Endocrine, Hematology/Immunology, GI, Renal/GU, Integumentary

21% of the CCRN · blueprint Adult CCRN Test Plan (exams on and after 2025-11-12)

Short answer

At 21% this is the largest single category on the adult CCRN. It covers adrenal insufficiency, diabetes insipidus, DKA and hyperosmolar hyperglycaemic state, SIADH and thyroid disorders; anaemia, coagulopathies such as DIC, HIT and ITP, myelosuppression, oncologic emergencies and transfusion reactions including TRALI and TACO; GI haemorrhage, bowel obstruction and infarction, hepatic failure and abdominal compartment syndrome; acute kidney injury and renal replacement therapy; and wounds and pressure injuries.

Why it matters on this exam

One in five scored items. Candidates who study only cardiac and pulmonary content fail here.

Key concepts

DKA vs HHS: DKA has ketones, acidosis and a shorter onset; HHS has extreme hyperglycaemia and hyperosmolality with minimal ketosis. Both need fluid first, then insulin, with potassium replacement before or alongside insulin.
SIADH vs DI: SIADH retains water (low sodium, concentrated urine); DI loses water (high sodium, dilute urine, high output).
Transfusion reactions: TRALI (hypoxaemia and bilateral infiltrates within 6 hours, not volume) vs TACO (volume overload, responds to diuresis); acute haemolytic reaction — stop the transfusion first.
DIC: consumption of platelets and factors, low fibrinogen, high D-dimer; treat the trigger.
HIT: platelet fall around days 5–10 with thrombosis, not bleeding; stop all heparin including flushes.
AKI and CRRT: prerenal vs intrinsic vs postrenal; indications for urgent dialysis (AEIOU), and CRRT-specific issues such as citrate anticoagulation and hypothermia.
Hepatic failure: encephalopathy grading, ammonia, coagulopathy, portal hypertension and variceal bleeding.
Abdominal compartment syndrome: bladder pressure, oliguria and high airway pressures.

Common mistakes

Starting insulin in DKA before checking potassium.
Diuresing a TRALI patient because the film looks like fluid overload.

Worked example

Platelets fall from 220 to 80 on day 7 of heparin, and a new DVT appears. That pattern is HIT: stop every heparin exposure and start a non-heparin anticoagulant — platelet transfusion is not the answer.

Original practice questions

Endocrine, Hematology/Immunology, GI, Renal/GU, IntegumentaryDifficulty 3/5

A patient in diabetic ketoacidosis has a serum potassium of 3.1 mEq/L. What is the priority before starting an insulin infusion?

AWithhold all fluids until the potassium has returned to the normal range
BBegin insulin immediately, because correcting the acidosis will restore potassium
CReplace potassium first, because insulin will drive it further down
DAdminister sodium bicarbonate to correct the acidosis before any electrolyte therapy

Show answer and rationale

Correct: C. Insulin shifts potassium into cells. Starting insulin in a patient who is already hypokalaemic risks dangerous arrhythmia, so potassium replacement comes first while fluid resuscitation continues.

B — Insulin lowers serum potassium further rather than restoring it.
D — Bicarbonate is not routine in DKA and does not address the potassium risk.
A — Fluid resuscitation is the first priority in DKA and should not be withheld.

Endocrine, Hematology/Immunology, GI, Renal/GU, IntegumentaryDifficulty 3/5

Two hours into a transfusion a patient develops hypoxaemia and bilateral pulmonary infiltrates with a normal central venous pressure and no response to diuretics. What is the most likely reaction?

AAcute haemolytic transfusion reaction from ABO incompatibility
BFebrile non-haemolytic reaction to donor leukocytes
CTransfusion-associated circulatory overload from excessive volume
DTransfusion-related acute lung injury, an immune non-cardiogenic oedema

Show answer and rationale

Correct: D. TRALI produces non-cardiogenic pulmonary oedema within about six hours of transfusion, with normal filling pressures and no diuretic response. TACO is volume overload with raised filling pressures that improves with diuresis.

C — Circulatory overload raises filling pressures and responds to diuretics.
A — Haemolysis presents with fever, flank pain, haemoglobinuria and shock rather than isolated infiltrates.
B — A febrile reaction causes fever without pulmonary infiltrates.

Endocrine, Hematology/Immunology, GI, Renal/GU, IntegumentaryDifficulty 3/5

Which laboratory pattern best supports disseminated intravascular coagulation?

ALow platelets, prolonged PT and aPTT, low fibrinogen, raised D-dimer
BNormal platelets, prolonged PT alone and a normal fibrinogen with no D-dimer rise
CHigh platelets, shortened clotting times and depressed D-dimer values
DIsolated thrombocytopenia with normal coagulation studies and normal fibrinogen

Show answer and rationale

Correct: A. DIC consumes platelets and clotting factors while generating fibrin degradation products: low platelets, prolonged PT and aPTT, falling fibrinogen and a raised D-dimer. Isolated thrombocytopenia with normal studies suggests another cause.

B — An isolated PT prolongation suggests factor VII deficiency or warfarin effect.
C — That pattern describes a hypercoagulable laboratory picture, not consumption.
D — Isolated thrombocytopenia with normal coagulation is not DIC.

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Primary references

CCRN Exam Handbook — Direct Care (July 2026) — AACN Certification Corporation · primary · retrieved 2026-09-22, verified 2026-09-22

Last reviewed: 2026-09-22Next review by: 2026-11-06Draft — pending editorial reviewHow we verify facts