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These cases are original study items written for the PCCN Adult test plan, not official AACN questions. They are designed for progressive-care nurses who already understand airway, breathing, circulation, and basic hemodynamic monitoring. If you are new to the exam structure, start with the AACN PCCN handbook before working through these scenarios. When you are ready, try the shorter quiz on free PCCN practice questions.
Sepsis at progressive-care level
Suspect sepsis when infection is accompanied by concerning changes such as hypotension, altered mental status or organ dysfunction. The 2026 Surviving Sepsis Campaign recommends NEWS/NEWS2, MEWS or SIRS over qSOFA as a single hospital screening tool. Lactate can support assessment but is not specific for sepsis or a stand-alone measure of tissue perfusion. Escalate clinical deterioration without waiting for a score threshold.
Sepsis and septic shock are emergencies. Begin urgent evaluation and authorized treatment without avoidable delay. Apply current guideline recommendations with individualized reassessment, including the patient’s fluid tolerance; local protocols do not make the evidence on timely antibiotics and resuscitation optional.
Case 1: Early sepsis escalation
A 74-year-old patient is admitted for community-acquired pneumonia. Overnight the nurse notes temperature 38.6°C, heart rate 112 bpm, respiratory rate 24/min, blood pressure 98/64 mmHg, and new confusion (the patient is asking where their deceased spouse is). Lactate is 2.8 mmol/L. WBC is 14,500/µL. Which action is most appropriate?
- A. Administer acetaminophen, recheck vital signs in 2 hours, and page the provider if the temperature rises.
- B. Notify the provider and activate the local deterioration pathway now; obtain indicated cultures without delaying ordered antibiotics and resuscitation.
- C. Insert an indwelling urinary catheter to measure hourly output before calling the provider.
- D. Start a 1 L crystalloid bolus independently because the blood pressure is borderline.
Correct answer: B. Infection with new confusion, hypotension and tachypnea warrants urgent evaluation for sepsis. Obtain blood cultures and source-specific specimens when indicated, preferably before antibiotics if that does not cause a harmful delay. A and C delay assessment; D starts a fixed bolus without the authorization or individual assessment stated as necessary. No qSOFA cutoff is required before escalating this patient.
Case 2: Recognizing sepsis deterioration
A 58-year-old patient with pyelonephritis has been on IV antibiotics for 6 hours. The nurse reassesses and finds blood pressure 86/54 mmHg, heart rate 128 bpm, respiratory rate 30/min, urine output 15 mL in the past hour, and lactate 4.4 mmol/L. The patient is cool and mottled. What is the priority nursing action?
- A. Increase the maintenance IV rate by 25 mL/hr and continue to monitor.
- B. Obtain a repeat lactate in 1 hour to confirm the trend before escalating.
- C. Activate the rapid response team and initiate sepsis/hemodynamic escalation per protocol.
- D. Administer a PRN anxiolytic because tachypnea may be anxiety-related.
Correct answer: C. Hypotension, tachycardia, tachypnea, oliguria, mottling, and lactate >4 mmol/L indicate progression toward septic shock. This requires immediate rapid-response activation and hemodynamic escalation per protocol, including provider evaluation, possible fluid resuscitation, and vasopressor therapy. A is inadequate for shock. B delays definitive care. D misattributes life-threatening hypoperfusion to anxiety.
Renal
AKI assessment includes creatinine trends, urine output, perfusion, medication exposure and possible obstruction. These cases practice potassium safety and renal-risk communication; they do not establish how frequently an exact topic appears on the exam.
Case 3: Hyperkalemia ECG and response
A patient with AKI stage 3 has a serum potassium of 6.8 mEq/L. The 12-lead ECG shows peaked T waves, a widened QRS complex, and flattened P waves. The patient is alert but reports palpitations and mild weakness. Which intervention is the priority?
- A. Administer oral sodium polystyrene sulfonate and recheck potassium in 4 hours.
- B. Notify the provider immediately, stop all potassium intake, and prepare for ordered calcium to stabilize the cardiac membrane.
- C. Begin emergent hemodialysis at the bedside.
- D. Give insulin and dextrose first, then calcium if the QRS continues to widen.
Correct answer: B. ECG changes at a potassium of 6.8 mEq/L represent cardiotoxic hyperkalemia. The first priority is protecting the myocardium with calcium (calcium gluconate or calcium chloride per protocol/order), alongside stopping potassium sources and notifying the provider. A is wrong because oral binders act too slowly for ECG changes. C is wrong because dialysis is ordered and performed by a specialized team, not initiated independently at the bedside. D reverses the usual sequence: cardiac membrane stabilization comes before potassium shifting.
Case 4: Contrast-dye renal risk
A 79-year-old patient with diabetes and a baseline creatinine of 1.6 mg/dL is scheduled for a CT angiogram with iodinated contrast for possible pulmonary embolism. Which nursing action best reduces the risk of contrast-associated acute kidney injury?
- A. Withhold metformin indefinitely after the scan regardless of renal function.
- B. Verify recent creatinine/eGFR and possible AKI, communicate risk factors and follow an individualized contrast and hydration plan.
- C. Administer IV sodium bicarbonate prophylactically to every patient receiving contrast.
- D. Refuse the scan because any contrast dose is unsafe when creatinine is elevated.
Correct answer: B. Verify current renal function and possible AKI, then communicate with the team weighing the scan’s urgency against kidney and fluid risks. Prophylactic IV hydration is not required for every contrast study and can be harmful in fluid-overloaded patients. Metformin handling depends on renal function, AKI and procedure details. Blanket bicarbonate administration or automatic refusal of a potentially necessary scan is inappropriate.
Endocrine
Endocrine emergencies in progressive care usually present as glucose crisis (hypoglycemia, DKA, HHS) or thyroid/adrenal crises. PCCN-level questions focus on recognition, safe initial response, and the complications of therapy — especially potassium shifts during insulin treatment.
Case 5: Hypoglycemia 15-15 rule application
A patient with type 2 diabetes is alert and cooperative. Point-of-care glucose is 58 mg/dL. The patient swallows safely and is given 15 g of glucose tablets. After 15 minutes the glucose is 62 mg/dL. Which action is most appropriate?
- A. Give another 15 g of fast-acting carbohydrate and recheck in 15 minutes.
- B. Administer 1 mg glucagon intramuscularly because the glucose did not normalize.
- C. Give a high-protein snack now to sustain the glucose.
- D. Start a dextrose 5% infusion to maintain glucose.
Correct answer: A. The 15-15 rule means 15 g of fast-acting carbohydrate, recheck in 15 minutes, and repeat if glucose remains below 70 mg/dL. A is correct because the glucose is still low. B is reserved for patients who cannot swallow or are unconscious. C is premature; protein/complex carbohydrate follows after glucose is corrected. D requires a provider order and is not the first step for an alert patient.
Case 6: DKA recognition from labs
A 26-year-old patient with type 1 diabetes presents with 24 hours of vomiting and abdominal pain. Labs show glucose 412 mg/dL, pH 7.24, bicarbonate 14 mEq/L, anion gap 24, and moderate ketonuria. Potassium is 3.6 mEq/L. Which statement best reflects the priority nursing consideration?
- A. This is hyperosmolar hyperglycemic state; start subcutaneous insulin and oral fluids.
- B. The anion gap is normal, so ketoacidosis is unlikely.
- C. DKA is present; insulin therapy will likely be ordered with close potassium monitoring because insulin lowers serum potassium.
- D. Insulin must be withheld until potassium exceeds 5.0 mEq/L.
Correct answer: C. Diabetes with hyperglycemia, ketosis and metabolic acidosis supports DKA here. Current consensus criteria do not require glucose above 250 mg/dL; DKA can occur with lower glucose. At potassium 3.6 mEq/L, closely monitored replacement and insulin can proceed under the treatment protocol. If potassium is below 3.5 mEq/L, the 2024 consensus recommends delaying insulin until it rises above 3.5. Waiting for potassium above 5.0 is not that recommendation. HHS alone does not explain this degree of ketosis and acidosis; an anion gap of 24 is elevated.
Case 7: DKA vs HHS recognition
A 68-year-old patient with type 2 diabetes is brought in with confusion. Glucose is 820 mg/dL, pH 7.34, bicarbonate 22 mEq/L, anion gap 12, and trace ketones. Serum osmolality is 330 mOsm/kg. Which diagnosis is most consistent with these findings?
- A. Diabetic ketoacidosis.
- B. Hyperosmolar hyperglycemic state.
- C. Hypoglycemic crisis.
- D. Thyroid storm.
Correct answer: B. Severe hyperglycemia (often >600 mg/dL), near-normal pH and bicarbonate, minimal ketones, and elevated serum osmolality with altered mental status are characteristic of HHS. DKA would show lower pH, lower bicarbonate, and larger ketosis. C and D do not fit the glucose and acid-base picture.
Case 8: Thyroid and adrenal red flags at recognition level
A patient with known severe hypothyroidism due to Hashimoto thyroiditis is admitted for pneumonia. Overnight the nurse finds temperature 35.2°C, blood pressure 84/50 mmHg, heart rate 52 bpm, glucose 58 mg/dL, and sodium 128 mEq/L. The patient is difficult to arouse. Which condition should the nurse suspect and escalate?
- A. Thyroid storm.
- B. Myxedema coma.
- C. Adrenal crisis.
- D. Hyperosmolar hyperglycemic state.
Correct answer: B. Severe hypothyroidism with hypothermia, bradycardia and impaired consciousness raises concern for myxedema coma and needs emergency escalation. Thyroid storm usually has a different temperature and heart-rate pattern; HHS does not fit the hypoglycemia. Adrenal insufficiency can coexist and is not excluded by this vignette or by a normal potassium value. The responding team must assess and treat the full emergency.
Practice cases summary
The eight original teaching cases sample multisystem, renal and endocrine reasoning. They are not a prediction of item frequency. The table summarizes each intended teaching point.
| Case | Topic | Correct answer | Key principle |
|---|---|---|---|
| 1 | Sepsis early recognition | B | Infection with new organ-dysfunction concerns requires prompt assessment and escalation; do not rely on qSOFA alone. |
| 2 | Sepsis deterioration | C | Hypotension, oliguria, lactate >4, and mottling indicate shock and require rapid response activation. |
| 3 | Hyperkalemia with ECG changes | B | Cardiac membrane stabilization with calcium is the priority when ECG changes are present. |
| 4 | Contrast nephropathy prevention | B | Check renal function and AKI, communicate risk, and individualize prophylaxis without delaying necessary diagnosis. |
| 5 | Hypoglycemia 15-15 rule | A | Repeat 15 g fast-acting carbohydrate if glucose remains <70 mg/dL after 15 minutes. |
| 6 | DKA recognition and insulin | C | Assess diabetes/hyperglycemia, ketosis and acidosis together; insulin treatment requires potassium safeguards. |
| 7 | HHS recognition | B | Severe hyperglycemia with near-normal pH, minimal ketones, and high osmolality suggests HHS. |
| 8 | Thyroid/adrenal red flags | B | Hypothermia, bradycardia, hyponatremia, and hypoglycemia in hypothyroidism suggest myxedema coma. |
These cases are study aids. Always follow your facility protocol, provider orders, pharmacy guidance, and scope of practice when caring for actual patients.
References
- [1] American Association of Critical-Care Nurses (AACN) (2026). PCCN (Adult) Direct Care Certification Handbook. aacn.org. aacn.org
- [2] Evans L, et al. (2021). Surviving Sepsis Campaign: 2026 adult guidelines. Intensive Care Medicine. Intensive Care Medicine
- [3] KDIGO Acute Kidney Injury Work Group (2012). KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International Supplements. Kidney International Supplements
- [4] American Diabetes Association (2026). Standards of Care in Diabetes—2026. Diabetes Care. Diabetes Care
- [5] KDIGO AKI Guideline Work Group (2012). KDIGO Clinical Practice Guideline for Acute Kidney Injury: Contrast-Induced AKI. Kidney International Supplements. Kidney International Supplements
- [6] ADA/EASD/JBDS/AACE/DTS consensus panel (2024). Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (2024). ADA/EASD/JBDS/AACE/DTS consensus panel; accessed October 3, 2026 (undated web resources use access year). ADA/EASD/JBDS/AACE/DTS consensus panel; accessed October 3, 2026 (undated web resources use access year)
Frequently asked questions
Under the current PCCN Adult test plan effective February 6, 2024, Multisystem is 15% of scored items, Endocrine is 6%, and Renal is 4%. Combined, these three areas account for 25% of all scored items (not 25% of the 80% Clinical Judgment block).
qSOFA uses low systolic pressure, rapid breathing and altered mentation as risk indicators. It must not be used alone to diagnose or exclude sepsis. The 2026 Surviving Sepsis Campaign prefers NEWS/NEWS2, MEWS or SIRS over qSOFA alone for hospital screening; clinical deterioration warrants escalation regardless of score.
Calcium stabilizes the cardiac cell membrane and protects against arrhythmias caused by hyperkalemia. It does not lower serum potassium. Insulin with glucose shifts potassium into cells and lowers serum potassium, but it does not protect the heart immediately. When ECG changes are present, cardiac membrane stabilization is the priority.
DKA requires diabetes/hyperglycemia, ketosis and metabolic acidosis; it can occur without marked hyperglycemia. HHS features severe hyperglycemia and hyperosmolality without substantial ketoacidosis. Mixed presentations occur. Use the current consensus criteria and the full laboratory assessment.
For an alert patient who can swallow safely, give 15 g of fast-acting carbohydrate, recheck glucose in 15 minutes, and repeat if the glucose remains below 70 mg/dL. Once normalized, follow with a snack containing protein or complex carbohydrate if the next meal is more than an hour away.
Use authorized orders or protocols to initiate treatment promptly and escalate suspected sepsis. Nursing authority depends on the clinical setting and jurisdiction; do not delay emergency help or infer that a local protocol permits independent prescribing.
Try more PCCN practice questions
Try the free PCCN question sampler, then use the explanations to choose what to review next. This is a short practice set, not a full-length exam.
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