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Kaplan Clinical Judgment Exam | 150 NGN Case
Study Questions and Answers
CASE STUDY 1: Acute Coronary Syndrome (Questions 1–10)
Scenario: A 62-year-old male arrives at the emergency department with
substernal chest pressure radiating to the left arm, diaphoresis, and nausea that
began 45 minutes ago. He has a history of hypertension, type 2 diabetes, and a
30-pack-year smoking history. Vital signs: BP 148/92, HR 108 irregular, RR 22,
SpO₂ 94% on room air. ECG shows ST-segment elevation in leads II, III, and aVF.
1. Recognize Cues – Which findings in the scenario are most concerning for an
acute inferior wall myocardial infarction? (Select all that apply)
A. ST elevation in leads II, III, aVF
B. Diaphoresis and nausea
C. History of hypertension
D. Smoking history
E. Substernal chest pressure radiating to left arm
Answer: A, B, E
Rationale: ST elevation in inferior leads directly indicates an acute myocardial
infarction. Diaphoresis, nausea, and radiation to the left arm are classic
autonomic and referred pain symptoms of MI. Hypertension and smoking history
are risk factors, but not acute diagnostic clues.
2. Analyze Cues – The ECG shows ST elevation in II, III, aVF. Which coronary
artery is most likely occluded?
A. Left anterior descending
B. Right coronary artery
C. Left circumflex
D. Left main
pg. 1
,2
Answer: B
Rationale: The inferior wall is typically supplied by the right coronary artery (RCA)
in right-dominant circulations. LAD (A) supplies the anterior wall. Left circumflex
(C) supplies the lateral wall. Left main (D) is a catastrophic occlusion affecting
both territories.
3. Prioritize Hypotheses – The patient’s chest pain began 45 minutes ago. What
is the priority intervention?
A. Administer sublingual nitroglycerin
B. Obtain a chest x-ray
C. Prepare for emergent percutaneous coronary intervention (PCI)
D. Start a heparin infusion
Answer: C
Rationale: For STEMI with symptom onset <90 minutes, the priority is reperfusion
via PCI (door-to-balloon time ≤90 minutes). Nitroglycerin (A) provides temporary
relief but does not restore perfusion. Chest x-ray (B) is not a priority. Heparin (D)
is an adjunct, not the primary intervention.
4. Generate Solutions – The patient is being prepared for PCI. Which
medications should be administered immediately? (Select all that apply)
A. Aspirin 325 mg chewed
B. Atorvastatin 80 mg PO
C. Morphine 4 mg IV
D. Clopidogrel 600 mg PO
E. Oxygen to maintain SpO₂ ≥94%
Answer: A, B, D
Rationale: Aspirin and a P2Y12 inhibitor (clopidogrel) are essential antiplatelet
agents for PCI. High-intensity statin (atorvastatin) is given early. Morphine (C) is
reserved for pain not relieved by nitrates and is not a routine requirement.
Oxygen (E) is only given if SpO₂ <90% per current guidelines.
pg. 2
,3
5. Take Actions – The patient becomes hypotensive (80/50) and bradycardic (HR
44) after nitroglycerin administration. Which action should the nurse take first?
A. Administer atropine 0.5 mg IV
B. Start a dopamine infusion
C. Place the patient in Trendelenburg position
D. Stop nitroglycerin and administer normal saline bolus
Answer: D
Rationale: Nitroglycerin can cause severe hypotension, especially in inferior MI
with right ventricular involvement. The first step is to stop the offending drug and
give fluids to increase preload. Atropine (A) may be needed for persistent
bradycardia. Dopamine (B) is second-line. Trendelenburg (C) is no longer
recommended.
6. Evaluate Outcomes – After PCI, the patient’s chest pain resolves, and ST
segments return to baseline. Which finding indicates a successful reperfusion?
A. Troponin rises from 2 to 15 ng/mL
B. Appearance of new Q waves
C. Resolution of ST elevation and relief of chest pain
D. Persistent tachycardia
Answer: C
Rationale: Successful reperfusion is indicated by resolution of ST elevation and
cessation of pain. Troponin (A) peaks due to washout and does not indicate
failure. New Q waves (B) may signify completed infarction. Tachycardia (D) is a
non-specific sign.
7. Recognize Cues – The nurse notes the patient has a new holosystolic murmur
at the apex radiating to the axilla. Which complication is suspected?
A. Ventricular septal rupture
B. Papillary muscle rupture causing acute mitral regurgitation
C. Pericarditis
D. Aortic dissection
pg. 3
, 4
Answer: B
Rationale: A holosystolic murmur at the apex radiating to the axilla after an MI
suggests papillary muscle rupture leading to acute mitral regurgitation. A VSD (A)
murmur is heard at the left sternal border. Pericarditis (C) has a friction rub.
8. Analyze Cues – The patient’s BP is 85/50, HR 120, and crackles are heard
bilaterally. Pulmonary artery catheter shows pulmonary capillary wedge
pressure (PCWP) 28 mmHg. What is the likely cause?
A. Hypovolemic shock
B. Cardiogenic shock from pump failure
C. Septic shock
D. Neurogenic shock
Answer: B
Rationale: Elevated PCWP (normal 8–12 mmHg) indicates left ventricular failure
with pulmonary congestion. The hypotension and tachycardia point to
cardiogenic shock. Hypovolemic shock (A) would have low PCWP. Septic (C) would
have normal or low PCWP with decreased SVR. Neurogenic (D) is associated with
bradycardia and loss of sympathetic tone.
9. Generate Solutions – The patient is in cardiogenic shock. Which
pharmacological intervention is most appropriate?
A. Dobutamine infusion
B. Norepinephrine infusion
C. Furosemide IV push
D. Metoprolol IV
Answer: A
Rationale: Dobutamine is a positive inotrope that improves cardiac output in
cardiogenic shock. Norepinephrine (B) is a vasopressor that may be added if
dobutamine fails. Furosemide (C) may worsen hypotension by reducing preload.
Beta-blockers (D) are contraindicated in acute shock.
pg. 4
Kaplan Clinical Judgment Exam | 150 NGN Case
Study Questions and Answers
CASE STUDY 1: Acute Coronary Syndrome (Questions 1–10)
Scenario: A 62-year-old male arrives at the emergency department with
substernal chest pressure radiating to the left arm, diaphoresis, and nausea that
began 45 minutes ago. He has a history of hypertension, type 2 diabetes, and a
30-pack-year smoking history. Vital signs: BP 148/92, HR 108 irregular, RR 22,
SpO₂ 94% on room air. ECG shows ST-segment elevation in leads II, III, and aVF.
1. Recognize Cues – Which findings in the scenario are most concerning for an
acute inferior wall myocardial infarction? (Select all that apply)
A. ST elevation in leads II, III, aVF
B. Diaphoresis and nausea
C. History of hypertension
D. Smoking history
E. Substernal chest pressure radiating to left arm
Answer: A, B, E
Rationale: ST elevation in inferior leads directly indicates an acute myocardial
infarction. Diaphoresis, nausea, and radiation to the left arm are classic
autonomic and referred pain symptoms of MI. Hypertension and smoking history
are risk factors, but not acute diagnostic clues.
2. Analyze Cues – The ECG shows ST elevation in II, III, aVF. Which coronary
artery is most likely occluded?
A. Left anterior descending
B. Right coronary artery
C. Left circumflex
D. Left main
pg. 1
,2
Answer: B
Rationale: The inferior wall is typically supplied by the right coronary artery (RCA)
in right-dominant circulations. LAD (A) supplies the anterior wall. Left circumflex
(C) supplies the lateral wall. Left main (D) is a catastrophic occlusion affecting
both territories.
3. Prioritize Hypotheses – The patient’s chest pain began 45 minutes ago. What
is the priority intervention?
A. Administer sublingual nitroglycerin
B. Obtain a chest x-ray
C. Prepare for emergent percutaneous coronary intervention (PCI)
D. Start a heparin infusion
Answer: C
Rationale: For STEMI with symptom onset <90 minutes, the priority is reperfusion
via PCI (door-to-balloon time ≤90 minutes). Nitroglycerin (A) provides temporary
relief but does not restore perfusion. Chest x-ray (B) is not a priority. Heparin (D)
is an adjunct, not the primary intervention.
4. Generate Solutions – The patient is being prepared for PCI. Which
medications should be administered immediately? (Select all that apply)
A. Aspirin 325 mg chewed
B. Atorvastatin 80 mg PO
C. Morphine 4 mg IV
D. Clopidogrel 600 mg PO
E. Oxygen to maintain SpO₂ ≥94%
Answer: A, B, D
Rationale: Aspirin and a P2Y12 inhibitor (clopidogrel) are essential antiplatelet
agents for PCI. High-intensity statin (atorvastatin) is given early. Morphine (C) is
reserved for pain not relieved by nitrates and is not a routine requirement.
Oxygen (E) is only given if SpO₂ <90% per current guidelines.
pg. 2
,3
5. Take Actions – The patient becomes hypotensive (80/50) and bradycardic (HR
44) after nitroglycerin administration. Which action should the nurse take first?
A. Administer atropine 0.5 mg IV
B. Start a dopamine infusion
C. Place the patient in Trendelenburg position
D. Stop nitroglycerin and administer normal saline bolus
Answer: D
Rationale: Nitroglycerin can cause severe hypotension, especially in inferior MI
with right ventricular involvement. The first step is to stop the offending drug and
give fluids to increase preload. Atropine (A) may be needed for persistent
bradycardia. Dopamine (B) is second-line. Trendelenburg (C) is no longer
recommended.
6. Evaluate Outcomes – After PCI, the patient’s chest pain resolves, and ST
segments return to baseline. Which finding indicates a successful reperfusion?
A. Troponin rises from 2 to 15 ng/mL
B. Appearance of new Q waves
C. Resolution of ST elevation and relief of chest pain
D. Persistent tachycardia
Answer: C
Rationale: Successful reperfusion is indicated by resolution of ST elevation and
cessation of pain. Troponin (A) peaks due to washout and does not indicate
failure. New Q waves (B) may signify completed infarction. Tachycardia (D) is a
non-specific sign.
7. Recognize Cues – The nurse notes the patient has a new holosystolic murmur
at the apex radiating to the axilla. Which complication is suspected?
A. Ventricular septal rupture
B. Papillary muscle rupture causing acute mitral regurgitation
C. Pericarditis
D. Aortic dissection
pg. 3
, 4
Answer: B
Rationale: A holosystolic murmur at the apex radiating to the axilla after an MI
suggests papillary muscle rupture leading to acute mitral regurgitation. A VSD (A)
murmur is heard at the left sternal border. Pericarditis (C) has a friction rub.
8. Analyze Cues – The patient’s BP is 85/50, HR 120, and crackles are heard
bilaterally. Pulmonary artery catheter shows pulmonary capillary wedge
pressure (PCWP) 28 mmHg. What is the likely cause?
A. Hypovolemic shock
B. Cardiogenic shock from pump failure
C. Septic shock
D. Neurogenic shock
Answer: B
Rationale: Elevated PCWP (normal 8–12 mmHg) indicates left ventricular failure
with pulmonary congestion. The hypotension and tachycardia point to
cardiogenic shock. Hypovolemic shock (A) would have low PCWP. Septic (C) would
have normal or low PCWP with decreased SVR. Neurogenic (D) is associated with
bradycardia and loss of sympathetic tone.
9. Generate Solutions – The patient is in cardiogenic shock. Which
pharmacological intervention is most appropriate?
A. Dobutamine infusion
B. Norepinephrine infusion
C. Furosemide IV push
D. Metoprolol IV
Answer: A
Rationale: Dobutamine is a positive inotrope that improves cardiac output in
cardiogenic shock. Norepinephrine (B) is a vasopressor that may be added if
dobutamine fails. Furosemide (C) may worsen hypotension by reducing preload.
Beta-blockers (D) are contraindicated in acute shock.
pg. 4
