PFCCS EXAM 2024/ WITH ALL CORRECT
ANSWERS!!
1. A patient with septic shock has a cardiac index of 2.2 L/min/m², pulmonary artery occlusion
pressure of 18 mmHg, and systemic vascular resistance of 600 dyn·s/cm u. After fluid resuscitation,
mean arterial pressure remains 55 mmHg. Which intervention is most appropriate next?
A. Initiate norepinephrine and reassess
B. Administer dobutamine for inotropic support
C. Start vasopressin as first-line agent
D. Titrate nitroglycerin to reduce preload
Answer: A
Rationale: Norepinephrine is the first-line vasopressor for septic shock per Surviving Sepsis Campaign
guidelines. The patient remains hypotensive despite adequate preload (PAOP 18) and low SVR;
dobutamine may increase cardiac output but could worsen hypotension. Vasopressin is second-line, and
nitroglycerin would exacerbate hypotension.
2. In a patient with acute respiratory distress syndrome (ARDS) on volume-controlled ventilation,
plateau pressure is 32 cmH ‚O, PEEP is 10 cmH ‚O, and tidal volume is 6 mL/kg predicted body
weight. Arterial blood gas shows pH 7.25, PaCO ‚ 60 mmHg, PaO ‚ 75 mmHg. Which ventilator
adjustment is most appropriate?
A. Increase tidal volume to 8 mL/kg to improve ventilation
B. Increase PEEP to 15 cmH ‚O to recruit alveoli
C. Increase respiratory rate to 30 breaths/min
D. Switch to pressure-controlled ventilation with same settings
Answer: C
Rationale: The patient has hypercapnic acidosis (pH 7.25) with plateau pressure already at the upper
limit (32 cmH ‚O). Increasing tidal volume would risk volutrauma. Increasing PEEP may further
increase plateau pressure. Increasing respiratory rate can enhance minute ventilation and lower PaCO ‚
without raising plateau pressure. Pressure-controlled ventilation may not guarantee tidal volume.
3. A patient with traumatic brain injury has an intracranial pressure (ICP) of 28 mmHg and
cerebral perfusion pressure (CPP) of 50 mmHg. Which intervention should be performed first?
A. Administer mannitol 1 g/kg IV
B. Elevate head of bed to 30 degrees
C. Start therapeutic hypothermia to 34°C
D. Perform decompressive craniectomy
Answer: B
Rationale: Elevating the head of bed improves cerebral venous drainage and can lower ICP quickly,
potentially restoring CPP. Mannitol is indicated after ensuring no hypovolemia. Hypothermia is a
second-tier therapy. Decompressive craniectomy is reserved for refractory intracranial hypertension.
Page 1
,4. Which of the following best describes the mechanism of action of levosimendan in acute
decompensated heart failure?
A. Phosphodiesterase-3 inhibition increasing cAMP in myocytes
B. Calcium sensitization of troponin C without increasing intracellular calcium
C. Beta-1 receptor agonism leading to increased contractility
D. Inhibition of sodium-potassium ATPase increasing intracellular sodium
Answer: B
Rationale: Levosimendan is a calcium sensitizer that binds to troponin C, enhancing myocyte
contractility without raising intracellular calcium, thus avoiding arrhythmias. PDE-3 inhibitors (e.g.,
milrinone) increase cAMP. Beta-agonists (e.g., dobutamine) increase cAMP. Digoxin inhibits Na+/K+
ATPase.
5. A patient with cirrhosis and ascites develops acute kidney injury. Urine sodium is 8 mEq/L,
fractional excretion of sodium is <1%, and there is no response to albumin withdrawal. Which
diagnosis is most consistent?
A. Acute tubular necrosis
B. Prerenal azotemia due to hypovolemia
C. Hepatorenal syndrome type 1
D. Acute interstitial nephritis
Answer: C
Rationale: Low urine sodium and FeNa <1% suggest prerenal physiology, but lack of response to volume
expansion (albumin withdrawal) points to hepatorenal syndrome. ATN typically has FeNa >2%.
Prerenal azotemia would improve with volume. Interstitial nephritis often has FeNa >1% and other
features like fever or rash.
6. In a patient with severe acute pancreatitis, which finding is most associated with the need for
early endoscopic retrograde cholangiopancreatography (ERCP)?
A. Serum lipase > 3 times upper limit of normal
B. Evidence of cholangitis with biliary obstruction
C. CT scan showing peripancreatic fluid collections
D. Elevated blood urea nitrogen and creatinine
Answer: B
Rationale: Early ERCP is indicated in acute pancreatitis when there is concomitant cholangitis or biliary
obstruction. Lipase elevation alone does not indicate obstruction. Fluid collections are managed
conservatively. BUN and creatinine elevation suggest severity but not need for ERCP.
7. A patient on continuous renal replacement therapy (CRRT) develops hypophosphatemia. Which
of the following is the most appropriate replacement strategy?
A. Administer oral phosphate supplements
B. Add sodium phosphate to the CRRT replacement fluid
C. Give intravenous potassium phosphate over 6 hours
D. Increase the CRRT dose to correct electrolyte imbalance
Page 2
,Answer: B
Rationale: Adding phosphate to the CRRT replacement fluid is efficient and avoids intravenous bolus
risks. Oral supplements may be poorly absorbed. IV potassium phosphate can cause hyperkalemia or
calcium precipitation. Increasing CRRT dose would worsen hypophosphatemia.
8. Which of the following ventilator waveforms suggests the presence of dynamic hyperinflation
(auto-PEEP) in a patient with obstructive lung disease?
A. Flow waveform showing expiratory flow not returning to zero before next inspiration
B. Pressure waveform showing a plateau pressure above 30 cmH ‚O
C. Volume waveform showing a tidal volume less than set
D. Flow-volume loop showing a concave expiratory limb
Answer: A
Rationale: In dynamic hyperinflation, expiratory flow does not return to zero before the next breath,
indicating incomplete exhalation and gas trapping. Plateau pressure >30 may indicate low compliance
but not specifically auto-PEEP. Concave expiratory limb suggests obstruction but not necessarily
dynamic hyperinflation.
9. A patient with refractory status epilepticus is on a midazolam infusion. Which of the following is
the most appropriate next step if seizures continue despite titrating to burst suppression?
A. Switch to propofol infusion
B. Add phenytoin loading dose
C. Administer pyridoxine
D. Perform video EEG monitoring
Answer: C
Rationale: Pyridoxine (vitamin B6) is indicated for refractory status epilepticus, especially in cases of
isoniazid toxicity or pyridoxine-dependent epilepsy. Propofol is another anesthetic but not the next step
if midazolam is already at burst suppression. Phenytoin is less effective in refractory status. Video EEG
is diagnostic but not therapeutic.
10. A patient with a pulmonary embolism and right ventricular strain develops hypotension.
Which of the following is the most appropriate immediate management?
A. Administer thrombolytic therapy
B. Start intravenous heparin infusion
C. Place an inferior vena cava filter
D. Perform surgical embolectomy
Answer: A
Rationale: In massive PE with hypotension and RV strain, thrombolytic therapy is indicated to rapidly
reduce clot burden. Heparin is for stable PE. IVC filter does not treat existing clot. Embolectomy is
reserved if thrombolysis contraindicated or fails.
Page 3
, 11. A patient with acute respiratory distress syndrome (ARDS) is managed with lung-protective
ventilation. The provider sets tidal volume at 6 mL/kg predicted body weight (PBW) and plateau
pressure target "d30 cm H2O. Despite these settings, the patient's PaCO2 rises to 68 mm Hg with
pH 7.20. Which of the following interventions is most appropriate to address the hypercapnia while
maintaining lung protection?
A. Increase tidal volume to 8 mL/kg PBW
B. Increase respiratory rate to 35 breaths/min
C. Administer sodium bicarbonate infusion
D. Switch to pressure-controlled ventilation
Answer: B
Rationale: Increasing respiratory rate can enhance minute ventilation and reduce PaCO2 without
increasing tidal volume or plateau pressure, thus maintaining lung protection. Increasing tidal volume
would risk ventilator-induced lung injury. Sodium bicarbonate is not recommended for acute respiratory
acidosis. Switching to pressure-controlled ventilation does not directly address hypercapnia.
12. In a patient with septic shock requiring norepinephrine at 0.5 mcg/kg/min with mean arterial
pressure (MAP) still 55 mm Hg, which of the following is the next best step according to current
Surviving Sepsis Campaign guidelines?
A. Add vasopressin 0.03 units/min
B. Increase norepinephrine to 0.8 mcg/kg/min
C. Start dobutamine 5 mcg/kg/min
D. Administer hydrocortisone 200 mg/day
Answer: A
Rationale: Guidelines recommend adding vasopressin as a second-line agent when norepinephrine dose
exceeds 0.25-0.5 mcg/kg/min to achieve target MAP. Increasing norepinephrine further may increase
adverse effects. Dobutamine is indicated for myocardial dysfunction. Hydrocortisone is considered only
if vasopressors are insufficient despite adequate fluid resuscitation.
13. A patient with traumatic brain injury (TBI) has intracranial pressure (ICP) of 28 mm Hg
despite sedation, head-of-bed elevation, and mild hyperventilation (PaCO2 32 mm Hg). The
cerebral perfusion pressure (CPP) is 50 mm Hg. Which intervention is most appropriate?
A. Administer 1 g/kg mannitol IV
B. Further hyperventilate to PaCO2 25 mm Hg
C. Initiate therapeutic hypothermia to 33°C
D. Decrease mean arterial pressure to reduce ICP
Answer: A
Rationale: Mannitol is an osmotic diuretic that reduces ICP by drawing water from brain tissue, and is
indicated for acute ICP elevation. Further hyperventilation risks cerebral ischemia. Therapeutic
hypothermia is not routinely recommended. Decreasing MAP would lower CPP further, worsening
ischemia.
Page 4
ANSWERS!!
1. A patient with septic shock has a cardiac index of 2.2 L/min/m², pulmonary artery occlusion
pressure of 18 mmHg, and systemic vascular resistance of 600 dyn·s/cm u. After fluid resuscitation,
mean arterial pressure remains 55 mmHg. Which intervention is most appropriate next?
A. Initiate norepinephrine and reassess
B. Administer dobutamine for inotropic support
C. Start vasopressin as first-line agent
D. Titrate nitroglycerin to reduce preload
Answer: A
Rationale: Norepinephrine is the first-line vasopressor for septic shock per Surviving Sepsis Campaign
guidelines. The patient remains hypotensive despite adequate preload (PAOP 18) and low SVR;
dobutamine may increase cardiac output but could worsen hypotension. Vasopressin is second-line, and
nitroglycerin would exacerbate hypotension.
2. In a patient with acute respiratory distress syndrome (ARDS) on volume-controlled ventilation,
plateau pressure is 32 cmH ‚O, PEEP is 10 cmH ‚O, and tidal volume is 6 mL/kg predicted body
weight. Arterial blood gas shows pH 7.25, PaCO ‚ 60 mmHg, PaO ‚ 75 mmHg. Which ventilator
adjustment is most appropriate?
A. Increase tidal volume to 8 mL/kg to improve ventilation
B. Increase PEEP to 15 cmH ‚O to recruit alveoli
C. Increase respiratory rate to 30 breaths/min
D. Switch to pressure-controlled ventilation with same settings
Answer: C
Rationale: The patient has hypercapnic acidosis (pH 7.25) with plateau pressure already at the upper
limit (32 cmH ‚O). Increasing tidal volume would risk volutrauma. Increasing PEEP may further
increase plateau pressure. Increasing respiratory rate can enhance minute ventilation and lower PaCO ‚
without raising plateau pressure. Pressure-controlled ventilation may not guarantee tidal volume.
3. A patient with traumatic brain injury has an intracranial pressure (ICP) of 28 mmHg and
cerebral perfusion pressure (CPP) of 50 mmHg. Which intervention should be performed first?
A. Administer mannitol 1 g/kg IV
B. Elevate head of bed to 30 degrees
C. Start therapeutic hypothermia to 34°C
D. Perform decompressive craniectomy
Answer: B
Rationale: Elevating the head of bed improves cerebral venous drainage and can lower ICP quickly,
potentially restoring CPP. Mannitol is indicated after ensuring no hypovolemia. Hypothermia is a
second-tier therapy. Decompressive craniectomy is reserved for refractory intracranial hypertension.
Page 1
,4. Which of the following best describes the mechanism of action of levosimendan in acute
decompensated heart failure?
A. Phosphodiesterase-3 inhibition increasing cAMP in myocytes
B. Calcium sensitization of troponin C without increasing intracellular calcium
C. Beta-1 receptor agonism leading to increased contractility
D. Inhibition of sodium-potassium ATPase increasing intracellular sodium
Answer: B
Rationale: Levosimendan is a calcium sensitizer that binds to troponin C, enhancing myocyte
contractility without raising intracellular calcium, thus avoiding arrhythmias. PDE-3 inhibitors (e.g.,
milrinone) increase cAMP. Beta-agonists (e.g., dobutamine) increase cAMP. Digoxin inhibits Na+/K+
ATPase.
5. A patient with cirrhosis and ascites develops acute kidney injury. Urine sodium is 8 mEq/L,
fractional excretion of sodium is <1%, and there is no response to albumin withdrawal. Which
diagnosis is most consistent?
A. Acute tubular necrosis
B. Prerenal azotemia due to hypovolemia
C. Hepatorenal syndrome type 1
D. Acute interstitial nephritis
Answer: C
Rationale: Low urine sodium and FeNa <1% suggest prerenal physiology, but lack of response to volume
expansion (albumin withdrawal) points to hepatorenal syndrome. ATN typically has FeNa >2%.
Prerenal azotemia would improve with volume. Interstitial nephritis often has FeNa >1% and other
features like fever or rash.
6. In a patient with severe acute pancreatitis, which finding is most associated with the need for
early endoscopic retrograde cholangiopancreatography (ERCP)?
A. Serum lipase > 3 times upper limit of normal
B. Evidence of cholangitis with biliary obstruction
C. CT scan showing peripancreatic fluid collections
D. Elevated blood urea nitrogen and creatinine
Answer: B
Rationale: Early ERCP is indicated in acute pancreatitis when there is concomitant cholangitis or biliary
obstruction. Lipase elevation alone does not indicate obstruction. Fluid collections are managed
conservatively. BUN and creatinine elevation suggest severity but not need for ERCP.
7. A patient on continuous renal replacement therapy (CRRT) develops hypophosphatemia. Which
of the following is the most appropriate replacement strategy?
A. Administer oral phosphate supplements
B. Add sodium phosphate to the CRRT replacement fluid
C. Give intravenous potassium phosphate over 6 hours
D. Increase the CRRT dose to correct electrolyte imbalance
Page 2
,Answer: B
Rationale: Adding phosphate to the CRRT replacement fluid is efficient and avoids intravenous bolus
risks. Oral supplements may be poorly absorbed. IV potassium phosphate can cause hyperkalemia or
calcium precipitation. Increasing CRRT dose would worsen hypophosphatemia.
8. Which of the following ventilator waveforms suggests the presence of dynamic hyperinflation
(auto-PEEP) in a patient with obstructive lung disease?
A. Flow waveform showing expiratory flow not returning to zero before next inspiration
B. Pressure waveform showing a plateau pressure above 30 cmH ‚O
C. Volume waveform showing a tidal volume less than set
D. Flow-volume loop showing a concave expiratory limb
Answer: A
Rationale: In dynamic hyperinflation, expiratory flow does not return to zero before the next breath,
indicating incomplete exhalation and gas trapping. Plateau pressure >30 may indicate low compliance
but not specifically auto-PEEP. Concave expiratory limb suggests obstruction but not necessarily
dynamic hyperinflation.
9. A patient with refractory status epilepticus is on a midazolam infusion. Which of the following is
the most appropriate next step if seizures continue despite titrating to burst suppression?
A. Switch to propofol infusion
B. Add phenytoin loading dose
C. Administer pyridoxine
D. Perform video EEG monitoring
Answer: C
Rationale: Pyridoxine (vitamin B6) is indicated for refractory status epilepticus, especially in cases of
isoniazid toxicity or pyridoxine-dependent epilepsy. Propofol is another anesthetic but not the next step
if midazolam is already at burst suppression. Phenytoin is less effective in refractory status. Video EEG
is diagnostic but not therapeutic.
10. A patient with a pulmonary embolism and right ventricular strain develops hypotension.
Which of the following is the most appropriate immediate management?
A. Administer thrombolytic therapy
B. Start intravenous heparin infusion
C. Place an inferior vena cava filter
D. Perform surgical embolectomy
Answer: A
Rationale: In massive PE with hypotension and RV strain, thrombolytic therapy is indicated to rapidly
reduce clot burden. Heparin is for stable PE. IVC filter does not treat existing clot. Embolectomy is
reserved if thrombolysis contraindicated or fails.
Page 3
, 11. A patient with acute respiratory distress syndrome (ARDS) is managed with lung-protective
ventilation. The provider sets tidal volume at 6 mL/kg predicted body weight (PBW) and plateau
pressure target "d30 cm H2O. Despite these settings, the patient's PaCO2 rises to 68 mm Hg with
pH 7.20. Which of the following interventions is most appropriate to address the hypercapnia while
maintaining lung protection?
A. Increase tidal volume to 8 mL/kg PBW
B. Increase respiratory rate to 35 breaths/min
C. Administer sodium bicarbonate infusion
D. Switch to pressure-controlled ventilation
Answer: B
Rationale: Increasing respiratory rate can enhance minute ventilation and reduce PaCO2 without
increasing tidal volume or plateau pressure, thus maintaining lung protection. Increasing tidal volume
would risk ventilator-induced lung injury. Sodium bicarbonate is not recommended for acute respiratory
acidosis. Switching to pressure-controlled ventilation does not directly address hypercapnia.
12. In a patient with septic shock requiring norepinephrine at 0.5 mcg/kg/min with mean arterial
pressure (MAP) still 55 mm Hg, which of the following is the next best step according to current
Surviving Sepsis Campaign guidelines?
A. Add vasopressin 0.03 units/min
B. Increase norepinephrine to 0.8 mcg/kg/min
C. Start dobutamine 5 mcg/kg/min
D. Administer hydrocortisone 200 mg/day
Answer: A
Rationale: Guidelines recommend adding vasopressin as a second-line agent when norepinephrine dose
exceeds 0.25-0.5 mcg/kg/min to achieve target MAP. Increasing norepinephrine further may increase
adverse effects. Dobutamine is indicated for myocardial dysfunction. Hydrocortisone is considered only
if vasopressors are insufficient despite adequate fluid resuscitation.
13. A patient with traumatic brain injury (TBI) has intracranial pressure (ICP) of 28 mm Hg
despite sedation, head-of-bed elevation, and mild hyperventilation (PaCO2 32 mm Hg). The
cerebral perfusion pressure (CPP) is 50 mm Hg. Which intervention is most appropriate?
A. Administer 1 g/kg mannitol IV
B. Further hyperventilate to PaCO2 25 mm Hg
C. Initiate therapeutic hypothermia to 33°C
D. Decrease mean arterial pressure to reduce ICP
Answer: A
Rationale: Mannitol is an osmotic diuretic that reduces ICP by drawing water from brain tissue, and is
indicated for acute ICP elevation. Further hyperventilation risks cerebral ischemia. Therapeutic
hypothermia is not routinely recommended. Decreasing MAP would lower CPP further, worsening
ischemia.
Page 4
