*Original post released 9/3/2020
Now that you’ve read part 1 of our CCRN prep article series, we’ll move on to discuss the test plan. As we discuss the test plan, I’ll touch on some of the major points I would make sure to know prior to heading into test day. Then at the end, I’ll be providing a downloadable document that contains an 8-week sample study plan for the exam. The three hour CCRN certification exam contains a total of 150 questions, 25 of which don’t count towards your overall score. You’ll need a minimum 83/125 to pass the exam…that’s only 66.4% which is COMPLETELY doable! Now let’s move on to break down the percentage of questions covered on the exam by content section.
Of the 150 questions included on the exam, 80% will be based on clinical judgment and the remaining 20% will focus on professional caring and ethical practice. For the latter portion, the caring and ethics, I’d take a look at pages 10, 11, and 14 of the CCRN handbook to help guide you in your decision making. As for the remaining 80% of the questions in the clinical judgement section, we’ll be breaking it down into cardiovascular, respiratory, endocrine/hematology/GI/renal/Integumentary, Musculoskeletal/Neuro/Psych, and multisystem as the test plan does. So, without further ado, let’s dive in!
There are 19 different cardiovascular topics covered on the CCRN test plan for which you are held accountable for knowing and may be tested over. Some major examples include acute coronary syndrome (ACS), dysrhythmias, cardiac tamponade, cardiogenic shock, cardiomyopathies, heart failure, and hypertensive crisis. At a bare minimum for this section, I would have a solid grasp on hemodynamic monitoring and how different states of shock affect hemodynamic parameters. Be able to identify common dysrhythmias and understand the appropriate nursing and ACLS interventions applicable to each scenario. Keep in mind that the patient’s level of stability may determine how you proceed with treating their dysrhythmia.
Take ample time to learn and understand how to interpret 12-lead ECGs to identify myocardial ischemia, infarction, and necrosis. You’ll want to be sure you understand how to identify the potential location (RCA, LAD, circumflex, posterior) of the ishemia/infarction, signs and symptoms associated with each location, and which potential complications to be monitoring for. Narrow down specific contraindications for each type as well; for example, you wouldn’t want to give morphine or nitroglycerin to a patient who has an RCA occlusion with right ventricular infarction as these patients are pre-load dependent and at high risk for right sided heart failure. Along with this also comes the understanding of the different types of ACS (angina, NSTEMI, STEMI), their assessment criteria, and the interventions required of each. Know what happens during a percutaneous coronary intervention as well as what is expected of the nurse for pre and post cath lab care.
It is highly possible that you’ll get a question about heart murmurs, so developing a solid foundation in cardiac A&P is crucial. Then you’ll need to know which valves close during diastole, and which close during systole. In cases of regurgitation, you’ll hear the murmur when the valve is closed. In cases of stenosis, you’ll hear the murmur when the valve is open. Be sure to study up on contraindications associated with each major valvular disorder (Ex: intra-aortic balloon pump therapy is contraindicated in those with aortic regurgitation and/or aortic dissection). This is why obtaining a thorough medical history is crucial whenever possible, as it can be the difference between life and death for your patient at times.
There are 14 different respiratory topics covered on the CCRN test plan for which you are held accountable for knowing and may be tested over. Some major examples include acute respiratory distress syndrome (ARDS), pulmonary embolus (PE), asthma, COPD, mechanical ventilation, etc. For this section of the exam, you’ll want to make sure you know how to interpret arterial blood gases like the back of your hand and understand the necessary interventions for abnormal/critical results.
It is incredibly important to understand the different methods to increase a patient’s oxygenation and/or provide mechanical ventilation. These methods can include nasal cannula (NC), high-flow NC, positive pressure non-invasive ventilation via BiPAP or CPAP, mechanical ventilation. Also, take into consideration the use of nitric oxide and prone positioning for ARDS patients. For ventilated patients, it’s imperative to know nursing interventions to prevent ventilator-associated events (VAEs) as well as how to perform sedation vacations and ventilatory weaning. The goal is to limit the number of ventilator days as much as possible. Tracheostomy care and management are also possible testable actions.
This section is fairly large and is made of five different body systems. Within the endocrine system, there are 10 testable conditions such as diabetes, diabetes insipidus (DI), diabetic ketoacidosis (DKA), thyroid dysfunction, and syndrome of inappropriate antidiuretic hormone (SIADH). To prep for this area on the CCRN, you’ll want to make sure you understand the differences between these conditions as well as how to identify them based on the patient’s presenting signs and symptoms. Understand which labs are pertinent to diagnosing these conditions and how to identify improvements and deterioration in their status.
In the hematology portion of the exam, there are 7 different topics that are testable: anemia, coagulopathies, immunodeficiency, leukopenia, oncologic complications, thrombocytopenia, and tranfusion reactions. In this area, my strongest suggestion would be to know your baseline normal labs for your CBC and coagulation studies. Understand which nursing interventions would be indicated for low platelets, low RBCs, low WBCs, elevated PT/PTT/INR, etc. In addition to this, be able to discern between disseminated intravascular coagulation (DIC), idiopathic thrombocytopenic purpura (ITP), and heparin-induce thrombocytopenia (HIT). Once you know how to recognize and separately identify each, you’ll need to know specific nursing interventions and precautions to take with each condition. Furthermore, be sure to understand different medications that are commonly used for anticoagulation as well as their antidotes in case of overdose or hemorrhage. Know the indications and possible reactions associated with transfusions like FFP, platelets, cryoprecipitate, and PCC or K-centra.
In the GI portion of the exam’s content, you’re expected to know 8 different conditions: abdominal compartment syndrome, trauma, GI bleed, infarction/obstruction/perforation, surgery, liver failure, malnutrition, and pancreatitis. I wouldn’t walk into test day without knowing how to measure intra-abdominal pressure, what’s considered to be normal parameters, and what is indicative of compartment syndrome. Know basic meds used in the treatment of a GI bleed and related nursing interventions. Know signs and symptoms indicative of reduced GI motility and how to identify suspected perforation (i.e. s/s of peritonitis). Understand the different causes of pancreatitis (because alcohol use is not the sole cause) and s/s of this condition. In addition to that, be aware of what lab values are commonly affected when your patient has pancreatitis such as elevated lipase, amylase, low calcium, high blood glucose, etc. It is also important to understand nursing care after procedures like an EGD or TEE as well as how to manage nutritional access lines/devices (NGT, OGT, PEG tubes, TPN via IV, etc.)
For the renal system, you’ll be expected to know about trauma, acute kidney injury (AKI), chronic kidney disease (CKD), infections, and electrolyte balance. Be able to identify the likely electrolyte abnormality based on a set of given signs and symptoms or test results (for example, a positive Chvostek’s sign can indicate hypocalcemia, but if that’s not your answer it may also be present in hypomagnesemia because calcium and magnesium tend to trend the same). Understand the concept of dialysis, its purpose, different indications for use, and what the potential complications can be during/after dialysis such as hypothermia, hypotension, and thrombosis. Be aware of which medications and other agents are damaging to the kidneys and how to reduce the likelihood of damage to the kidneys if these agents MUST be used.
Finally, for the integumentary system knowledge, you’ll want to make sure you’re aware of how to manage cellulitis, IV infiltration, necrotizing fasciitis, pressure injuries, and wounds (surgical/infectious/traumatic). This means being able to identify these conditions and intervene to prevent further deterioration of skin integrity. For IV infiltrations, make sure you know what the antidote is for the medication you’re infusing if there is one. Understand the complications that are associated with each of these conditions as well, and the nursing measures that can be taken to prevent them. For instance, again in regards to IV infiltration, you might apply topical Nitrobid paste to cause vasodilation and improved blood flow to the area to prevent ischemia to the site and distally. Know how to use and care for the patient with a wound vac system.
The musculoskeletal section is relatively small compared to other areas of knowledge covered on the CCRN exam. You’ll need to know and understand compartment syndrome, fractures, functional issues related to immobility/falls/etc., osteomyelitis, and rhabdomyolysis. Know which patient’s need to be monitored for compartment syndrome, how to do so, and when/how to intervene if suspected. Understand which labs are altered in the settings of osteomyelitis and rhabdomyolysis. Be able to answer questions related to the care of those patients who require progressive mobility and assistance.
The neurological area of comprehension on the CCRN is extensive; it contains over 20 areas for competency. Don’t take this section lightly, especially if you work in a unit where neurology is not the specialty. For this area of knowledge, you’ll want to be sure (at a minimum) that you can recognize the signs and symptoms of altered mental status such as stroke, neurogenic shock, and high intracranial pressure. Understand indications for neurologic monitoring devices and drains such as a ventriculostomy. Be able to trouble shoot these devices and understand which conditions or actions increase or decrease ICP. If stroke has occurred or is suspected, know how to perform a swallow evaluation and assess for dysphagia. Anticipate nursing interventions for those patients requiring neurological intervention for procedures such as coiling, thrombectomy, endarterectomy, craniotomy, and spinal immobilization. Be able to know the process of determining ischemic vs. hemorrhagic stroke (via imaging) because these two conditions often present in a very similar manner.
Some behavioral and psychosocial topics to be aware of prior to sitting for the CCRN certification exam would be: abuse, neglect, aggression, agitation, anxiety, suicidal ideation/behaviors, depression, PTSD, and substance use. When approaching these situations, it is imperative to keep in mind the skills of therapeutic communication, de-escalation techniques, and nonviolent crisis intervention. Understand how to utilize standardized assessment tools for substance use/abuse (CIWA), delirium (CAM), and how to assess for cognitive impairments. Understand the indications for use, nursing interventions, side effects, and potential complications associated with using medicinal management of these conditions or behaviors as well as restraints (chemical/physical). Above all, always keep in mind the safety of yourself, the patient, and others at ALL times.
The multisystem section contains a minimum of 19 concepts for required competency that can include but is not limited to sepsis, shock states, trauma affecting multiple organs, pain, temperature management, toxic ingestions, OB complications, end of life care, etc. These topics incorporate your knowledge of multiple areas to assess overall competency. At a minimum, make sure you understand the concept of targeted temperature management and how to recognize and treat different shock states. Additionally, ensure your competency in managing patients that require sedation, neuromuscular blockade, and end of life care interventions (Morphine, Ativan, extubation if applicable, etc.).
Now, let’s wrap this article up with some last minute tips!
Whenever this test plan starts to feel overwhelming, remember why you’re pursuing the certification in the first place. Maybe it’s for professional and personal development, or maybe you’re pursuing grad school for CRNA or AGACNP. Promise me, in the end it’s worth the struggle to get your certification. Once you’ve scheduled your test date, stick to it unless there are extenuating circumstances for your situation. You’re allowed one reschedule during your testing eligibility period (which is currently 180 days thanks to COVID-19). If you stick to that test date, you’re more likely to be motivated to study and prepare adequately. If you’re working and receive orders from a provider that you’re unfamiliar with or question, be sure to ask them about it…especially if you know of current evidence-based practice that contradicts these orders! The same goes for inquiring about a situation with your charge nurse. Doing so shows initiative and autonomy in your nursing practice as a critical care nurse and advocates for your patients.
Try seeking out new learning opportunities while at work. If your patient assignment load is something you’ve dealt with before, see if another nurse is caring for a patient with lesser common therapy (Ex: IABP, abdominal pressure monitoring, etc.) and dive into care with them! Have them explain their device/monitoring systems. I also highly encourage you to request more difficult assignments from your charge or director. If you have a specific skill in mind, request to be assigned to that case the next time you’re there or even offer to come in if its a rare opportunity. Trust me, they’ll not only be impressed with your initiative, but they’ll also likely be overtly grateful and give you preference for that patient’s care for offering to come in. Be honest with yourself and others about your weak areas and try to take on cases that will help them transform into your strengths.
I truly hope both parts of this article series helped provide insight and tips to help you prepare for and have confidence when taking your certification exam. Stay tuned for next week’s release of the sample 8-week study plan which I hope helps direct the focus of your studies. Included in that document will be some tips on how to vary your study methods and attack CCRN prep!