valves to
open and close. The papillary muscles are in parallel alignment to the ventricular wall.
20
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mouth, and the beautiful broad brow drooping with the weight of
thought, and yet with an eternal youth and freshness shining out of it
as from the morning forehead of a boy, are all remarkable, and their
harmony with each other in a placid tenderness not less so.
Mr. Lowell, in illustration, read from the “Man of Law’s Tale,” and
other of the poems.
VI
Chaucer had been in his grave one hundred and fifty years before
England had secreted choice material enough to produce another
great poet. Or, perhaps, we take it for granted that Nature
understands her own business too well to make such productions
cheap. Beauty, we know, has no charm like that of its eternal
unexpectedness, and the best delight is that which blossoms from a
stem of bare and long days.
Or is it that the spirit of man, of every race of men, has its fatal ebbs
and floods, its oscillations between the fluid ideal and the solid
matter-of-fact, so that the doubtful line of shore between is in one
generation a hard sandy actuality, with only such resemblances of
beauty as a dead sea-moss here and there, and in the next is
whelmed with those graceful curves of ever-gaining, ever-receding
foam, and that dance of joyous spray which knows not, so bright is it,
whether it be sea or sunshine.
Before the “Faëry Queene,” also, two long poems were printed and
popular—the “Mirror for Magistrates,” and “Albion’s England.” How
the first of these was ever read it is hard to conceive, unless we
accept the theory of some theologians that our earth is only a kind of
penal colony where men are punished for sins committed in some
previous state of existence. The other was the work of one Warner, a
conveyancer, and has a certain philological value now from its
abounding in the popular phrases of the day. It is worth notice, also,
as containing the most perfect example in the English language of
what is called a conceit. It occurs in his account of Queen Elinor’s
treatment of Fair Rosamond:
Which is nonsense and not poetry, though Dr. Percy admired it. Dr.
Donne, and the poets whom Dr. Johnson called metaphysical (as if
all poets are not so), is thought to be full of conceits. But the essence
of a conceit is not in a comparison being far-fetched,—the
imagination can make fire and water friendly when it likes,—but in
playing upon the meanings of two words where one is taken in a
metaphorical sense. This is a mark of the superficial mind always;
whereas Donne’s may be called a subterficial one, which went down
to the roots of thought instead of playing with its blossoms.
Not long after the “Faëry Queene” were published the “Polyolbion” of
Drayton, and the “Civil Wars” of Daniel. Both of these men were
respectable poets (especially Drayton), but neither of them could
reconcile poetry with gazetteering or chronicle-making. They are as
unlike as a declaration in love and a declaration in law.
This was the period of the Saurians in English Poetry, interminable
poems, book after book and canto after canto, like far-stretching
vertebræ, prodigious creatures that rendered the earth unfit for the
dwelling of Man. They are all dead now, the unwieldy monsters—
ichthyo-, plesio-, and megalosauri—they all sleep well, and their
huge remains are found imbedded in those vast morasses, the
“Collections of the Poets.” We wonder at the length of face and
general atra-bilious look that mark the portraits of that generation;
but it is no marvel when even the poetry was such downright hard
work. Poems of this sort might have served to while away the three-
centuried evening of antediluvian lives. It is easy to understand how
our ancestors could achieve great things when they encountered
such hardships for mere amusement. If we agree with Horace in
pitying the pre-Homeric heroes because they were without poets, we
may sincerely commiserate our forefathers of that generation
because they had them. The reading of one of these productions
must have been nearly as long a business as the taking of Troy, and
deserved a poet to sing it. Perhaps fathers, when their time on earth
was up, folded the leaf down and left the task to be finished by their
sons—a dreary inheritance.
Spenser was the pure sense of the Beautiful put into a human body
only that it might have the means of communicating with men. His
own description of Clarion, the butterfly in his “Muiopotmos,” gives,
perhaps, the best possible idea of his own character.
What poet has ever left us such a portrait of himself as this? In that
butterfly Spenser has symbolized the purely poetical nature. It will be
seen that there is no recognition of the moral sense whatever. The
poetic nature considered abstractly craves only beauty and delight—
without any thought beyond—
But how did it happen that this lightsome creature, whose only
business was
should have attempted in his greatest work to mix together two such
incoherent things as sermon and poem? In the first place, the age
out of which a man is born is the mother of his mind, and imprints
her own likeness more or less clearly on the features of her child.
There are two destinies from which no one can escape, his own
idiosyncrasy, and that of the time in which he lives. Or shall we say
that where the brain is in flower of its conceptions, the very air is full
of thought-pollen, or some wandering bee will bring it, we know not
from what far field, to hybridize the fruit?
In Spenser’s time England was just going through the vinous stage
of that Puritanic fermentation which became acetous in Milton, and
putrefactive in the Fifth Monarchy men. Here was one motive. But,
besides this, it is evident that Spenser’s fancy had been colored by
the Romances which were popular in his day; and these had all been
allegorized by the monks, who turned them into prose. The
adventure of the San Grail in the “Morte d’Arthur” reads almost like
an extract from the “Pilgrim’s Progress.” Allegories were the fashion,
and Spenser put one on as he did a ruff, not because it was the most
convenient or becoming thing in the world, but because other people
did.
Spenser has characterized his own poem in the song which the
Sirens sing to Sir Guyon in the twelfth canto of the second book. The
whole passage also may be called his musical as distinguished from
his picturesque style.
In reading Spenser one may see all the great galleries of painting
without stepping over his threshold. Michael Angelo is the only artist
that he will not find there. It may be said of him that he is not a
narrative poet at all, that he tells no stories, but paints them.
I have said that among our poets Spenser stands for the
personification of the poetic sense and temperament. In him the
senses were so sublimed and etherealized, and sympathized so
harmoniously with an intellect of the subtlest quality that, with Dr.
Donne, we “could almost say his body thought.” This benign
introfusion of sense and spirit it is which gives his poetry the charm
of crystalline purity without loss of warmth. He is ideal without being
merely imaginative; he is sensuous without any suggestion of flesh
and blood. He is full of feeling, and yet of such a kind that we can
neither call it mere intellectual perception of what is fair and good
and touching, nor associate it with that throbbing warmth which leads
us to call sensibility by its human name of heart. In the world into
which he carries us there is neither space nor time, and so far it is
purely intellectual, but then it is full of form and color and all earthly
gorgeousness, and so far it is sensual. There are no men and
women in it, and yet it throngs with airy and immortal shapes that
have the likeness of men and women.
And to read him puts one in the condition of reverie—a state of mind
in which one’s thoughts and feelings float motionless as you may
see fishes do in a swift brook, only vibrating their fins enough to keep
themselves from being swept down the current, while their bodies
yield to all its curvings and quiver with the thrills of its fluid and
sinuous delight. It is a luxury beyond luxury itself, for it is not only
dreaming awake, but dreaming without the trouble of doing it
yourself; letting it be done for you, in truth, by the finest dreamer that
ever lived, who has the art of giving you all his own visions through
the medium of music.
VII
Between Spenser and Milton occurred the most truly imaginative
period of English poetry. It is the time of Shakspeare and of the other
dramatists only less than he. It seems to have been the moment in
which the English mind culminated.
It was during this lull, as we may call it, that followed the mighty day
of the Dramatists, that Milton was growing up. He was born in
London on the ninth of December, 1608, and was therefore in his
eighth year when Shakspeare died. His father was of a good family,
which still adhered to the Roman Catholic faith. What is of more
importance, he was disinherited by his father for having adopted
Puritan principles; and he was a excellent musician. Milton was very
early an indefatigable student, even in his twelfth year seldom
leaving his books before midnight. At the university he was
distinguished as a Latin scholar and writer of Latin verses. He was
intended for the Church, but had already formed opinions of his own
which put conformity out of the question. He was by nature an
Independent, and could not, as he says, “subscribe slave.”
Dr. Johnson sneers at Milton for having come home from Italy
because he could not stay abroad while his countrymen were
struggling for their freedom, and then quietly settling down as a
teacher of a few boys for bread. It might, with equal reason, have
been asked of the Doctor why, instead of writing “Taxation no
Tyranny,” he did not volunteer in the war against the rebel American
provinces? Milton sacrificed to the cause he thought holy something
dearer to him than life—the hope of an earthly immortality in a great
poem. He suffered his eyes to be put out for the sake of his country
as deliberately as Scævola thrust his hand into the flame. He gave to
freedom something better than a sword—words that were victories.