PCCN cardiovascular review: the heaviest 20% of the exam
Cardiovascular is the heaviest single area on the PCCN: 20% of the exam, about 25 of the 125 scored questions. Most of those points sit in acute coronary syndromes, heart failure and dysrhythmias, so study those three before anything else here. The whole exam is Clinical Judgment 80% and Professional Caring and Ethical Practice 20%, and the pass line is 82 of the 125 scored questions.
The American Association of Critical-Care Nurses test plan for exams taken on or after February 6, 2024 puts cardiovascular inside Clinical Judgment at 20%, the largest of the 12 test-plan areas. Under it sits a long list of conditions, and AACN gives no count per condition. The ranking below is ours: it follows how often a topic drives a priority or pattern-recognition question in AACN's published sample items and in our own bank.
Cardiovascular topics in the current test plan, ranked by our estimate of yield
Topic names are paraphrased from AACN's test plan. AACN publishes area weights only; the yield column is our judgment, not an item count.
The devices are progressive care devices: arterial lines, CVP, noninvasive hemodynamics, femoral and radial sheaths, temporary and permanent pacemakers including biventricular ones, cardioversion, ablation, pericardial drains and ventricular assist devices. Any of them can be the setting of a question, so know what a complication of each looks like at the bedside.
Triage
Rank the topics before you study them
1First
ACS, heart failure, dysrhythmias and cardiogenic shock. They are what a step-down nurse gets called to most, and they leak into multisystem (15%) and renal (4%) questions through shock, potassium and contrast. Work them until you can name the first action without looking.
2Next
Tamponade and the inflammatory three (pericarditis, myocarditis, endocarditis), hypertensive crisis and dissection, and care after cath and CABG. Each is a pattern: learn the three or four findings that give it away and the one action that comes first.
3Last
Cardiomyopathy subtypes, structural procedures, murmurs, PAD and carotid disease. One defining fact each is enough. Reread the table above in the final week and let them go.
A fifth of the exam, and the same patterns come back in shock and renal questions.
ACS
ACS: tell the three apart, then act
Acute coronary syndromes side by side
Type
ECG
Troponin
What the exam wants
Unstable angina
No ST elevation; ST depression or T-wave inversion, or a normal tracing
Not elevated
Antiplatelet and anticoagulant therapy, serial ECGs and troponins, risk stratification
NSTEMI
No persistent ST elevation; ST depression or T-wave inversion common
Rises
The same drugs, plus an invasive strategy timed by risk
STEMI
ST elevation in two or more contiguous leads
Rises, but reperfusion never waits for it
Primary PCI with a door-to-balloon goal of 90 minutes, or a fibrinolytic within 30 minutes when PCI cannot happen within 120
Oxygen goes on only when SpO2 is below 90%. An answer that puts oxygen on a chest-pain patient saturating 96% on room air is the old MONA reflex, and current ACC/AHA guidance dropped it. Chewed aspirin comes early in almost every ACS vignette unless the stem gives a reason it cannot. For the second antiplatelet, ticagrelor or prasugrel is preferred over clopidogrel, and prasugrel is out after a stroke or TIA. An oral beta-blocker starts within 24 hours unless there are signs of heart failure, low output or shock.
After PCI, the step-down questions move to the access site: bleeding, hematoma, and pulses, color and warmth below it. Back or flank pain with a falling blood pressure after femoral access is a retroperitoneal bleed until proven otherwise.
HF
Heart failure: the drugs and what you watch
HFrEF questions test guideline-directed medical therapy and, more often, the monitoring that comes with it. Current AHA/ACC/HFSA guidance builds therapy on four drug classes; the loop diuretic treats the congestion on top of them.
Heart failure drugs and the bedside monitoring each one brings
Blood pressure, potassium, creatinine, angioedema; 36 hours off an ACE inhibitor before an ARNI starts
Beta-blocker
carvedilol, metoprolol succinate, bisoprolol
Heart rate and blood pressure; not started while the patient is decompensated
Mineralocorticoid antagonist
spironolactone, eplerenone
Potassium and creatinine
SGLT2 inhibitor
dapagliflozin, empagliflozin
Volume status, genital infection, ketoacidosis with near-normal glucose; held before planned surgery
Loop diuretic
furosemide, bumetanide
Daily weight, intake and output, potassium, magnesium, creatinine
Metoprolol tartrate is not the heart failure beta-blocker; the succinate is. Diltiazem and verapamil are avoided in HFrEF. In acute decompensation the move is an IV loop diuretic at or above the home oral dose, and the guideline drugs continue unless the patient is hypotensive, in shock or hyperkalemic. Discharge teaching is a daily weight, with a call for a gain of 2 to 3 pounds in a day or 5 in a week.
Rhythms
Dysrhythmias on a step-down unit
Every rhythm question opens the same fork: does the patient have a pulse, and are they stable? Look at the patient before the monitor; a flat line on a patient who is talking to you is a lead off.
Dysrhythmia priorities for a monitored step-down patient
Rhythm
Pulse, stable
Unstable or pulseless
Atrial fibrillation with rapid response
Rate control: a beta-blocker, or diltiazem or verapamil only if EF is 40% or higher. Anticoagulate by stroke risk, a DOAC over warfarin unless there is a mechanical valve or moderate-to-severe mitral stenosis
Synchronized cardioversion
Regular narrow-complex tachycardia (SVT)
Vagal maneuvers, then adenosine by rapid IV push
Synchronized cardioversion
Monomorphic VT with a pulse
An antiarrhythmic infusion such as amiodarone or procainamide
Synchronized cardioversion
Polymorphic VT, torsades
IV magnesium; stop QT-prolonging drugs; correct potassium and magnesium
Defibrillation, not synchronized
Symptomatic bradycardia
Find the cause: drugs, ischemia, electrolytes
Atropine 1 mg every 3 to 5 minutes up to 3 mg, then transcutaneous pacing or a dopamine or epinephrine infusion
Pulseless VT or VF
None: there is no stable version
CPR and defibrillation; epinephrine 1 mg every 3 to 5 minutes; amiodarone for a shock-refractory rhythm
Electrolytes are the hidden half of rhythm questions. Hyperkalemia with peaked T waves gets IV calcium first, and a low potassium or magnesium sits behind a lot of ectopy and torsades.
Patterns
The pattern topics, one line each
Medium-yield cardiac patterns in one line each
Condition
What gives it away
What comes first
Tamponade
Hypotension, JVD, muffled heart sounds, pulsus paradoxus; after cardiac surgery, chest tube drainage that suddenly stops while the CVP climbs
Call it early; pericardiocentesis or return to surgery
Pericarditis
Sharp pain that eases sitting up and leaning forward, a friction rub, diffuse ST elevation
NSAID or aspirin plus colchicine; after an MI, aspirin; watch for effusion
Hypertensive emergency
Very high pressure with new organ damage: chest pain, neuro change, kidney injury
Lower the pressure by no more than 25% in the first hour, then toward 160/100 over the next 2 to 6 hours
Aortic dissection
Tearing chest or back pain, a pressure difference between the arms
Beta-blocker first (esmolol, labetalol): heart rate below 60, systolic below 120 mm Hg
PAD versus venous disease
Arterial: pain on walking, pallor on elevation, cool limb, weak pulses. Venous: edema, brown discoloration, aching
Know which is which; a cold, pulseless limb is an emergency
Test
12 PCCN cardiac questions
Twelve items from area 1A, written to the current test plan: tamponade, cardiogenic shock, heart failure, inflammatory heart disease, aneurysm, cardiac surgery and angina, plus two bedside calculations. They are practice items, not exam questions. When you finish, the 60-question practice test mixes cardiovascular with the other 11 areas at exam weight.
Item 1 of 12
0 answered · 0 right
Item 01 Cardiovascular (1A)
A hypotensive patient with a narrowing pulse pressure has arterial line systolic pressures of 116 mm Hg on expiration and 98 mm Hg on inspiration. This finding is BEST interpreted as
Tick one box. The rationale is written here once you answer.
Right.Not the keyed answer.
Keyed answer, C: an exaggerated inspiratory fall suggesting tamponade
An inspiratory fall in systolic pressure greater than 10 mm Hg (here 18 mm Hg) is pulsus paradoxus, which with narrowing pulse pressure strongly suggests tamponade. Normal variation is under 10 mm Hg. Overdamping blunts the whole waveform rather than producing a respiratory pattern, and pulsus alternans is beat-to-beat alternation unrelated to respiration.
Your pick, A: Normal respiratory variation in systolic pressure is less than 10 mm Hg.
Your pick, B: Pulsus alternans alternates beat to beat and is not tied to inspiration.
Your pick, D: Overdamping blunts the whole waveform; it does not create a breathing-linked drop.
Item 02 Cardiovascular (1A)
A patient with ischemic cardiomyopathy has an EF of 30% after 3 months of optimal GDMT and NYHA class II symptoms. Which device is recommended to prevent sudden cardiac death?
Tick one box. The rationale is written here once you answer.
Right.Not the keyed answer.
Keyed answer, B: an implantable defibrillator
An ICD is indicated for primary prevention in patients with EF of 35% or less and NYHA class II–III symptoms despite at least 3 months of GDMT, because it terminates lethal ventricular dysrhythmias. A pacemaker treats bradycardia, and loop recorders and Holter monitors only record rhythms without treating them.
Your pick, A: A loop recorder only records rhythms; it cannot treat them.
Your pick, C: A Holter monitor records rhythms for a short time and gives no protection.
Your pick, D: A pacemaker treats bradycardia and cannot stop VT or VF.
Item 03 Cardiovascular (1A)
A patient in cardiogenic shock has BP 90/60, CVP 22 mm Hg, marked JVD, bilateral crackles, and urine output 10 mL/h. The oliguria is MOST LIKELY due to
Tick one box. The rationale is written here once you answer.
A high CVP with JVD and crackles indicates venous congestion, which raises renal venous pressure and lowers the renal perfusion gradient (MAP minus CVP) in a low-output state. Hypovolemia is contradicted by CVP 22 and JVD. Retention and contrast-induced injury are not suggested by the findings described.
Your pick, A: A CVP of 22 and marked JVD rule out hypovolemia.
Your pick, B: Nothing in the findings points to bladder outlet obstruction.
Your pick, C: No contrast exposure is described, and congestion explains the oliguria better.
Item 04 Cardiovascular (1A)
A patient with cardiogenic shock has ABG pH 7.24, PaCO2 32 mm Hg, HCO3 14 mEq/L, and lactate 6.1 mmol/L. The nurse understands the PRIMARY cause of the acidosis is
Tick one box. The rationale is written here once you answer.
Right.Not the keyed answer.
Keyed answer, A: anaerobic metabolism from hypoperfusion
A low bicarbonate with elevated lactate indicates lactic acidosis from anaerobic metabolism due to inadequate tissue perfusion. The low PaCO2 excludes hypoventilation, there is no history of diarrhea, and loop diuretics cause metabolic alkalosis rather than acidosis.
Your pick, B: Loop diuretics cause metabolic alkalosis, not acidosis.
Your pick, C: The PaCO2 is low at 32, so the patient is hyperventilating to compensate, not hypoventilating.
Your pick, D: There is no history of diarrhea to explain bicarbonate loss.
Item 05 Cardiovascular (1A)
A patient with a prosthetic mitral valve has fever for 5 days, a new regurgitant murmur, and splinter hemorrhages. Which diagnostic step is the PRIORITY before antibiotics are started?
Tick one box. The rationale is written here once you answer.
Right.Not the keyed answer.
Keyed answer, A: obtaining three sets of blood cultures
Suspected endocarditis requires at least three sets of blood cultures from separate venipunctures before antibiotics, because the organism guides months of therapy. Transesophageal echocardiography confirms vegetations but should not delay cultures and antibiotics, and urine cultures and the INR do not identify the causative organism.
Your pick, B: A urine culture does not identify the organism infecting the valve.
Your pick, C: The INR matters for anticoagulation but does not come before cultures.
Your pick, D: A TEE confirms vegetations but should not delay cultures and antibiotics.
Item 06 Cardiovascular (1A)
A 24-year-old athlete is being discharged after viral myocarditis. EF has improved from 40% to 50%. Which instruction should the nurse include?
Tick one box. The rationale is written here once you answer.
Right.Not the keyed answer.
Keyed answer, D: Avoid competitive sports for 3 to 6 months
Exercise during active or recovering myocarditis increases the risk of arrhythmias and sudden death, so competitive sports are avoided for at least 3–6 months, with return guided by repeat testing. NSAIDs are discouraged in myocarditis without pericardial involvement because they may worsen myocardial injury. Follow-up imaging and rhythm monitoring are needed even after troponin normalizes.
Your pick, A: Follow-up imaging and rhythm checks are still needed after the troponin normalizes.
Your pick, B: NSAIDs are discouraged in myocarditis because they may worsen myocardial injury.
Your pick, C: One week is far too early to resume full training after myocarditis.
Item 07 Cardiovascular (1A)
A patient with a 4.8 cm abdominal aortic aneurysm is being followed with imaging. Which symptom should the nurse teach the patient to report IMMEDIATELY?
Tick one box. The rationale is written here once you answer.
Right.Not the keyed answer.
Keyed answer, C: Sudden abdominal, back, or flank pain
New or sudden abdominal, back, or flank pain can signal rapid expansion or rupture, which is fatal without emergency repair. Calf cramps with walking suggest claudication from peripheral artery disease, which needs evaluation but is not an emergency. Dependent ankle swelling and heartburn are not signs of aneurysm expansion.
Your pick, A: Dependent ankle swelling at the end of the day is not a sign of aneurysm expansion.
Your pick, B: Heartburn after large meals is not related to the aneurysm.
Your pick, D: Calf cramps with walking suggest claudication from PAD, which needs follow-up but is not an emergency.
Item 08 Cardiovascular (1A)
A patient with multivessel coronary disease who takes aspirin and ticagrelor is scheduled for elective CABG in 1 week. Which medication plan should the nurse anticipate?
Tick one box. The rationale is written here once you answer.
Right.Not the keyed answer.
Keyed answer, D: Continue aspirin through the day of surgery
Aspirin is continued before CABG because it reduces perioperative ischemic events and graft occlusion with little added bleeding. P2Y12 inhibitors cause significant surgical bleeding, so ticagrelor is stopped several days before elective CABG (clopidogrel about 5 days, prasugrel 7). Stopping ticagrelor only the morning of surgery or continuing it leaves full platelet inhibition in the operating room.
Your pick, A: Stopping ticagrelor on the day of surgery is too late; it should stop several days before.
Your pick, B: Stopping aspirin removes its protection against perioperative ischemia.
Your pick, C: Continuing ticagrelor to surgery leaves full platelet inhibition in the operating room.
Item 09 Cardiovascular (1A)
A patient with chronic stable angina is prescribed a nitroglycerin transdermal patch. Which instruction should the nurse give?
Tick one box. The rationale is written here once you answer.
Right.Not the keyed answer.
Keyed answer, B: Remove the patch for 10–12 hours each day
Continuous nitrate exposure causes tolerance within a day or two, so a daily nitrate-free interval of 10–12 hours, usually overnight, keeps the drug effective. Cutting a patch alters its release and dose. Leaving the old patch on while applying a new one doubles the dose and can cause hypotension, and headaches usually lessen with continued use.
Your pick, A: Continuous wear for 24 hours leads to nitrate tolerance within a day or two.
Your pick, C: Cutting a patch changes how the drug is released; headaches usually ease with continued use.
Your pick, D: Leaving the old patch on doubles the dose and can cause hypotension.
Item 10 Cardiovascular (1A)
A patient with HFrEF on empagliflozin has nausea and vomiting 2 days after surgery. Glucose 182 mg/dL, pH 7.21, HCO3 12 mEq/L, and serum beta-hydroxybutyrate is elevated. The MOST LIKELY diagnosis is
Tick one box. The rationale is written here once you answer.
Right.Not the keyed answer.
Keyed answer, B: euglycemic diabetic ketoacidosis
SGLT2 inhibitors can cause ketoacidosis with near-normal glucose, especially after surgery or poor intake; elevated ketones with an anion-gap acidosis confirm it, which is why these drugs are held before surgery. Lactic acidosis would not raise beta-hydroxybutyrate, HHS requires glucose of 600 mg/dL or more without significant acidosis, and no contrast exposure is described.
Your pick, A: No contrast exposure is described, and kidney injury would not explain the ketones.
Your pick, C: HHS needs a glucose of 600 mg/dL or more without significant acidosis.
Your pick, D: Lactic acidosis does not raise beta-hydroxybutyrate.
Item 11 Cardiovascular (1A)
A 92 kg patient with NSTEMI is prescribed enoxaparin 1 mg/kg subcutaneously every 12 hours. The calculated creatinine clearance is 24 mL/min. Which dose is appropriate?
Tick one box. The rationale is written here once you answer.
Right.Not the keyed answer.
Keyed answer, A: 92 mg once daily
Enoxaparin is renally cleared, so when creatinine clearance is below 30 mL/min the therapeutic dose stays at 1 mg/kg but the interval is extended to once every 24 hours. Continuing every 12 hours causes accumulation and bleeding, and halving the dose while keeping twice-daily dosing does not match the labeled adjustment. The 1.5 mg/kg once-daily regimen is for venous thromboembolism with normal renal function.
Your pick, B: Keeping the 12-hour interval with poor renal clearance causes accumulation and bleeding.
Your pick, C: 138 mg is 1.5 mg/kg, a once-daily VTE regimen used with normal renal function.
Your pick, D: Halving the dose and keeping twice-daily dosing is not the labeled renal adjustment.
Item 12 Cardiovascular (1A)
A patient on a furosemide infusion has a urine output of 250 mL/h with a urine potassium of 40 mEq/L. How much potassium is being lost each hour?
Tick one box. The rationale is written here once you answer.
Right.Not the keyed answer.
Keyed answer, C: 10 mEq/h
Hourly potassium loss equals urine volume in liters times concentration: 0.25 L × 40 mEq/L = 10 mEq/h, which explains rapidly falling serum levels during brisk diuresis. A value of 40 mEq/h uses the concentration as the loss, 100 mEq/h misplaces the decimal, and 6.25 mEq/h divides instead of multiplying.
Your pick, A: 6.25 mEq/h comes from dividing the volume by the concentration instead of multiplying.
Your pick, B: 40 mEq/h treats the concentration as if it were the hourly loss.
Your pick, D: 100 mEq/h is a tenfold decimal error.
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.
Traps
The traps behind those questions
Traps built into the 12 items above, paraphrased from their rationales
The tempting answer
Why it loses
What wins
A fluid bolus for low urine output in cardiogenic shock
A high CVP with JVD and crackles is congestion: the kidney is under-perfused because venous pressure is high, not because the tank is empty
Read the CVP and the lungs before any bolus
Calling an inspiratory drop in arterial pressure a damped line
A systolic fall of more than 10 mm Hg on inspiration is pulsus paradoxus; with a narrowing pulse pressure it points to tamponade
Match the whole picture, not one number
Hypoventilation as the cause of a low pH in shock
A low PaCO2 is compensation; low bicarbonate with a high lactate is hypoperfusion
Name the primary process, then the compensation
Imaging before cultures in suspected endocarditis
The organism steers weeks of antibiotics; a TEE confirms vegetations but can wait
Three sets of blood cultures from separate sites before the first dose
A normal-looking glucose ruling out DKA
SGLT2 inhibitors can cause ketoacidosis with near-normal glucose, above all after surgery or poor intake
Check pH, anion gap and ketones in a vomiting SGLT2 patient
Stopping aspirin before CABG
Aspirin protects the grafts at little bleeding cost; the P2Y12 inhibitor is what bleeds
Continue aspirin; stop ticagrelor or clopidogrel several days ahead, prasugrel longer
A nitrate patch worn around the clock
Continuous exposure builds tolerance within a day or two
A nitrate-free interval of 10 to 12 hours a day, usually overnight
Twice-daily enoxaparin with poor kidneys
It is renally cleared and accumulates when creatinine clearance is below 30 mL/min
The same mg/kg dose, once every 24 hours
Low yield
What not to over-study
Also low yield: grading every murmur, memorizing every cardiomyopathy drug, and 12-lead localization beyond the basics. Know that inferior changes raise the right ventricle question, that takotsubo follows a physical or emotional stressor and usually recovers, and that a hypertrophic heart hates dehydration and nitrates. That covers most of what the lower-yield rows can ask.
Where the CCRN picks up
CCRN patients are critically ill and unstable; typically 1 nurse to 1 or 2 patients; that is where the PA catheter and the titration belong. If your shifts are mostly that, read PCCN vs CCRN, side by side before you book.
Summary
Before you move on
End-of-shift summary
Cardiovascular is 20% of the PCCN, about 25 scored items. Study it first.
ACS, heart failure, dysrhythmias and cardiogenic shock carry most of it.
Oxygen only below 90%; no nitrates in a right ventricular infarct, after a recent PDE-5 inhibitor or with a systolic pressure below 90.
In heart failure, the question is often a lab: potassium, creatinine, ketones.
Adenosine only for regular rhythms; 48 hours of AF means anticoagulation or a TEE before cardioversion.
Skip PA catheter numbers, balloon pumps and drip titration.
Next by weight: multisystem (15%), whose guide is still being written, so drill its chip in the practice test; then the respiratory guide (14%). The PCCN study guide lays out all seven domains, and the exam format page covers timing and scoring.
FAQ
Questions nurses ask
How many cardiovascular questions are on the PCCN?
About 25. Cardiovascular is weighted at 20% and the exam has 125 scored questions, so 20% of 125 gives roughly 25. It is an approximation: AACN publishes area weights, not item counts per topic.
What cardiac topics are on the PCCN exam?
Acute coronary syndromes, heart failure, dysrhythmias and cardiogenic shock carry the most weight. The test plan also lists tamponade, pericarditis, myocarditis, endocarditis, hypertensive crisis, aneurysm and dissection, cath and PCI, cardiac surgery, structural and valve disease, cardiomyopathies and vascular disease.
Does the PCCN show ECG strips?
AACN's published sample items are text only: rhythms and ECG changes are described in words. Learn what each description means for the patient and what you do first, rather than drilling strip measurements.
Are vasoactive drips and PA catheters on the PCCN?
Not as core skills under the current test plan. Know why norepinephrine is the first vasopressor in cardiogenic shock and move on; wedge pressures and titration tables belong to critical care.
Are these real PCCN cardiac questions?
No. They are original practice items written to the current test plan and checked against current guidance. Exam questions are confidential.
Next
Cardiac first, then the rest of the exam
Run the full practice test next: it weights cardiovascular like the exam and its score sheet names the system that is costing you the most points.