Critical Care Nursing Certification: Preparation, Review, and

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 PROGRESSIVE
CARE NURSING
CERTIFICATION
Preparation, Review, and Practice Exams
Second Edition

Alexander P. Johnson, MSN, RN, ACNP-BC, CCNS, CCRN

Clinical Nurse Specialist of Critical Care
Northwestern Medicine
Central DuPage Hospital
Winfield, Illinois

Hillary S. Crumlett, BSN, MS, RN, ANL

Director of Critical Care Services
Northwestern Medicine
Central DuPage Hospital
Winfield, Illinois

New York Chicago San Francisco Athens London Madrid

Mexico City Milan New Delhi Singapore Sydney Toronto

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 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

To Chuck, William, Henry, and Lily

You showed me an inspired world that has taught me that dreams can become reality.

To my parents, Maureen and Roger

For always believing in me more than I ever believed in myself, it has
meant everything.
Hillary S. Crumlett, BSN, MS, RN, ANL

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 Contents

Reviewers...............................................................................................................................................................................................................xi

Contributors.........................................................................................................................................................................................................xiii

Preface.................................................................................................................................................................................................................. xv

Acknowledgments ...............................................................................................................................................................................................xvii

Test-Taking Tips..................................................................................................................................................................................................xix

Part I. CARDIOVASCULAR..................................................................................................................................1
1. Cardiovascular Anatomy and Physiology.......................................................................................................................3
2. Diagnosis and Treatment of Cardiovascular Disorders.............................................................................................. 15
3. The Normal ECG.............................................................................................................................................................. 25
4. The 12-Lead ECG............................................................................................................................................................. 31
5. Hemodynamic Monitoring............................................................................................................................................. 43
6. Acute Coronary Syndrome (Angina Pectoris and Myocardial Infarction).............................................................. 53
7. Conduction Blocks.......................................................................................................................................................... 65
8. Heart Failure: Congestive Heart Failure, Pulmonary Edema, and Hypertensive Crisis........................................ 75
9. Cardiogenic Shock.......................................................................................................................................................... 85
10. Hemorrhagic (Hypovolemic) Shock............................................................................................................................. 89
11. Interpreting Dysrhythmias.............................................................................................................................................. 95
12. Cardiomyopathies and Pericarditis............................................................................................................................... 111
13. Treatment of Cardiac, Valvular, and Vascular Insufficiency and Trauma............................................................... 115
Cardiovascular Practice Exam..................................................................................................................................................... 127

Part II. PULMONARY................................................................................. 165

14. Pulmonary Anatomy and Physiology..........................................................................................................................167
15. Diagnosis and Treatment of Pulmonary Disorders...................................................................................................185
16. Alternative Methods of Ventilatory Support...............................................................................................................195
17. Acute Respiratory Dysfunction....................................................................................................................................205

vii

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 viii CONTENTS

18. Acute Pulmonary Embolism and Aspiration...............................................................................................................215

19. Thoracic Trauma and Air-Leak Syndromes................................................................................................................221
Pulmonary Practice Exam........................................................................................................................................................... 231

Part III. ENDOCRINE.................................................................................247

20. Introduction to the Endocrine System.......................................................................................................................249
21. Anatomy, Physiology, and Dysfunction of the Pituitary Gland................................................................................253
22. Anatomy, Physiology, and Dysfunction of the Thyroid and Parathyroid Glands.................................................259
23. Anatomy, Physiology, and Dysfunction of the Pancreas........................................................................................269
24. Anatomy, Physiology, and Dysfunction of the Adrenal Glands.............................................................................. 277
Endocrine Practice Exam............................................................................................................................................................. 285

Part IV. IMMUNOLOGY AND HEMATOLOGY............................................. 291

25. Physiology of the Immunologic and Hematologic Systems...................................................................................293
26. Diagnosis and Treatment of Immunologic and Hematologic Problems..............................................................309
27. Hematologic and Immunologic Failure and Its Effects on Other Organ Systems...............................................317
28. Organ Transplantation..................................................................................................................................................333
29. Life-Threatening Coagulopathies............................................................................................................................... 337
Immunology and Hematology Practice Exam.............................................................................................................................. 345

Part V. NEUROLOGY................................................................................. 351

30. Anatomy and Physiology of the Nervous System...................................................................................................353
31. Intracranial Pressure...................................................................................................................................................... 373
32. Acute Head Injuries and Craniotomies...................................................................................................................... 377
33. Stroke and Intracranial Aneurysms.............................................................................................................................385
34. The Vertebrae and Spinal Cord....................................................................................................................................391
35. Encephalopathies and Coma.......................................................................................................................................401
36. Meningitis, Muscular Dystrophy, and Myasthenia Gravis........................................................................................405
37. Seizures and Status Epilepticus..................................................................................................................................409
Neurology Practice Exam............................................................................................................................................................. 417

Part VI. GASTROENTEROLOGY................................................................ 431

38. Anatomy and Physiology of the Gastrointestinal System.......................................................................................433
39. Gastrointestinal Hemorrhage and Esophageal Varices..........................................................................................453
40. Acute and Chronic Hepatic Failure, Cirrhosis, Hepatitis, and Acute Pancreatitis...............................................463

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 CONTENTS ix

41. Intestinal Infarction, Obstruction, Perforation, and Trauma.................................................................................... 479

42. Management of the Patient with a Gastrointestinal Disturbance..........................................................................489
Gastroenterology Practice Exam................................................................................................................................................... 493

Part VII. RENAL.........................................................................................503

43. Anatomy and Physiology of the Renal System........................................................................................................505
44. Renal Regulation of Electrolytes..................................................................................................................................517
45. Diagnosis and Treatment of Kidney Injury................................................................................................................. 527
Renal Practice Exam.................................................................................................................................................................... 541

Part VIII. MULTIORGAN PROBLEMS......................................................... 551

46. Sepsis and Multiorgan Syndrome...............................................................................................................................553
47. Toxic Emergencies........................................................................................................................................................559
48. Airway Obstruction........................................................................................................................................................565
49. Burns................................................................................................................................................................................ 567
Multisystem Organ Dysfunction Practice Exam........................................................................................................................... 575

Part IX. PROFESSIONALISM, ETHICS, AND SYNERGY............................. 581

50. Professional Caring and Ethical Practice...................................................................................................................583
Synergy Practice Exam................................................................................................................................................................. 587

Part X. BEHAVIOR.....................................................................................597
51. Behavioral and Psychologic Factors in Progressive Care......................................................................................599
Behavior Practice Exam............................................................................................................................................................... 611

Index..................................................................................................................................................................................617

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 Reviewers

Thomas Ahrens, PhD RN FAAN Diane C. McLaughlin, DNP, RN, AGACNP-BC, CCRN
Chief Learning Officer-NovEx Acute Care Nurse Practitioner
St. Louis, Missouri Mayo Clinic Hospital
Jacksonville, Florida
Tonja M. Hartjes, DNP, ACNP-BC, CCRN-CSC, FAANP
University of Florida, College of Nursing Donna Prentice, RN, MSN(R), PhD(c), ACNS-BC,
Clinical Associate Professor and Track Coordinator CCRN, FCCM
Adult Gerontology Acute Care Nurse Practitioner program Clinical Nurse Specialist
University of Florida Health Hospital Barnes-Jewish Hospital
Gainesville, Florida St. Louis, Missouri

Alison M. Keck, MSN, APN, AGCNS-BC, CCRN Ashley N. Thompson, DNP, AGACNP-BC
Cardiac and Medical–Surgical Clinical Nurse Specialist Acute Care Nurse Practitioner
Northwestern Medicine-Central DuPage Hospital UF Health Surgical Critical Care Medicine
Winfield, Illinois University of Florida Health Hospital
Gainesville, Florida
Jennifer MacDermott, MS, RN, NP-C, ACNS-BC, CCRN
Critical Care Nurse Practitioner
Riverside Methodist Hospital-OhioHealth
Columbus, Ohio

xi

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 Contributors

Anne C. Lindstrom, MS, RN, FNP-BC, SCRN Donna Schweitzer, APN, CCNS, CCRN
Stroke Program Manager Critical Care Clinical Nurse Specialist
Northwestern Medicine Central DuPage Hospital Advocate BroMenn Medical Center
Winfield, Illinois Normal, Illinois
Northwestern Medicine Delnor Hospital Chapter 14: Pulmonary Anatomy and Physiology
Geneva, Illinois Chapter 15: Diagnosis and Treatment of Pulmonary Disorders
Chapter 30: Anatomy and Physiology of the Nervous System Chapter 16: Alternative Methods of Ventilatory Support
Chapter 31: Intracranial Pressure Chapter 17: Acute Respiratory Dysfunction
Chapter 32: Acute Head Injuries and Craniotomies Chapter 18: Acute Pulmonary Embolism and Aspiration
Chapter 33: Stroke and Intracranial Aneurysms Chapter 19: Thoracic Trauma and Air-Leak Syndromes
Chapter 34: The Vertebrae and Spinal Cord Chapter 20: Introduction to the Endocrine System
Chapter 35: Encephalopathies and Coma Chapter 21: Anatomy, Physiology, and Dysfunction of the
Chapter 36: Meningitis, Muscular Dystrophy, and Pituitary Gland
Myasthenia Gravis Chapter 22: Anatomy, Physiology, and Dysfunction of the
Chapter 37: Seizures and Status Epilepticus Thyroid and Parathyroid Glands
Chapter 23: Anatomy, Physiology, and Dysfunction of the
Kelly A. Thompson-Brazill, DNP, ACNP-BC, RN, Pancreas
CCRN-CSC, PCCN, FCCM Chapter 24: Anatomy, Physiology, and Dysfunction of the
Nurse Practitioner, Cardiothoracic Surgery, Adrenal Glands
Wake Med Heart & Vascular Physicians Chapter 43: Anatomy and Physiology of the Renal System
Raleigh, North Carolina Chapter 44: Renal Regulation of Electrolytes
Chapter 1: Cardiovascular Anatomy and Physiology Chapter 45: Diagnosis and Treatment of Kidney Injury
Chapter 3: The Normal ECG
Chapter 5: Hemodynamic Monitoring Robin R. Gutmann, MSN, RN, PMHCNS-BC
Chapter 7: Conduction Blocks Adult Psychiatric and Mental Health Clinical Nurse
Chapter 9: Cardiogenic Shock Specialist
Chapter 11: Interpreting Dysrhythmias Adjunct Faculty Goldfarb School of Nursing
Chapter 13: Treatment of Cardiac, Valvular, and Vascular Saint Louis, Missouri
Insufficiency, and Trauma Chapter 51: Behavioral and Psychologic Factors in
Chapter 38: Anatomy and Physiology of the Gastrointestinal Progressive Care
System
Chapter 39: Gastrointestinal Hemorrhage and Esophageal Laura M. Berryman, MSN, ACNS, RN-BC, CEN
Varices Clinical Nurse Specialist
Chapter 40: Acute and Chronic Hepatic Failure, Cirrhosis, Parkland Hospital, Dallas, Texas
Hepatitis, and Acute Pancreatitis Chapter 51: Behavioral and Psychologic Factors
Chapter 41: Intestinal Infarction, Obstruction, Perforation, in Progressive Care
and Trauma
Chapter 42: Management of the Patient with a
Gastrointestinal Disturbance

xiii

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 Preface

In this edition of Progressive Care Nursing Certification: The PCCN exam generally reflects what you see every
Preparation, Review, and Practice Exams, we have updated day in your practice. A focus is placed on the 80/20 rule,
the content in light of the latest changes to the PCCN and unusually encountered concepts and conditions are not
exam. However, we have honored the vision and format of emphasized on the exam. The content of the exam is some-
previous editions: We hope that this edition may also serve thing that you will generally see in your practice. In fact, one
as a comprehensive progressive care reference text (using of the best ways to study for the exam is to use the informa-
short, easy to read chapters) as well as a certification prepa- tion in this book in your clinical practice.
ration book. In this edition, in the “Editor’s Note” section, Best of luck on the exam. Passing the exam is a major
we have provided some general test-taking strategies at the milestone in your career and helps validate your knowledge
beginning of each chapter, as well as an estimated amount and commitment to your patients and your practice. To
of questions that you will be likely to see from that chap- paraphrase a famous quote, “We are not telling you it will be
ter on the exam. Another new addition to this edition has easy, but we can tell you it is going to be worth it.”
been answer rationales for each review question that help
Alexander Johnson, RN, MSN,
provide and reinforce test-taking information, tactics, and
ACNP-BC, CCNS, CCRN
techniques that are designed to increase success on future
Hillary Crumlett, BSN, MS, RN, ANL
exam questions.

xv

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 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.

xvii

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 Test-Taking Tips

The following are some general test-taking tips. Follow them mind that in 2017, the first time pass rate of the “PCCN”
as you prepare for the examinations in this text and on the was 73.1%, which is very strong.
“PCCN” examination. They can make the difference in 7. Achieving approximately 70% or greater on the practice
several points on the examination. examinations is often a very strong sign of readiness and
1. Answer all questions. Unanswered questions are counted adequate preparedness for the examination. Similarly, a
as incorrect. Use your knowledge to rule out incorrect raw score of 68 out of 100 (68%) is what is required to
answers whenever in doubt. pass the examination. So again, do not be discouraged by
questions that may seem challenging.
2. Be well rested before the examination. Get a good night’s
sleep before the examination. Do not try to “cram” on In addition, general practice trends in progressive care
the morning of the test: You may confuse yourself if you nursing are reflected on the exam. However, more focused
study right before the test. information that only reflects regional or institutional trends
3. Have a good but light breakfast. You will be taking the are not covered, such as the technical specifications of an
test for perhaps two and a half hours (the exam is 125 esophageal Doppler monitor or stop-cock functionality.
total questions [100 are scored] to be answered within Remain mindful of this when considering “obscure” questions
the two and half hour time frame). Eat food that is not to anticipate.
all carbohydrates so that you can make it through the 1. Do not let the fact that other people finish early (or that
examination without becoming hungry or getting a you finish before others) disturb you. People work at dif-
headache. ferent rates without necessarily a difference in results.
4. Do not change answers unless you are absolutely sure. 2. If you feel thirsty or need to go to the restroom, ask per-
Many first impressions are accurate. mission from the monitor. Always try to maintain your
5. Mark on a piece of scrap paper the questions that are physiological status at optimal levels. An aspirin (or simi-
difficult. Then go back and review the difficult questions. lar analgesic) may be in order if a headache develops dur-
Do not be discouraged if there are many hard questions. ing the test.
6. Do not expect to answer all questions correctly. If you 3. Do not try to establish patterns in how the items are
do not know the answer to a question, make an educated written (eg, “Two B’s have occurred, now some other
guess and go on. Do not let it bother you that you missed choice is likely”). The AACN Certification Corporation
a few questions. You will not have a good perception of has excellent test-writing mechanisms. Patterns in test
how you did until you get the results. However, bear in answers, if they occur, are coincidental.

xix

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 I
CARDIOVASCULAR

Kelly A. Thompson-Brazill
Alexander P. Johnson

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 1
Cardiovascular Anatomy
and Physiology

EDITORS’ NOTE edge of the sternum, whereas the lower right point of the
triangle represents the apex of the heart. The apex is usu-
ally at the left midclavicular line at the fifth intercostal
Although basic anatomy is not commonly addressed in space. The average adult heart is about 5 in. long and
the Progressive Care Certified Nurse (PCCN) exam, an 3½ in. wide, which is about the size of an average man’s
understanding of the principles of anatomy may help your clenched fist. The heart weighs about 2 g for each pound
perception of more specific questions regarding cardiovas- of ideal body weight.
cular 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 NORMAL ANATOMY OF THE HEART
also addresses background information on cardiovascular
concepts sometimes found on the PCCN exam. If you do not The heart is supported by a fibrous skeleton (Fig. 1-2)
have a strong background in anatomy and physiology, study composed of dense connective tissue. This skeleton con-
this section closely. You may want to review the cardiovascu- nects the four valve rings (annuli) of the heart: the tricus-
lar sections of physiology textbooks as well. pid, mitral, pulmonic, and aortic valves. Attached to the
The PCCN exam places most emphasis on the cardio- superior (top) surface of this skeleton are the right and
vascular component, with approximately 33% of the test left atria, the pulmonary artery, and the aorta. Attached
questions being in this content area. While many nurses to the inferior (lower) surface of the skeleton are the right
are relatively strong in cardiovascular concepts, do not take and left ventricles, and the mitral and tricuspid valve
this part of the exam lightly. The better you perform in any cusps.
one area, the greater your chances of overall success on the The heart can be studied as two parallel pumps:
exam. 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 the atria
through a one-way valve into the ventricles. From each
NORMAL LOCATION AND SIZE ventricle, blood is ejected into a circulatory system. The
OF THE HEART right ventricle ejects blood into the pulmonary circula-
tion, while the left ventricle ejects blood into the systemic
The heart lies in the mediastinum, above the diaphragm, circulation. Although there are differences between the
surrounded on both sides by the lungs. If one looks at right and left sides of the heart, the gross anatomy of
a frontal (anterior) view, the heart resembles a triangle each side is similar. Structural features of each chamber
(Fig. 1-1). The base of the heart is parallel to the right are discussed below.

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