NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
NR 572 / NR572
Advanced Acute Care Management
MIDTERM EXAM GUIDE
75 High-Difficulty Questions with Detailed Rationales
✦ New 2025/2026 Update ✦ Grade A ✦ 100% Correct Verified Solutions ✦
Chamberlain University | AGACNP Certification Prep
pg. 1
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
EXAMINATION OVERVIEW & INSTRUCTIONS
This comprehensive midterm examination guide covers the highest-yield and most-tested topics in NR 572
Advanced Acute Care Management at Chamberlain University. All 75 questions are crafted at the application
and analysis level, reflecting current 2025/2026 clinical guidelines (ACC/AHA, GOLD, Surviving Sepsis
Campaign, ADA, IDSA, and more). Each question includes all five answer choices with detailed rationales
explaining correct and incorrect options. Study all rationales carefully—understanding why wrong answers are
wrong is as important as knowing the correct answer.
Topics Covered: Cardiogenic Shock | STEMI/NSTEMI | Heart Failure | ARDS | Mechanical Ventilation | Sepsis &
Septic Shock | DKA/HHS | Acute Liver Failure | Subarachnoid Hemorrhage | Aortic Dissection | PE/DVT | COPD
Exacerbation | Neurocritical Care | Toxicology | Renal Emergencies | Hematology | Oncologic Emergencies |
Perioperative Management | Rheumatologic Emergencies | Infectious Disease | Obstetric Emergencies | Ethics &
Goals of Care | Pharmacology in Organ Dysfunction
75 EXAMINATION QUESTIONS WITH VERIFIED ANSWERS
Question 1 of 75
A 68-year-old male is admitted to the ICU following a massive ST-elevation myocardial
infarction (STEMI). He is in cardiogenic shock with a BP of 72/40 mmHg, HR 120 bpm, and O2
sat 88% on 6L NC. He has received aspirin, heparin, and dual antiplatelet therapy. Which of
the following is the MOST appropriate immediate intervention?
A. Initiate norepinephrine infusion and emergent PCI
B. Administer IV furosemide 80 mg and initiate BiPAP
C. Insert intra-aortic balloon pump (IABP) and administer dobutamine only
D. Begin IV fibrinolysis with alteplase and monitor hemodynamics
E. Place central venous catheter and administer IV crystalloid bolus 2L
✔ CORRECT ANSWER: A
RATIONALE & CLINICAL EXPLANATION
Cardiogenic shock from STEMI requires emergent reperfusion via PCI (Class I, Level A evidence).
Norepinephrine is the vasopressor of choice in cardiogenic shock (ESC 2021 Guidelines) as it increases MAP
without significantly increasing myocardial oxygen demand compared to dopamine. Diuretics (B) are
contraindicated in hypotension. IABP alone (C) is insufficient without reperfusion. Fibrinolysis (D) is inferior to
PCI when cathlab is available. Fluids (E) worsen pulmonary edema in cardiogenic shock.
Question 2 of 75
A 54-year-old female with known COPD exacerbation presents with acute hypercapnic
respiratory failure. ABG shows pH 7.22, PaCO2 78 mmHg, PaO2 58 mmHg, HCO3 31 mEq/L on
4L NC. She is alert and cooperative. Which intervention is MOST appropriate as initial
management?
A. Immediate endotracheal intubation and mechanical ventilation
B. Non-invasive positive pressure ventilation (NIV/BiPAP)
C. High-flow nasal cannula (HFNC) at 40L/min
D. Heliox therapy via non-rebreather mask
E. Increase FiO2 via Venturi mask and recheck ABG in 2 hours
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
pg. 2
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
NIV/BiPAP is first-line for acute hypercapnic respiratory failure in COPD (GOLD Guidelines). It reduces
mortality, intubation rates, and hospital LOS. This patient is alert and cooperative—ideal NIV candidate.
Intubation (A) is reserved for NIV failure or contraindications. HFNC (C) is better suited for hypoxemic failure.
Heliox (D) has limited evidence. Increasing FiO2 alone (E) will worsen hypercapnia by relieving hypoxic drive
and worsening V/Q mismatch.
Question 3 of 75
A 72-year-old male post-CABG day 2 develops sudden hypotension (BP 78/50), JVD, muffled
heart sounds, pulsus paradoxus >20 mmHg, and sinus tachycardia. CVP is 22 mmHg. Cardiac
index is 1.4 L/min/m2. What is the MOST likely diagnosis and appropriate next step?
A. Tension pneumothorax; immediate needle decompression
B. Acute cardiac tamponade; emergent pericardiocentesis or surgical drainage
C. Right ventricular failure; initiate inhaled nitric oxide
D. ARDS; initiate lung-protective ventilation with PEEP 10 cmH2O
E. Distributive shock; administer broad-spectrum antibiotics and IV fluids
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
Beck's triad (hypotension, JVD, muffled heart sounds) + pulsus paradoxus >10 mmHg = classic cardiac
tamponade. Post-cardiac surgery tamponade is a surgical emergency requiring immediate drainage—
pericardiocentesis may be insufficient for clotted blood, often requiring mediastinal re-exploration. Elevated
CVP with low CI indicates obstructive shock physiology. Tension pneumothorax (A) would show absent breath
sounds and tracheal deviation. RV failure (C), ARDS (D), and sepsis (E) do not explain this constellation.
Question 4 of 75
An AGACNP is managing a 45-year-old female with septic shock secondary to pneumonia.
After initial fluid resuscitation with 30 mL/kg crystalloid, her MAP remains 58 mmHg, lactate
4.8 mmol/L, CVP 14 mmHg. She is on norepinephrine 0.15 mcg/kg/min. Which is the MOST
appropriate next intervention per Surviving Sepsis Campaign guidelines?
A. Add vasopressin 0.03 units/min and initiate corticosteroid therapy
B. Administer additional 1L NS bolus and increase norepinephrine to 0.3 mcg/kg/min
C. Switch norepinephrine to phenylephrine and add dobutamine
D. Initiate albumin 5% infusion and reduce norepinephrine dose
E. Begin sodium bicarbonate infusion for lactic acidosis management
✔ CORRECT ANSWER: A
RATIONALE & CLINICAL EXPLANATION
Per Surviving Sepsis Campaign 2021 guidelines, vasopressin (up to 0.03 units/min) should be added when
norepinephrine doses exceed 0.25 mcg/kg/min OR to achieve target MAP—it has a norepinephrine-sparing
effect. Hydrocortisone 200 mg/day is recommended for refractory septic shock. CVP 14 suggests adequate
preload; additional fluids (B) risk fluid overload. Phenylephrine (C) is not preferred in septic shock (pure
vasoconstriction without inotropy). Albumin (D) has limited mortality benefit. Bicarbonate (E) is not
recommended for lactic acidosis when pH >7.15.
Question 5 of 75
A 61-year-old male with ESRD on hemodialysis presents with peaked T-waves, PR
prolongation, and wide QRS complexes on ECG. Serum potassium is 7.2 mEq/L. He is
hemodynamically stable. What is the CORRECT order of treatment interventions?
pg. 3
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
A. Sodium bicarbonate → insulin/dextrose → kayexalate → emergent dialysis
B. Calcium gluconate → insulin + D50W → sodium bicarbonate → emergent dialysis
C. Furosemide IV → calcium chloride → albuterol nebulizer → patiromer
D. Emergent dialysis immediately without other interventions
E. Insulin + D50W → albuterol → kayexalate → calcium gluconate
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
Treatment follows membrane stabilization → intracellular shift → elimination: 1) Calcium gluconate (stabilizes
cardiac membrane—onset 1-3 min, duration 30-60 min); 2) Insulin + D50W (shifts K+ intracellularly—onset 15-
30 min); 3) Sodium bicarbonate (shifts K+ in acidotic patients); 4) Emergent dialysis (definitive removal in
ESRD—kayexalate is unreliable). Furosemide (C) is ineffective in ESRD. Never delay calcium for cardiac
protection (E). Dialysis alone (D) takes time to initiate and does not provide immediate cardiac protection.
Question 6 of 75
A 58-year-old male is intubated for respiratory failure. Ventilator settings: AC/VC mode, TV
550 mL (8.5 mL/kg IBW), RR 18, PEEP 8, FiO2 0.6. Plateau pressure is 34 cmH2O, driving
pressure 26 cmH2O. ABG: pH 7.38, PaCO2 42, PaO2 78. CXR shows bilateral infiltrates. P/F
ratio is 130. Which change is MOST appropriate?
A. Increase TV to 650 mL to improve oxygenation
B. Decrease TV to 6 mL/kg IBW and increase PEEP to 12-14 cmH2O
C. Switch to SIMV mode and add pressure support 10 cmH2O
D. Increase RR to 24 and decrease FiO2 to 0.4
E. Add inhaled nitric oxide and prone position immediately
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
This patient has moderate ARDS (P/F 100-200). ARDSnet ARMA trial demonstrated mortality benefit with
lung-protective ventilation: TV 6 mL/kg IBW (plateau pressure <30 cmH2O). Current plateau pressure of 34
and driving pressure 26 (goal <15) indicate volutrauma/barotrauma risk. Increasing PEEP improves
oxygenation and recruits alveoli. TV increase (A) worsens lung injury. SIMV (C) doesn't address the core
problem. Increasing RR (D) without reducing TV risks auto-PEEP. Prone positioning (E) is indicated for severe
ARDS (P/F <150) after optimizing ventilator settings first.
Question 7 of 75
A 29-year-old female with type 1 diabetes presents with blood glucose 520 mg/dL, serum
bicarbonate 10 mEq/L, pH 7.08, anion gap 28, positive urine ketones. She is obtunded and
vomiting. Initial K+ is 3.2 mEq/L. Which statement regarding DKA management is MOST
accurate?
A. Begin insulin infusion immediately at 0.1 units/kg/hr without potassium replacement
B. Hold insulin until K+ ≥ 3.5 mEq/L; begin aggressive IV potassium replacement
C. Administer sodium bicarbonate to correct acidosis before starting insulin
D. Begin insulin and potassium simultaneously since K+ is only mildly low
E. Use SubQ insulin glargine instead of IV infusion for more stable glucose control
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
ADA/Endocrine Society guidelines: Insulin MUST be held when K+ < 3.5 mEq/L because insulin drives K+
intracellularly, risking life-threatening hypokalemia and fatal arrhythmias. Aggressive IV KCl replacement (20-
pg. 4
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
40 mEq/hr) until K+ ≥ 3.5 mEq/L is required. Choice A risks fatal hypokalemia. Bicarbonate (C) is not
recommended unless pH <6.9 due to risks of paradoxical CNS acidosis and hypokalemia. Choice D is
incorrect—K+ 3.2 requires correction first. SubQ insulin (E) is inappropriate in acute DKA.
Question 8 of 75
A 77-year-old male with atrial fibrillation on warfarin (INR 4.8) presents with sudden severe
headache, vomiting, and right-sided hemiplegia. CT head shows hemorrhagic stroke. Which
intervention is HIGHEST priority?
A. Administer tPA 0.9 mg/kg IV for acute ischemic stroke
B. Administer 4-factor prothrombin complex concentrate (PCC) and vitamin K IV
C. Administer fresh frozen plasma (FFP) and hold for cross-match
D. Perform emergent craniotomy for hematoma evacuation
C. Administer protamine sulfate and schedule urgent MRI
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
Warfarin-associated intracerebral hemorrhage (WAICH) with supratherapeutic INR requires emergent reversal.
4-factor PCC (Kcentra) is preferred over FFP because: faster INR reversal (minutes vs hours), smaller volume,
no thromboembolic risk of FFP in elderly. IV Vitamin K is added for sustained effect. tPA (A) is absolutely
contraindicated in hemorrhagic stroke. FFP (C) requires large volumes and takes hours. Surgical evacuation
(D) may be indicated but only after coagulopathy is corrected. Protamine (E) reverses heparin, not warfarin.
Question 9 of 75
A 52-year-old male is admitted with acute pancreatitis. Ranson criteria score is 5 at 48 hours.
CT shows 60% pancreatic necrosis. He is febrile (39.4°C), WBC 22,000, HR 118, BP 92/58
mmHg. Which is the MOST appropriate management strategy?
A. Immediate surgical debridement of pancreatic necrosis
B. Aggressive IV fluid resuscitation, ICU monitoring, and broad-spectrum antibiotics prophylactically
C. CT-guided fine needle aspiration to rule out infected necrosis; antibiotics only if positive
D. Early enteral nutrition via nasogastric tube within 24 hours of admission
E. ERCP within 24 hours to decompress the pancreatic duct
✔ CORRECT ANSWER: C
RATIONALE & CLINICAL EXPLANATION
Current guidelines (ACG, IAP/APA): Prophylactic antibiotics are NOT recommended for sterile necrosis—they
increase antibiotic resistance without mortality benefit. CT-guided FNA distinguishes sterile from infected
necrosis (Gram stain/culture). Antibiotics are indicated only for documented infected necrosis. Surgery (A) is
generally delayed (step-up approach: percutaneous drainage first, then minimally invasive debridement if
needed). Choice D is correct for nutrition but not the MOST appropriate for this presentation with septic
physiology. ERCP (E) is indicated for biliary pancreatitis with cholangitis, not necrosis.
Question 10 of 75
An AGACNP is caring for a patient with new-onset ascites. Diagnostic paracentesis shows:
total protein 1.2 g/dL, albumin 0.8 g/dL, serum albumin 3.2 g/dL. SAAG is calculated as 2.4
g/dL. WBC 120 cells/mm3 (85% PMNs). Which diagnosis and management is MOST
appropriate?
A. Malignant ascites; refer to oncology for chemotherapy
B. Spontaneous bacterial peritonitis (SBP); cefotaxime 2g IV q8h + albumin 1.5 g/kg
pg. 5
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
C. Tuberculous peritonitis; initiate anti-tuberculosis therapy
D. Chylous ascites; initiate low-fat diet and octreotide
E. Cardiac ascites; initiate diuresis with furosemide and spironolactone
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
SAAG ≥1.1 g/dL indicates portal hypertension (hepatic etiology). PMN count ≥250 cells/mm3 in ascitic fluid =
SBP diagnosis, even without positive culture. Treatment: Cefotaxime (covers enteric organisms) + IV albumin
(1.5 g/kg on day 1, 1 g/kg on day 3) significantly reduces renal impairment and mortality (Sort trial). Malignant
ascites (A) has SAAG <1.1. TB peritonitis (C) is exudative with lymphocytic predominance. Chylous (D) shows
milky fluid. Cardiac ascites (E) has SAAG >1.1 but PMN count is typically normal.
Question 11 of 75
A 63-year-old female post-op day 1 following elective colectomy develops fever 38.9°C, HR
108, BP 100/65, RR 22, WBC 18,500. Wound site is intact. UA shows >100,000 CFU E. coli with
Foley catheter in place. Creatinine has risen from 0.9 to 1.8 mg/dL. Which intervention is
MOST appropriate?
A. Start ceftriaxone 1g IV q24h and maintain the Foley catheter
B. Remove the Foley catheter immediately; treat as catheter-associated UTI only if symptoms persist
C. Remove the Foley catheter, obtain blood cultures, and initiate empiric antibiotics
D. Change the Foley catheter over a guidewire and start nitrofurantoin
E. Obtain renal ultrasound and consult nephrology for acute kidney injury
✔ CORRECT ANSWER: C
RATIONALE & CLINICAL EXPLANATION
This patient meets SIRS criteria (fever, tachycardia, elevated WBC, elevated RR) with a likely source (CAUTI).
Per IDSA/CDC CAUTI guidelines: Remove Foley ASAP (most important intervention). However, given sepsis
criteria and AKI, blood cultures must be obtained before antibiotics and empiric IV antibiotics initiated (not oral
nitrofurantoin—C). Asymptomatic bacteriuria in catheterized patients does not require treatment—but this
patient is symptomatic with sepsis physiology. Changing catheter over guidewire (D) is never recommended.
Nephrology consult (E) is premature without addressing source.
Question 12 of 75
A 48-year-old male presents with substernal chest pain radiating to the back, BP 195/110 right
arm vs 162/88 left arm, pulse deficit, and widened mediastinum on CXR. CT angiography
shows a Type A aortic dissection. What is the MOST critical next step?
A. Administer IV heparin anticoagulation and admit to cardiac ICU for monitoring
B. Initiate IV labetalol to target HR <60 bpm and systolic BP <120 mmHg; emergent
cardiothoracic surgery
C. Administer tPA for thrombus dissolution and repeat CT in 6 hours
D. Perform emergent percutaneous coronary intervention to rule out concurrent MI
E. Begin nitroprusside infusion alone and consult interventional radiology for TEVAR
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
Type A aortic dissection (ascending) is a surgical emergency with 1-2% mortality per hour if untreated. Medical
management bridges to surgery: IV beta-blockers first (labetalol or esmolol) to reduce HR (<60 bpm) and BP
(systolic <120 mmHg), decreasing aortic wall stress (dP/dt). Then vasodilators if needed. Heparin (A) is
contraindicated—risks hemopericardium and tamponade. tPA (C) is absolutely contraindicated. PCI (D) is
pg. 6
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
unnecessary and delays surgery. Nitroprusside alone (E) causes reflex tachycardia worsening dissection;
TEVAR is for Type B.
Question 13 of 75
A 35-year-old female presents with progressive ascending weakness, areflexia, bilateral facial
weakness, and respiratory muscle involvement over 3 weeks following a GI illness. NCS/EMG
shows demyelinating polyneuropathy. CSF analysis: protein 285 mg/dL, WBC 3 cells/mm3.
Which is the MOST appropriate treatment?
A. High-dose IV methylprednisolone 1g/day for 5 days
B. Plasmapheresis (IVIG) OR intravenous immunoglobulin (IVIG) — either is equally effective
C. Oral prednisone taper over 6 weeks
D. Cyclophosphamide infusion for immunosuppression
E. Empiric broad-spectrum antibiotics for bacterial meningitis
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
Guillain-Barré syndrome (GBS) is confirmed by clinical presentation + albuminocytologic dissociation (high
protein, normal cells). Both plasmapheresis and IVIG are equally efficacious (Class I evidence, AAN
Guidelines). IVIG is preferred for ease of administration. Steroids (A, C) are NOT recommended—they do not
improve outcomes and may worsen recovery. Cyclophosphamide (D) has no role. Antibiotics (E) are
inappropriate given CSF and clinical picture. Key monitoring: FVC <20 mL/kg or NIF < -30 cmH2O = intubation
threshold.
Question 14 of 75
An AGACNP is evaluating a patient 48 hours after elective knee arthroplasty who develops
sudden pleuritic chest pain, dyspnea, O2 sat 89% on RA, HR 122, BP 108/72. CTA chest
shows bilateral segmental pulmonary emboli. BNP is 890 pg/mL, troponin 0.8 ng/mL. Echo
shows RV dilation with septal bowing. Which risk stratification and management is MOST
appropriate?
A. Low-risk PE; anticoagulate with rivaroxaban and discharge home
B. Massive PE; administer systemic tPA and ICU admission
C. Submassive (intermediate-high risk) PE; anticoagulate with UFH and consider catheter-
directed thrombolysis or surgical embolectomy
D. Intermediate-low risk PE; start LMWH and admit to step-down unit
E. High-risk PE; immediate surgical embolectomy is the only option
✔ CORRECT ANSWER: C
RATIONALE & CLINICAL EXPLANATION
This is submassive (intermediate-high risk) PE: hemodynamically STABLE but with RV dysfunction (echo: RV
dilation, septal bowing) AND myocardial injury (elevated troponin + BNP). PESI score is elevated.
Management: UFH anticoagulation + close ICU monitoring. If clinical deterioration occurs, catheter-directed
thrombolysis (CDT) or surgical embolectomy may be considered. Systemic tPA (B) is for MASSIVE PE
(hemodynamic compromise: SBP <90 for >15 min). The patient is hemodynamically borderline but not in
collapse. CDT offers targeted thrombolysis with lower bleeding risk than systemic tPA.
Question 15 of 75
A 66-year-old male with CKD stage 3 is prescribed lisinopril for hypertension. One week later,
potassium is 5.8 mEq/L, creatinine increased from 1.6 to 2.1 mg/dL (31% increase). His BP is
now 138/88 mmHg. How should the AGACNP manage this patient?
pg. 7
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
A. Discontinue lisinopril immediately and start amlodipine
B. Continue lisinopril; creatinine increase <30% and K+ elevation are expected and acceptable
C. Continue lisinopril; the creatinine increase is concerning, add furosemide for potassium
D. Switch to losartan which does not cause hyperkalemia or creatinine elevation
E. Reduce lisinopril dose by half and recheck labs in 48 hours
✔ CORRECT ANSWER: A
RATIONALE & CLINICAL EXPLANATION
ACEi-induced AKI: A creatinine increase >30% (this patient: 31%) from baseline indicates hemodynamically
significant renal impairment—typically from bilateral renal artery stenosis or severe renal hypoperfusion.
Combined with hyperkalemia (K+ 5.8), lisinopril should be discontinued. ARBs (D) would cause the same issue
(same mechanism). A creatinine increase <30% is generally acceptable with ACEi/ARB therapy. The key
cutoffs: >30% rise = hold/discontinue; K+ consistently >5.5 = reassess therapy. Dose reduction alone (E) may
not be sufficient with this degree of deterioration.
Question 16 of 75
A 71-year-old female is admitted to the neuro-ICU with a Hunt-Hess grade III subarachnoid
hemorrhage (SAH). Day 4 post-bleed, she develops new confusion and right arm weakness
not present on admission. CT angiography shows no re-bleeding. TCD shows elevated
velocities in the MCA (>200 cm/s). What is the MOST likely complication and treatment?
A. Hydrocephalus; emergent ventriculostomy placement
B. Re-bleeding from unsecured aneurysm; emergent coiling or clipping
C. Cerebral vasospasm; initiate Triple-H therapy (hypertension, hypervolemia, hemodilution)
D. Cerebral vasospasm; maintain euvolemia and induce hypertension with vasopressors
E. Hyponatremia from SIADH; restrict fluid to 1L/day
✔ CORRECT ANSWER: D
RATIONALE & CLINICAL EXPLANATION
TCD velocities >200 cm/s + new neurological deficits on day 4-14 post-SAH = cerebral vasospasm. Modern
guidelines (Neurocritical Care Society 2023) have shifted AWAY from classic Triple-H therapy. Current
evidence supports: euvolemia (NOT hypervolemia—hypervolemia shows no benefit and risks pulmonary
edema) + induced hypertension (vasopressors to raise MAP 20-25% above baseline). Nimodipine (oral
calcium channel blocker) prevents vasospasm and must be continued. Endovascular therapy (IA
vasodilators/angioplasty) is reserved for refractory cases. Hydrocephalus (A) causes gradual decline, not focal
deficits.
Question 17 of 75
A 55-year-old male presents with acute liver failure. INR 3.8, total bilirubin 22 mg/dL,
creatinine 3.1 mg/dL, ammonia 210 mcg/dL, grade III encephalopathy. Acetaminophen level is
42 mcg/mL at 12 hours post-ingestion. Which treatment is MOST critical to initiate
immediately?
A. N-acetylcysteine (NAC) IV infusion, regardless of time since ingestion
B. Liver transplant evaluation only; NAC ineffective >10 hours post-ingestion
C. Fresh frozen plasma to correct coagulopathy and prevent bleeding
D. Lactulose enemas and rifaximin for hepatic encephalopathy management
E. Hemodialysis for acetaminophen removal and renal protection
✔ CORRECT ANSWER: A
pg. 8
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
RATIONALE & CLINICAL EXPLANATION
NAC is the antidote for acetaminophen toxicity AND is beneficial in ALL causes of acute liver failure (not just
APAP) when given early. Even beyond 24 hours post-ingestion, IV NAC improves transplant-free survival in
APAP-induced ALF (Cochrane evidence). NAC replenishes glutathione stores and has anti-inflammatory
effects. Time to transplant evaluation is also critical (King's College Criteria). FFP (C) should NOT be given
prophylactically—INR is used as a prognostic marker. Lactulose (D) can cause aspiration; rifaximin is
preferred. Hemodialysis (E) has limited evidence for APAP removal.
Question 18 of 75
An AGACNP is managing a mechanically ventilated patient with suspected hospital-acquired
pneumonia (HAP) on day 7 of hospitalization. What is the MOST appropriate empiric antibiotic
regimen considering MDR organism risk?
A. Azithromycin + ceftriaxone (community-acquired pneumonia coverage)
B. Piperacillin-tazobactam + vancomycin
C. Meropenem + colistin (for pan-resistant organisms)
D. Ciprofloxacin monotherapy (adequate gram-negative coverage)
E. Ceftriaxone + metronidazole (aspiration pneumonia coverage)
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
IDSA/ATS HAP/VAP 2016 Guidelines: HAP with MDR risk factors (≥5 days hospitalization, prior antibiotic use,
structural lung disease) requires coverage for MRSA (vancomycin or linezolid) and anti-pseudomonal gram-
negatives (piperacillin-tazobactam, cefepime, meropenem, or aztreonam). The combination piperacillin-
tazobactam + vancomycin covers most HAP pathogens. CAP regimen (A) is insufficient for HAP. Colistin (C) is
reserved for pan-resistant MDR organisms. Fluoroquinolone monotherapy (D) has insufficient gram-positive
coverage. De-escalate based on culture results.
Question 19 of 75
A 42-year-old female with systemic lupus erythematosus presents with sudden onset
dyspnea, pleuritic chest pain, fever 39.1°C, and a new pericardial friction rub. ECG shows
diffuse ST elevation and PR depression in all leads except aVR. Echo shows 500 mL
pericardial effusion without tamponade. Anti-dsDNA is elevated. What is the MOST
appropriate initial treatment?
A. NSAIDs + colchicine for idiopathic pericarditis
B. High-dose corticosteroids for lupus serositis
C. Pericardiocentesis for diagnostic and therapeutic drainage
D. IV methylprednisolone + hydroxychloroquine continuation + colchicine
E. Methotrexate and pericardial window for recurrent pericarditis
✔ CORRECT ANSWER: D
RATIONALE & CLINICAL EXPLANATION
Lupus pericarditis with significant effusion (500 mL) and active serology (elevated anti-dsDNA, fever) requires
systemic immunosuppression. High-dose corticosteroids (methylprednisolone 1 mg/kg/day) are first-line for
lupus serositis with significant effusion. Hydroxychloroquine should be continued as maintenance therapy.
Colchicine provides additive anti-inflammatory benefit. NSAIDs (A) are used for idiopathic/viral pericarditis, not
lupus. Pericardiocentesis (C) is not indicated without tamponade. Methotrexate (E) is for refractory disease.
NSAIDs can worsen lupus nephritis.
Question 20 of 75
pg. 9
, NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
A 70-year-old male post-cardiac arrest with ROSC is admitted to the ICU. He is unresponsive
(GCS 5), hemodynamically stable with MAP 85 mmHg. His core temperature is 36.2°C. Which
intervention provides the STRONGEST evidence for neurological outcome improvement?
A. Targeted Temperature Management (TTM) at 33°C for 24 hours
B. Prevent fever (T>37.5°C) with active temperature control at 36°C
C. Active normothermia at 36°C; aggressive early rewarming to 38°C has benefit
D. Immediate therapeutic hypothermia at 32°C for 48 hours
E. Temperature management is no longer recommended based on TTM2 trial
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
The TTM2 trial (NEJM 2021) compared TTM at 33°C vs targeted normothermia (avoiding fever >37.8°C) and
found NO significant difference in mortality or neurological outcomes at 6 months. Current AHA/ERC 2021
guidelines recommend: Fever prevention (T>37.5-38°C) with active temperature management targeting 36°C
for at least 72 hours post-arrest. Temperature management IS still recommended (E is wrong)—fever is
independently harmful post-ROSC. TTM at 32-36°C may still be used (A, D), but the evidence now supports
fever prevention as the minimum standard.
Question 21 of 75
A 58-year-old male with metastatic non-small cell lung cancer is admitted with acute altered
mental status. Serum calcium is 14.8 mg/dL (ionized: 1.85 mmol/L), creatinine 2.0 mg/dL, BUN
42. ECG shows shortened QTc and J-waves. Symptoms include polyuria, polydipsia,
constipation, and confusion. What is the MOST appropriate initial management?
A. Furosemide 80 mg IV and restrict IV fluids
B. Aggressive IV normal saline hydration + calcitonin + zoledronic acid
C. IV pamidronate alone; it is the most effective single agent
D. Dialysis immediately for severe symptomatic hypercalcemia
E. Oral bisphosphonate + IV normal saline hydration
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
Hypercalcemia of malignancy management: 1) IV NS resuscitation (2-4L/day—restore volume first, most
critical step); 2) Calcitonin 4 units/kg q12h (fastest onset, 4-6 hours, but tachyphylaxis in 48-72 hours); 3) IV
bisphosphonate (zoledronic acid preferred—onset 2-4 days, sustained 3-4 weeks). Furosemide (A) is NO
longer recommended upfront—give fluids first. Pamidronate alone (C) has delayed onset. Dialysis (D) is
reserved for refractory cases or severe renal failure. Oral bisphosphonates (E) are not effective in acute severe
hypercalcemia. The combination addresses all phases simultaneously.
Question 22 of 75
A 48-year-old female is found unresponsive with miosis, bradycardia (HR 45), hypotension
(BP 78/50), hypersalivation, bronchospasm, and urinary incontinence. Her skin is diaphoretic.
Which antidote and mechanism is MOST appropriate?
A. Naloxone 0.4 mg IV; opioid receptor antagonist
B. Atropine 2-4 mg IV + pralidoxime (2-PAM); anticholinergic + oxime for organophosphate
toxicity
C. Physostigmine 2 mg IV; acetylcholinesterase inhibitor for anticholinergic syndrome
D. Flumazenil 0.2 mg IV; benzodiazepine receptor antagonist
E. Sodium bicarbonate 1-2 mEq/kg IV; TCA toxicity reversal
pg. 10
NR 572 / NR572
Advanced Acute Care Management
MIDTERM EXAM GUIDE
75 High-Difficulty Questions with Detailed Rationales
✦ New 2025/2026 Update ✦ Grade A ✦ 100% Correct Verified Solutions ✦
Chamberlain University | AGACNP Certification Prep
pg. 1
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
EXAMINATION OVERVIEW & INSTRUCTIONS
This comprehensive midterm examination guide covers the highest-yield and most-tested topics in NR 572
Advanced Acute Care Management at Chamberlain University. All 75 questions are crafted at the application
and analysis level, reflecting current 2025/2026 clinical guidelines (ACC/AHA, GOLD, Surviving Sepsis
Campaign, ADA, IDSA, and more). Each question includes all five answer choices with detailed rationales
explaining correct and incorrect options. Study all rationales carefully—understanding why wrong answers are
wrong is as important as knowing the correct answer.
Topics Covered: Cardiogenic Shock | STEMI/NSTEMI | Heart Failure | ARDS | Mechanical Ventilation | Sepsis &
Septic Shock | DKA/HHS | Acute Liver Failure | Subarachnoid Hemorrhage | Aortic Dissection | PE/DVT | COPD
Exacerbation | Neurocritical Care | Toxicology | Renal Emergencies | Hematology | Oncologic Emergencies |
Perioperative Management | Rheumatologic Emergencies | Infectious Disease | Obstetric Emergencies | Ethics &
Goals of Care | Pharmacology in Organ Dysfunction
75 EXAMINATION QUESTIONS WITH VERIFIED ANSWERS
Question 1 of 75
A 68-year-old male is admitted to the ICU following a massive ST-elevation myocardial
infarction (STEMI). He is in cardiogenic shock with a BP of 72/40 mmHg, HR 120 bpm, and O2
sat 88% on 6L NC. He has received aspirin, heparin, and dual antiplatelet therapy. Which of
the following is the MOST appropriate immediate intervention?
A. Initiate norepinephrine infusion and emergent PCI
B. Administer IV furosemide 80 mg and initiate BiPAP
C. Insert intra-aortic balloon pump (IABP) and administer dobutamine only
D. Begin IV fibrinolysis with alteplase and monitor hemodynamics
E. Place central venous catheter and administer IV crystalloid bolus 2L
✔ CORRECT ANSWER: A
RATIONALE & CLINICAL EXPLANATION
Cardiogenic shock from STEMI requires emergent reperfusion via PCI (Class I, Level A evidence).
Norepinephrine is the vasopressor of choice in cardiogenic shock (ESC 2021 Guidelines) as it increases MAP
without significantly increasing myocardial oxygen demand compared to dopamine. Diuretics (B) are
contraindicated in hypotension. IABP alone (C) is insufficient without reperfusion. Fibrinolysis (D) is inferior to
PCI when cathlab is available. Fluids (E) worsen pulmonary edema in cardiogenic shock.
Question 2 of 75
A 54-year-old female with known COPD exacerbation presents with acute hypercapnic
respiratory failure. ABG shows pH 7.22, PaCO2 78 mmHg, PaO2 58 mmHg, HCO3 31 mEq/L on
4L NC. She is alert and cooperative. Which intervention is MOST appropriate as initial
management?
A. Immediate endotracheal intubation and mechanical ventilation
B. Non-invasive positive pressure ventilation (NIV/BiPAP)
C. High-flow nasal cannula (HFNC) at 40L/min
D. Heliox therapy via non-rebreather mask
E. Increase FiO2 via Venturi mask and recheck ABG in 2 hours
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
pg. 2
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
NIV/BiPAP is first-line for acute hypercapnic respiratory failure in COPD (GOLD Guidelines). It reduces
mortality, intubation rates, and hospital LOS. This patient is alert and cooperative—ideal NIV candidate.
Intubation (A) is reserved for NIV failure or contraindications. HFNC (C) is better suited for hypoxemic failure.
Heliox (D) has limited evidence. Increasing FiO2 alone (E) will worsen hypercapnia by relieving hypoxic drive
and worsening V/Q mismatch.
Question 3 of 75
A 72-year-old male post-CABG day 2 develops sudden hypotension (BP 78/50), JVD, muffled
heart sounds, pulsus paradoxus >20 mmHg, and sinus tachycardia. CVP is 22 mmHg. Cardiac
index is 1.4 L/min/m2. What is the MOST likely diagnosis and appropriate next step?
A. Tension pneumothorax; immediate needle decompression
B. Acute cardiac tamponade; emergent pericardiocentesis or surgical drainage
C. Right ventricular failure; initiate inhaled nitric oxide
D. ARDS; initiate lung-protective ventilation with PEEP 10 cmH2O
E. Distributive shock; administer broad-spectrum antibiotics and IV fluids
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
Beck's triad (hypotension, JVD, muffled heart sounds) + pulsus paradoxus >10 mmHg = classic cardiac
tamponade. Post-cardiac surgery tamponade is a surgical emergency requiring immediate drainage—
pericardiocentesis may be insufficient for clotted blood, often requiring mediastinal re-exploration. Elevated
CVP with low CI indicates obstructive shock physiology. Tension pneumothorax (A) would show absent breath
sounds and tracheal deviation. RV failure (C), ARDS (D), and sepsis (E) do not explain this constellation.
Question 4 of 75
An AGACNP is managing a 45-year-old female with septic shock secondary to pneumonia.
After initial fluid resuscitation with 30 mL/kg crystalloid, her MAP remains 58 mmHg, lactate
4.8 mmol/L, CVP 14 mmHg. She is on norepinephrine 0.15 mcg/kg/min. Which is the MOST
appropriate next intervention per Surviving Sepsis Campaign guidelines?
A. Add vasopressin 0.03 units/min and initiate corticosteroid therapy
B. Administer additional 1L NS bolus and increase norepinephrine to 0.3 mcg/kg/min
C. Switch norepinephrine to phenylephrine and add dobutamine
D. Initiate albumin 5% infusion and reduce norepinephrine dose
E. Begin sodium bicarbonate infusion for lactic acidosis management
✔ CORRECT ANSWER: A
RATIONALE & CLINICAL EXPLANATION
Per Surviving Sepsis Campaign 2021 guidelines, vasopressin (up to 0.03 units/min) should be added when
norepinephrine doses exceed 0.25 mcg/kg/min OR to achieve target MAP—it has a norepinephrine-sparing
effect. Hydrocortisone 200 mg/day is recommended for refractory septic shock. CVP 14 suggests adequate
preload; additional fluids (B) risk fluid overload. Phenylephrine (C) is not preferred in septic shock (pure
vasoconstriction without inotropy). Albumin (D) has limited mortality benefit. Bicarbonate (E) is not
recommended for lactic acidosis when pH >7.15.
Question 5 of 75
A 61-year-old male with ESRD on hemodialysis presents with peaked T-waves, PR
prolongation, and wide QRS complexes on ECG. Serum potassium is 7.2 mEq/L. He is
hemodynamically stable. What is the CORRECT order of treatment interventions?
pg. 3
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
A. Sodium bicarbonate → insulin/dextrose → kayexalate → emergent dialysis
B. Calcium gluconate → insulin + D50W → sodium bicarbonate → emergent dialysis
C. Furosemide IV → calcium chloride → albuterol nebulizer → patiromer
D. Emergent dialysis immediately without other interventions
E. Insulin + D50W → albuterol → kayexalate → calcium gluconate
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
Treatment follows membrane stabilization → intracellular shift → elimination: 1) Calcium gluconate (stabilizes
cardiac membrane—onset 1-3 min, duration 30-60 min); 2) Insulin + D50W (shifts K+ intracellularly—onset 15-
30 min); 3) Sodium bicarbonate (shifts K+ in acidotic patients); 4) Emergent dialysis (definitive removal in
ESRD—kayexalate is unreliable). Furosemide (C) is ineffective in ESRD. Never delay calcium for cardiac
protection (E). Dialysis alone (D) takes time to initiate and does not provide immediate cardiac protection.
Question 6 of 75
A 58-year-old male is intubated for respiratory failure. Ventilator settings: AC/VC mode, TV
550 mL (8.5 mL/kg IBW), RR 18, PEEP 8, FiO2 0.6. Plateau pressure is 34 cmH2O, driving
pressure 26 cmH2O. ABG: pH 7.38, PaCO2 42, PaO2 78. CXR shows bilateral infiltrates. P/F
ratio is 130. Which change is MOST appropriate?
A. Increase TV to 650 mL to improve oxygenation
B. Decrease TV to 6 mL/kg IBW and increase PEEP to 12-14 cmH2O
C. Switch to SIMV mode and add pressure support 10 cmH2O
D. Increase RR to 24 and decrease FiO2 to 0.4
E. Add inhaled nitric oxide and prone position immediately
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
This patient has moderate ARDS (P/F 100-200). ARDSnet ARMA trial demonstrated mortality benefit with
lung-protective ventilation: TV 6 mL/kg IBW (plateau pressure <30 cmH2O). Current plateau pressure of 34
and driving pressure 26 (goal <15) indicate volutrauma/barotrauma risk. Increasing PEEP improves
oxygenation and recruits alveoli. TV increase (A) worsens lung injury. SIMV (C) doesn't address the core
problem. Increasing RR (D) without reducing TV risks auto-PEEP. Prone positioning (E) is indicated for severe
ARDS (P/F <150) after optimizing ventilator settings first.
Question 7 of 75
A 29-year-old female with type 1 diabetes presents with blood glucose 520 mg/dL, serum
bicarbonate 10 mEq/L, pH 7.08, anion gap 28, positive urine ketones. She is obtunded and
vomiting. Initial K+ is 3.2 mEq/L. Which statement regarding DKA management is MOST
accurate?
A. Begin insulin infusion immediately at 0.1 units/kg/hr without potassium replacement
B. Hold insulin until K+ ≥ 3.5 mEq/L; begin aggressive IV potassium replacement
C. Administer sodium bicarbonate to correct acidosis before starting insulin
D. Begin insulin and potassium simultaneously since K+ is only mildly low
E. Use SubQ insulin glargine instead of IV infusion for more stable glucose control
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
ADA/Endocrine Society guidelines: Insulin MUST be held when K+ < 3.5 mEq/L because insulin drives K+
intracellularly, risking life-threatening hypokalemia and fatal arrhythmias. Aggressive IV KCl replacement (20-
pg. 4
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
40 mEq/hr) until K+ ≥ 3.5 mEq/L is required. Choice A risks fatal hypokalemia. Bicarbonate (C) is not
recommended unless pH <6.9 due to risks of paradoxical CNS acidosis and hypokalemia. Choice D is
incorrect—K+ 3.2 requires correction first. SubQ insulin (E) is inappropriate in acute DKA.
Question 8 of 75
A 77-year-old male with atrial fibrillation on warfarin (INR 4.8) presents with sudden severe
headache, vomiting, and right-sided hemiplegia. CT head shows hemorrhagic stroke. Which
intervention is HIGHEST priority?
A. Administer tPA 0.9 mg/kg IV for acute ischemic stroke
B. Administer 4-factor prothrombin complex concentrate (PCC) and vitamin K IV
C. Administer fresh frozen plasma (FFP) and hold for cross-match
D. Perform emergent craniotomy for hematoma evacuation
C. Administer protamine sulfate and schedule urgent MRI
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
Warfarin-associated intracerebral hemorrhage (WAICH) with supratherapeutic INR requires emergent reversal.
4-factor PCC (Kcentra) is preferred over FFP because: faster INR reversal (minutes vs hours), smaller volume,
no thromboembolic risk of FFP in elderly. IV Vitamin K is added for sustained effect. tPA (A) is absolutely
contraindicated in hemorrhagic stroke. FFP (C) requires large volumes and takes hours. Surgical evacuation
(D) may be indicated but only after coagulopathy is corrected. Protamine (E) reverses heparin, not warfarin.
Question 9 of 75
A 52-year-old male is admitted with acute pancreatitis. Ranson criteria score is 5 at 48 hours.
CT shows 60% pancreatic necrosis. He is febrile (39.4°C), WBC 22,000, HR 118, BP 92/58
mmHg. Which is the MOST appropriate management strategy?
A. Immediate surgical debridement of pancreatic necrosis
B. Aggressive IV fluid resuscitation, ICU monitoring, and broad-spectrum antibiotics prophylactically
C. CT-guided fine needle aspiration to rule out infected necrosis; antibiotics only if positive
D. Early enteral nutrition via nasogastric tube within 24 hours of admission
E. ERCP within 24 hours to decompress the pancreatic duct
✔ CORRECT ANSWER: C
RATIONALE & CLINICAL EXPLANATION
Current guidelines (ACG, IAP/APA): Prophylactic antibiotics are NOT recommended for sterile necrosis—they
increase antibiotic resistance without mortality benefit. CT-guided FNA distinguishes sterile from infected
necrosis (Gram stain/culture). Antibiotics are indicated only for documented infected necrosis. Surgery (A) is
generally delayed (step-up approach: percutaneous drainage first, then minimally invasive debridement if
needed). Choice D is correct for nutrition but not the MOST appropriate for this presentation with septic
physiology. ERCP (E) is indicated for biliary pancreatitis with cholangitis, not necrosis.
Question 10 of 75
An AGACNP is caring for a patient with new-onset ascites. Diagnostic paracentesis shows:
total protein 1.2 g/dL, albumin 0.8 g/dL, serum albumin 3.2 g/dL. SAAG is calculated as 2.4
g/dL. WBC 120 cells/mm3 (85% PMNs). Which diagnosis and management is MOST
appropriate?
A. Malignant ascites; refer to oncology for chemotherapy
B. Spontaneous bacterial peritonitis (SBP); cefotaxime 2g IV q8h + albumin 1.5 g/kg
pg. 5
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
C. Tuberculous peritonitis; initiate anti-tuberculosis therapy
D. Chylous ascites; initiate low-fat diet and octreotide
E. Cardiac ascites; initiate diuresis with furosemide and spironolactone
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
SAAG ≥1.1 g/dL indicates portal hypertension (hepatic etiology). PMN count ≥250 cells/mm3 in ascitic fluid =
SBP diagnosis, even without positive culture. Treatment: Cefotaxime (covers enteric organisms) + IV albumin
(1.5 g/kg on day 1, 1 g/kg on day 3) significantly reduces renal impairment and mortality (Sort trial). Malignant
ascites (A) has SAAG <1.1. TB peritonitis (C) is exudative with lymphocytic predominance. Chylous (D) shows
milky fluid. Cardiac ascites (E) has SAAG >1.1 but PMN count is typically normal.
Question 11 of 75
A 63-year-old female post-op day 1 following elective colectomy develops fever 38.9°C, HR
108, BP 100/65, RR 22, WBC 18,500. Wound site is intact. UA shows >100,000 CFU E. coli with
Foley catheter in place. Creatinine has risen from 0.9 to 1.8 mg/dL. Which intervention is
MOST appropriate?
A. Start ceftriaxone 1g IV q24h and maintain the Foley catheter
B. Remove the Foley catheter immediately; treat as catheter-associated UTI only if symptoms persist
C. Remove the Foley catheter, obtain blood cultures, and initiate empiric antibiotics
D. Change the Foley catheter over a guidewire and start nitrofurantoin
E. Obtain renal ultrasound and consult nephrology for acute kidney injury
✔ CORRECT ANSWER: C
RATIONALE & CLINICAL EXPLANATION
This patient meets SIRS criteria (fever, tachycardia, elevated WBC, elevated RR) with a likely source (CAUTI).
Per IDSA/CDC CAUTI guidelines: Remove Foley ASAP (most important intervention). However, given sepsis
criteria and AKI, blood cultures must be obtained before antibiotics and empiric IV antibiotics initiated (not oral
nitrofurantoin—C). Asymptomatic bacteriuria in catheterized patients does not require treatment—but this
patient is symptomatic with sepsis physiology. Changing catheter over guidewire (D) is never recommended.
Nephrology consult (E) is premature without addressing source.
Question 12 of 75
A 48-year-old male presents with substernal chest pain radiating to the back, BP 195/110 right
arm vs 162/88 left arm, pulse deficit, and widened mediastinum on CXR. CT angiography
shows a Type A aortic dissection. What is the MOST critical next step?
A. Administer IV heparin anticoagulation and admit to cardiac ICU for monitoring
B. Initiate IV labetalol to target HR <60 bpm and systolic BP <120 mmHg; emergent
cardiothoracic surgery
C. Administer tPA for thrombus dissolution and repeat CT in 6 hours
D. Perform emergent percutaneous coronary intervention to rule out concurrent MI
E. Begin nitroprusside infusion alone and consult interventional radiology for TEVAR
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
Type A aortic dissection (ascending) is a surgical emergency with 1-2% mortality per hour if untreated. Medical
management bridges to surgery: IV beta-blockers first (labetalol or esmolol) to reduce HR (<60 bpm) and BP
(systolic <120 mmHg), decreasing aortic wall stress (dP/dt). Then vasodilators if needed. Heparin (A) is
contraindicated—risks hemopericardium and tamponade. tPA (C) is absolutely contraindicated. PCI (D) is
pg. 6
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
unnecessary and delays surgery. Nitroprusside alone (E) causes reflex tachycardia worsening dissection;
TEVAR is for Type B.
Question 13 of 75
A 35-year-old female presents with progressive ascending weakness, areflexia, bilateral facial
weakness, and respiratory muscle involvement over 3 weeks following a GI illness. NCS/EMG
shows demyelinating polyneuropathy. CSF analysis: protein 285 mg/dL, WBC 3 cells/mm3.
Which is the MOST appropriate treatment?
A. High-dose IV methylprednisolone 1g/day for 5 days
B. Plasmapheresis (IVIG) OR intravenous immunoglobulin (IVIG) — either is equally effective
C. Oral prednisone taper over 6 weeks
D. Cyclophosphamide infusion for immunosuppression
E. Empiric broad-spectrum antibiotics for bacterial meningitis
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
Guillain-Barré syndrome (GBS) is confirmed by clinical presentation + albuminocytologic dissociation (high
protein, normal cells). Both plasmapheresis and IVIG are equally efficacious (Class I evidence, AAN
Guidelines). IVIG is preferred for ease of administration. Steroids (A, C) are NOT recommended—they do not
improve outcomes and may worsen recovery. Cyclophosphamide (D) has no role. Antibiotics (E) are
inappropriate given CSF and clinical picture. Key monitoring: FVC <20 mL/kg or NIF < -30 cmH2O = intubation
threshold.
Question 14 of 75
An AGACNP is evaluating a patient 48 hours after elective knee arthroplasty who develops
sudden pleuritic chest pain, dyspnea, O2 sat 89% on RA, HR 122, BP 108/72. CTA chest
shows bilateral segmental pulmonary emboli. BNP is 890 pg/mL, troponin 0.8 ng/mL. Echo
shows RV dilation with septal bowing. Which risk stratification and management is MOST
appropriate?
A. Low-risk PE; anticoagulate with rivaroxaban and discharge home
B. Massive PE; administer systemic tPA and ICU admission
C. Submassive (intermediate-high risk) PE; anticoagulate with UFH and consider catheter-
directed thrombolysis or surgical embolectomy
D. Intermediate-low risk PE; start LMWH and admit to step-down unit
E. High-risk PE; immediate surgical embolectomy is the only option
✔ CORRECT ANSWER: C
RATIONALE & CLINICAL EXPLANATION
This is submassive (intermediate-high risk) PE: hemodynamically STABLE but with RV dysfunction (echo: RV
dilation, septal bowing) AND myocardial injury (elevated troponin + BNP). PESI score is elevated.
Management: UFH anticoagulation + close ICU monitoring. If clinical deterioration occurs, catheter-directed
thrombolysis (CDT) or surgical embolectomy may be considered. Systemic tPA (B) is for MASSIVE PE
(hemodynamic compromise: SBP <90 for >15 min). The patient is hemodynamically borderline but not in
collapse. CDT offers targeted thrombolysis with lower bleeding risk than systemic tPA.
Question 15 of 75
A 66-year-old male with CKD stage 3 is prescribed lisinopril for hypertension. One week later,
potassium is 5.8 mEq/L, creatinine increased from 1.6 to 2.1 mg/dL (31% increase). His BP is
now 138/88 mmHg. How should the AGACNP manage this patient?
pg. 7
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
A. Discontinue lisinopril immediately and start amlodipine
B. Continue lisinopril; creatinine increase <30% and K+ elevation are expected and acceptable
C. Continue lisinopril; the creatinine increase is concerning, add furosemide for potassium
D. Switch to losartan which does not cause hyperkalemia or creatinine elevation
E. Reduce lisinopril dose by half and recheck labs in 48 hours
✔ CORRECT ANSWER: A
RATIONALE & CLINICAL EXPLANATION
ACEi-induced AKI: A creatinine increase >30% (this patient: 31%) from baseline indicates hemodynamically
significant renal impairment—typically from bilateral renal artery stenosis or severe renal hypoperfusion.
Combined with hyperkalemia (K+ 5.8), lisinopril should be discontinued. ARBs (D) would cause the same issue
(same mechanism). A creatinine increase <30% is generally acceptable with ACEi/ARB therapy. The key
cutoffs: >30% rise = hold/discontinue; K+ consistently >5.5 = reassess therapy. Dose reduction alone (E) may
not be sufficient with this degree of deterioration.
Question 16 of 75
A 71-year-old female is admitted to the neuro-ICU with a Hunt-Hess grade III subarachnoid
hemorrhage (SAH). Day 4 post-bleed, she develops new confusion and right arm weakness
not present on admission. CT angiography shows no re-bleeding. TCD shows elevated
velocities in the MCA (>200 cm/s). What is the MOST likely complication and treatment?
A. Hydrocephalus; emergent ventriculostomy placement
B. Re-bleeding from unsecured aneurysm; emergent coiling or clipping
C. Cerebral vasospasm; initiate Triple-H therapy (hypertension, hypervolemia, hemodilution)
D. Cerebral vasospasm; maintain euvolemia and induce hypertension with vasopressors
E. Hyponatremia from SIADH; restrict fluid to 1L/day
✔ CORRECT ANSWER: D
RATIONALE & CLINICAL EXPLANATION
TCD velocities >200 cm/s + new neurological deficits on day 4-14 post-SAH = cerebral vasospasm. Modern
guidelines (Neurocritical Care Society 2023) have shifted AWAY from classic Triple-H therapy. Current
evidence supports: euvolemia (NOT hypervolemia—hypervolemia shows no benefit and risks pulmonary
edema) + induced hypertension (vasopressors to raise MAP 20-25% above baseline). Nimodipine (oral
calcium channel blocker) prevents vasospasm and must be continued. Endovascular therapy (IA
vasodilators/angioplasty) is reserved for refractory cases. Hydrocephalus (A) causes gradual decline, not focal
deficits.
Question 17 of 75
A 55-year-old male presents with acute liver failure. INR 3.8, total bilirubin 22 mg/dL,
creatinine 3.1 mg/dL, ammonia 210 mcg/dL, grade III encephalopathy. Acetaminophen level is
42 mcg/mL at 12 hours post-ingestion. Which treatment is MOST critical to initiate
immediately?
A. N-acetylcysteine (NAC) IV infusion, regardless of time since ingestion
B. Liver transplant evaluation only; NAC ineffective >10 hours post-ingestion
C. Fresh frozen plasma to correct coagulopathy and prevent bleeding
D. Lactulose enemas and rifaximin for hepatic encephalopathy management
E. Hemodialysis for acetaminophen removal and renal protection
✔ CORRECT ANSWER: A
pg. 8
,NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
RATIONALE & CLINICAL EXPLANATION
NAC is the antidote for acetaminophen toxicity AND is beneficial in ALL causes of acute liver failure (not just
APAP) when given early. Even beyond 24 hours post-ingestion, IV NAC improves transplant-free survival in
APAP-induced ALF (Cochrane evidence). NAC replenishes glutathione stores and has anti-inflammatory
effects. Time to transplant evaluation is also critical (King's College Criteria). FFP (C) should NOT be given
prophylactically—INR is used as a prognostic marker. Lactulose (D) can cause aspiration; rifaximin is
preferred. Hemodialysis (E) has limited evidence for APAP removal.
Question 18 of 75
An AGACNP is managing a mechanically ventilated patient with suspected hospital-acquired
pneumonia (HAP) on day 7 of hospitalization. What is the MOST appropriate empiric antibiotic
regimen considering MDR organism risk?
A. Azithromycin + ceftriaxone (community-acquired pneumonia coverage)
B. Piperacillin-tazobactam + vancomycin
C. Meropenem + colistin (for pan-resistant organisms)
D. Ciprofloxacin monotherapy (adequate gram-negative coverage)
E. Ceftriaxone + metronidazole (aspiration pneumonia coverage)
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
IDSA/ATS HAP/VAP 2016 Guidelines: HAP with MDR risk factors (≥5 days hospitalization, prior antibiotic use,
structural lung disease) requires coverage for MRSA (vancomycin or linezolid) and anti-pseudomonal gram-
negatives (piperacillin-tazobactam, cefepime, meropenem, or aztreonam). The combination piperacillin-
tazobactam + vancomycin covers most HAP pathogens. CAP regimen (A) is insufficient for HAP. Colistin (C) is
reserved for pan-resistant MDR organisms. Fluoroquinolone monotherapy (D) has insufficient gram-positive
coverage. De-escalate based on culture results.
Question 19 of 75
A 42-year-old female with systemic lupus erythematosus presents with sudden onset
dyspnea, pleuritic chest pain, fever 39.1°C, and a new pericardial friction rub. ECG shows
diffuse ST elevation and PR depression in all leads except aVR. Echo shows 500 mL
pericardial effusion without tamponade. Anti-dsDNA is elevated. What is the MOST
appropriate initial treatment?
A. NSAIDs + colchicine for idiopathic pericarditis
B. High-dose corticosteroids for lupus serositis
C. Pericardiocentesis for diagnostic and therapeutic drainage
D. IV methylprednisolone + hydroxychloroquine continuation + colchicine
E. Methotrexate and pericardial window for recurrent pericarditis
✔ CORRECT ANSWER: D
RATIONALE & CLINICAL EXPLANATION
Lupus pericarditis with significant effusion (500 mL) and active serology (elevated anti-dsDNA, fever) requires
systemic immunosuppression. High-dose corticosteroids (methylprednisolone 1 mg/kg/day) are first-line for
lupus serositis with significant effusion. Hydroxychloroquine should be continued as maintenance therapy.
Colchicine provides additive anti-inflammatory benefit. NSAIDs (A) are used for idiopathic/viral pericarditis, not
lupus. Pericardiocentesis (C) is not indicated without tamponade. Methotrexate (E) is for refractory disease.
NSAIDs can worsen lupus nephritis.
Question 20 of 75
pg. 9
, NR 572 / NR572 | Advanced Acute Care Management | Midterm Exam 2025/2026
A 70-year-old male post-cardiac arrest with ROSC is admitted to the ICU. He is unresponsive
(GCS 5), hemodynamically stable with MAP 85 mmHg. His core temperature is 36.2°C. Which
intervention provides the STRONGEST evidence for neurological outcome improvement?
A. Targeted Temperature Management (TTM) at 33°C for 24 hours
B. Prevent fever (T>37.5°C) with active temperature control at 36°C
C. Active normothermia at 36°C; aggressive early rewarming to 38°C has benefit
D. Immediate therapeutic hypothermia at 32°C for 48 hours
E. Temperature management is no longer recommended based on TTM2 trial
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
The TTM2 trial (NEJM 2021) compared TTM at 33°C vs targeted normothermia (avoiding fever >37.8°C) and
found NO significant difference in mortality or neurological outcomes at 6 months. Current AHA/ERC 2021
guidelines recommend: Fever prevention (T>37.5-38°C) with active temperature management targeting 36°C
for at least 72 hours post-arrest. Temperature management IS still recommended (E is wrong)—fever is
independently harmful post-ROSC. TTM at 32-36°C may still be used (A, D), but the evidence now supports
fever prevention as the minimum standard.
Question 21 of 75
A 58-year-old male with metastatic non-small cell lung cancer is admitted with acute altered
mental status. Serum calcium is 14.8 mg/dL (ionized: 1.85 mmol/L), creatinine 2.0 mg/dL, BUN
42. ECG shows shortened QTc and J-waves. Symptoms include polyuria, polydipsia,
constipation, and confusion. What is the MOST appropriate initial management?
A. Furosemide 80 mg IV and restrict IV fluids
B. Aggressive IV normal saline hydration + calcitonin + zoledronic acid
C. IV pamidronate alone; it is the most effective single agent
D. Dialysis immediately for severe symptomatic hypercalcemia
E. Oral bisphosphonate + IV normal saline hydration
✔ CORRECT ANSWER: B
RATIONALE & CLINICAL EXPLANATION
Hypercalcemia of malignancy management: 1) IV NS resuscitation (2-4L/day—restore volume first, most
critical step); 2) Calcitonin 4 units/kg q12h (fastest onset, 4-6 hours, but tachyphylaxis in 48-72 hours); 3) IV
bisphosphonate (zoledronic acid preferred—onset 2-4 days, sustained 3-4 weeks). Furosemide (A) is NO
longer recommended upfront—give fluids first. Pamidronate alone (C) has delayed onset. Dialysis (D) is
reserved for refractory cases or severe renal failure. Oral bisphosphonates (E) are not effective in acute severe
hypercalcemia. The combination addresses all phases simultaneously.
Question 22 of 75
A 48-year-old female is found unresponsive with miosis, bradycardia (HR 45), hypotension
(BP 78/50), hypersalivation, bronchospasm, and urinary incontinence. Her skin is diaphoretic.
Which antidote and mechanism is MOST appropriate?
A. Naloxone 0.4 mg IV; opioid receptor antagonist
B. Atropine 2-4 mg IV + pralidoxime (2-PAM); anticholinergic + oxime for organophosphate
toxicity
C. Physostigmine 2 mg IV; acetylcholinesterase inhibitor for anticholinergic syndrome
D. Flumazenil 0.2 mg IV; benzodiazepine receptor antagonist
E. Sodium bicarbonate 1-2 mEq/kg IV; TCA toxicity reversal
pg. 10
