NR-571 Complex Diagnosis and Management in Acute Care
Practicum – NR 571 Study Guide, Original Practice
Questions & Answers, Comprehensive AGACNP Exam
Preparation, Acute Care Diagnosis & Management Review,
Advanced Patient Assessment, Differential Diagnosis,
Cardiovascular Disorders, Respiratory Disorders,
Neurological Conditions, Endocrine & Metabolic
Disorders, Renal & Genitourinary Conditions,
Gastrointestinal Disorders, Infectious Diseases, Critical
Care, Pharmacology, Diagnostic Testing, Clinical Decision-
Making & Patient Safety
Question 1: A 68-year-old male with a history of hypertension and type 2
diabetes mellitus presents to the emergency department with acute onset of
severe, tearing chest pain that radiates to his back. His blood pressure is
180/110 mmHg in the right arm and 100/60 mmHg in the left arm. Which of
the following is the most appropriate initial imaging modality to confirm the
suspected diagnosis?
A. Transthoracic echocardiogram
B. Computed tomography angiography (CTA) of the chest
C. Magnetic resonance angiography (MRA) of the chest
D. Standard chest X-ray
CORRECT ANSWER: B. Computed tomography angiography (CTA) of the chest
Rationale: The presentation is classic for an acute aortic dissection. CTA of the chest is
the initial imaging modality of choice due to its high sensitivity and specificity, rapid
acquisition time, and widespread availability. It clearly delineates the intimal flap and the
extent of the dissection. A transthoracic echocardiogram is less sensitive for visualizing
the ascending aorta and is not the primary diagnostic tool. MRA takes too long and is
not readily available in an emergency setting, and a chest X-ray is non-specific.
Question 2: A 55-year-old female with a history of chronic obstructive
pulmonary disease (COPD) is admitted with acute respiratory failure. Her
arterial blood gas (ABG) on a 50% Venturi mask shows: pH 7.28, PaCO2 70
mmHg, PaO2 65 mmHg, HCO3- 28 mEq/L. She is confused and lethargic.
Which of the following is the most appropriate immediate intervention?
A. Administer intravenous sodium bicarbonate
B. Initiate non-invasive positive pressure ventilation (NIPPV)
C. Intubate and initiate mechanical ventilation
D. Increase the FiO2 to 100% via non-rebreather mask
CORRECT ANSWER: C. Intubate and initiate mechanical ventilation
Rationale: This patient has acute-on-chronic respiratory failure with severe
hypercapnia (PaCO2 70 mmHg) and significant acidemia (pH 7.28) resulting in altered
mental status. These are indications for intubation and invasive mechanical ventilation.
,NIPPV is contraindicated in patients with a decreased level of consciousness due to the
risk of aspiration. Sodium bicarbonate is not indicated for respiratory acidosis and could
worsen the condition. Increasing FiO2 alone will not correct the hypercapnia or
acidemia.
Question 3: A 72-year-old male with a history of heart failure with reduced
ejection fraction (HFrEF) is brought in with severe shortness of breath. He is
diaphoretic, tachypneic, and has jugular venous distension and crackles
throughout both lung fields. Which of the following hemodynamic parameters
is most consistent with this presentation?
A. Elevated cardiac index with low systemic vascular resistance (SVR)
B. Elevated pulmonary capillary wedge pressure (PCWP) with low cardiac output
C. Low central venous pressure (CVP) with high cardiac output
D. Normal PCWP with low SVR
CORRECT ANSWER: B. Elevated pulmonary capillary wedge pressure (PCWP)
with low cardiac output
Rationale: The patient is presenting with acute decompensated heart failure,
characterized by cardiogenic pulmonary edema. This results in an elevated PCWP (left
ventricular end-diastolic pressure) and a subsequent reduction in cardiac output and
cardiac index due to the failing left ventricle. Elevated cardiac index with low SVR is
seen in distributive shock. Low CVP and normal PCWP are not consistent with this
clinical picture.
Question 4: A 60-year-old male with a history of cirrhosis and ascites is
admitted with a two-day history of worsening confusion and jaundice. On
exam, he is febrile and has asterixis. A paracentesis is performed and the
ascitic fluid analysis reveals a polymorphonuclear (PMN) cell count of 850
cells/mm3. Which of the following is the most appropriate empiric antibiotic
regimen?
A. Oral ciprofloxacin
B. Intravenous ceftriaxone
C. Intravenous vancomycin and piperacillin-tazobactam
D. Oral rifaximin
CORRECT ANSWER: B. Intravenous ceftriaxone
Rationale: This patient has spontaneous bacterial peritonitis (SBP), diagnosed by an
ascitic fluid PMN count > 250 cells/mm3. The most appropriate empiric antibiotic
therapy is a third-generation cephalosporin, such as intravenous ceftriaxone, to cover the
most common organisms (E. coli, Klebsiella, and Streptococcus pneumoniae). Oral
antibiotics are not appropriate for empiric treatment of SBP in a symptomatic patient,
and vancomycin/piperacillin-tazobactam is overly broad for initial empiric therapy.
Rifaximin is not used to treat acute SBP.
,Question 5: A 45-year-old male presents with acute, severe epigastric pain
radiating to the back. He is a known heavy drinker. Serum amylase and lipase
are significantly elevated. He is hypotensive and tachycardic. Which of the
following is the most appropriate initial fluid resuscitation strategy?
A. 0.9% normal saline at 1.5 mL/kg/hour
B. 0.9% normal saline bolus 10-20 mL/kg
C. 5% Dextrose in water at 100 mL/hour
D. 3% hypertonic saline at 50 mL/hour
CORRECT ANSWER: B. 0.9% normal saline bolus 10-20 mL/kg
Rationale: The patient is in acute pancreatitis with signs of hypovolemic shock.
Aggressive fluid resuscitation with isotonic crystalloids (e.g., 0.9% normal saline or
Lactated Ringer's) is crucial in the first 12-24 hours. A bolus of 10-20 mL/kg is the
recommended initial strategy to restore intravascular volume and prevent complications
like pancreatic necrosis. The maintenance rate is insufficient for a patient in shock, and
other fluids are not appropriate for initial resuscitation.
Question 6: A 70-year-old female is on a mechanical ventilator with the
following settings: Assist-Control, Tidal Volume 450 mL, Respiratory Rate 14
breaths/min, FiO2 50%, PEEP 5 cm H2O. Her ABG shows pH 7.31, PaCO2 55
mmHg, PaO2 80 mmHg, HCO3- 25 mEq/L. Which of the following ventilator
adjustments would best address the primary acid-base abnormality?
A. Increase FiO2 to 60%
B. Increase PEEP to 10 cm H2O
C. Increase the respiratory rate to 18 breaths/min
D. Increase the tidal volume to 550 mL
CORRECT ANSWER: C. Increase the respiratory rate to 18 breaths/min
Rationale: The primary acid-base abnormality is respiratory acidosis (pH < 7.35 and
PaCO2 > 45). The most direct and effective way to correct this is to increase alveolar
minute ventilation by increasing the respiratory rate. This will facilitate the elimination of
CO2. Increasing FiO2 or PEEP will address oxygenation but not ventilation. Increasing
tidal volume could increase CO2 elimination but also increases the risk of
barotrauma/volutrauma; adjusting the respiratory rate is the safer and more appropriate
first step.
Question 7: A 65-year-old male with a past medical history of coronary artery
disease presents with acute, substernal chest pain. His ECG shows ST-segment
elevations in leads V1-V4. His blood pressure is 85/55 mmHg. Which of the
following is the most appropriate immediate pharmacologic therapy?
A. Sublingual nitroglycerin
B. Intravenous furosemide
C. Intravenous dopamine
D. Primary percutaneous coronary intervention (PCI)
, CORRECT ANSWER: D. Primary percutaneous coronary intervention (PCI)
Rationale: The patient is presenting with an acute anterior ST-segment elevation
myocardial infarction (STEMI) and is in cardiogenic shock. The most appropriate
immediate therapy is primary PCI to restore coronary perfusion. While this is a
pharmacologic question, the definitive treatment is mechanical. If the question forces a
pharmacologic choice, the next best is often a vasopressor like dopamine while awaiting
PCI, but the immediate and most appropriate intervention overall for a STEMI with
shock is urgent revascularization.
Question 8: A 58-year-old patient with a history of chronic kidney disease
(CKD) is admitted with severe hyperkalemia (potassium 7.2 mEq/L) and
peaked T waves on ECG. Which of the following treatments is the most rapidly
acting to stabilize the cardiac membrane?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Intravenous insulin and dextrose
C. Intravenous calcium gluconate
D. Intravenous sodium bicarbonate
CORRECT ANSWER: C. Intravenous calcium gluconate
Rationale: In severe hyperkalemia with ECG changes, the most immediate life-
threatening concern is cardiac arrhythmias. Intravenous calcium gluconate does not
lower potassium levels but directly stabilizes the cardiac myocyte membrane, reducing
the risk of arrhythmias. It is the fastest-acting agent, working within minutes. Insulin and
dextrose, sodium bicarbonate, and Kayexalate all lower serum potassium but take longer
to have an effect.
Question 9: A 48-year-old female presents with a sudden onset of severe
headache and a seizure. Her blood pressure is 200/120 mmHg. She is known to
be non-compliant with her antihypertensive medications. Which of the
following is the most appropriate initial intravenous antihypertensive agent for
this hypertensive emergency?
A. Oral labetalol
B. Intravenous nitroprusside
C. Intravenous nicardipine
D. Intravenous hydralazine
CORRECT ANSWER: C. Intravenous nicardipine
Rationale: This is a hypertensive emergency with neurologic symptoms (headache,
seizure). The goal is to reduce blood pressure by no more than 25% within the first hour.
Intravenous nicardipine (a calcium channel blocker) is a first-line agent due to its ease of
titration, predictable response, and fewer adverse effects compared to nitroprusside
(which can cause cyanide toxicity). Oral labetalol is not appropriate for acute
management, and hydralazine can cause reflex tachycardia and is not a first-line agent.
Practicum – NR 571 Study Guide, Original Practice
Questions & Answers, Comprehensive AGACNP Exam
Preparation, Acute Care Diagnosis & Management Review,
Advanced Patient Assessment, Differential Diagnosis,
Cardiovascular Disorders, Respiratory Disorders,
Neurological Conditions, Endocrine & Metabolic
Disorders, Renal & Genitourinary Conditions,
Gastrointestinal Disorders, Infectious Diseases, Critical
Care, Pharmacology, Diagnostic Testing, Clinical Decision-
Making & Patient Safety
Question 1: A 68-year-old male with a history of hypertension and type 2
diabetes mellitus presents to the emergency department with acute onset of
severe, tearing chest pain that radiates to his back. His blood pressure is
180/110 mmHg in the right arm and 100/60 mmHg in the left arm. Which of
the following is the most appropriate initial imaging modality to confirm the
suspected diagnosis?
A. Transthoracic echocardiogram
B. Computed tomography angiography (CTA) of the chest
C. Magnetic resonance angiography (MRA) of the chest
D. Standard chest X-ray
CORRECT ANSWER: B. Computed tomography angiography (CTA) of the chest
Rationale: The presentation is classic for an acute aortic dissection. CTA of the chest is
the initial imaging modality of choice due to its high sensitivity and specificity, rapid
acquisition time, and widespread availability. It clearly delineates the intimal flap and the
extent of the dissection. A transthoracic echocardiogram is less sensitive for visualizing
the ascending aorta and is not the primary diagnostic tool. MRA takes too long and is
not readily available in an emergency setting, and a chest X-ray is non-specific.
Question 2: A 55-year-old female with a history of chronic obstructive
pulmonary disease (COPD) is admitted with acute respiratory failure. Her
arterial blood gas (ABG) on a 50% Venturi mask shows: pH 7.28, PaCO2 70
mmHg, PaO2 65 mmHg, HCO3- 28 mEq/L. She is confused and lethargic.
Which of the following is the most appropriate immediate intervention?
A. Administer intravenous sodium bicarbonate
B. Initiate non-invasive positive pressure ventilation (NIPPV)
C. Intubate and initiate mechanical ventilation
D. Increase the FiO2 to 100% via non-rebreather mask
CORRECT ANSWER: C. Intubate and initiate mechanical ventilation
Rationale: This patient has acute-on-chronic respiratory failure with severe
hypercapnia (PaCO2 70 mmHg) and significant acidemia (pH 7.28) resulting in altered
mental status. These are indications for intubation and invasive mechanical ventilation.
,NIPPV is contraindicated in patients with a decreased level of consciousness due to the
risk of aspiration. Sodium bicarbonate is not indicated for respiratory acidosis and could
worsen the condition. Increasing FiO2 alone will not correct the hypercapnia or
acidemia.
Question 3: A 72-year-old male with a history of heart failure with reduced
ejection fraction (HFrEF) is brought in with severe shortness of breath. He is
diaphoretic, tachypneic, and has jugular venous distension and crackles
throughout both lung fields. Which of the following hemodynamic parameters
is most consistent with this presentation?
A. Elevated cardiac index with low systemic vascular resistance (SVR)
B. Elevated pulmonary capillary wedge pressure (PCWP) with low cardiac output
C. Low central venous pressure (CVP) with high cardiac output
D. Normal PCWP with low SVR
CORRECT ANSWER: B. Elevated pulmonary capillary wedge pressure (PCWP)
with low cardiac output
Rationale: The patient is presenting with acute decompensated heart failure,
characterized by cardiogenic pulmonary edema. This results in an elevated PCWP (left
ventricular end-diastolic pressure) and a subsequent reduction in cardiac output and
cardiac index due to the failing left ventricle. Elevated cardiac index with low SVR is
seen in distributive shock. Low CVP and normal PCWP are not consistent with this
clinical picture.
Question 4: A 60-year-old male with a history of cirrhosis and ascites is
admitted with a two-day history of worsening confusion and jaundice. On
exam, he is febrile and has asterixis. A paracentesis is performed and the
ascitic fluid analysis reveals a polymorphonuclear (PMN) cell count of 850
cells/mm3. Which of the following is the most appropriate empiric antibiotic
regimen?
A. Oral ciprofloxacin
B. Intravenous ceftriaxone
C. Intravenous vancomycin and piperacillin-tazobactam
D. Oral rifaximin
CORRECT ANSWER: B. Intravenous ceftriaxone
Rationale: This patient has spontaneous bacterial peritonitis (SBP), diagnosed by an
ascitic fluid PMN count > 250 cells/mm3. The most appropriate empiric antibiotic
therapy is a third-generation cephalosporin, such as intravenous ceftriaxone, to cover the
most common organisms (E. coli, Klebsiella, and Streptococcus pneumoniae). Oral
antibiotics are not appropriate for empiric treatment of SBP in a symptomatic patient,
and vancomycin/piperacillin-tazobactam is overly broad for initial empiric therapy.
Rifaximin is not used to treat acute SBP.
,Question 5: A 45-year-old male presents with acute, severe epigastric pain
radiating to the back. He is a known heavy drinker. Serum amylase and lipase
are significantly elevated. He is hypotensive and tachycardic. Which of the
following is the most appropriate initial fluid resuscitation strategy?
A. 0.9% normal saline at 1.5 mL/kg/hour
B. 0.9% normal saline bolus 10-20 mL/kg
C. 5% Dextrose in water at 100 mL/hour
D. 3% hypertonic saline at 50 mL/hour
CORRECT ANSWER: B. 0.9% normal saline bolus 10-20 mL/kg
Rationale: The patient is in acute pancreatitis with signs of hypovolemic shock.
Aggressive fluid resuscitation with isotonic crystalloids (e.g., 0.9% normal saline or
Lactated Ringer's) is crucial in the first 12-24 hours. A bolus of 10-20 mL/kg is the
recommended initial strategy to restore intravascular volume and prevent complications
like pancreatic necrosis. The maintenance rate is insufficient for a patient in shock, and
other fluids are not appropriate for initial resuscitation.
Question 6: A 70-year-old female is on a mechanical ventilator with the
following settings: Assist-Control, Tidal Volume 450 mL, Respiratory Rate 14
breaths/min, FiO2 50%, PEEP 5 cm H2O. Her ABG shows pH 7.31, PaCO2 55
mmHg, PaO2 80 mmHg, HCO3- 25 mEq/L. Which of the following ventilator
adjustments would best address the primary acid-base abnormality?
A. Increase FiO2 to 60%
B. Increase PEEP to 10 cm H2O
C. Increase the respiratory rate to 18 breaths/min
D. Increase the tidal volume to 550 mL
CORRECT ANSWER: C. Increase the respiratory rate to 18 breaths/min
Rationale: The primary acid-base abnormality is respiratory acidosis (pH < 7.35 and
PaCO2 > 45). The most direct and effective way to correct this is to increase alveolar
minute ventilation by increasing the respiratory rate. This will facilitate the elimination of
CO2. Increasing FiO2 or PEEP will address oxygenation but not ventilation. Increasing
tidal volume could increase CO2 elimination but also increases the risk of
barotrauma/volutrauma; adjusting the respiratory rate is the safer and more appropriate
first step.
Question 7: A 65-year-old male with a past medical history of coronary artery
disease presents with acute, substernal chest pain. His ECG shows ST-segment
elevations in leads V1-V4. His blood pressure is 85/55 mmHg. Which of the
following is the most appropriate immediate pharmacologic therapy?
A. Sublingual nitroglycerin
B. Intravenous furosemide
C. Intravenous dopamine
D. Primary percutaneous coronary intervention (PCI)
, CORRECT ANSWER: D. Primary percutaneous coronary intervention (PCI)
Rationale: The patient is presenting with an acute anterior ST-segment elevation
myocardial infarction (STEMI) and is in cardiogenic shock. The most appropriate
immediate therapy is primary PCI to restore coronary perfusion. While this is a
pharmacologic question, the definitive treatment is mechanical. If the question forces a
pharmacologic choice, the next best is often a vasopressor like dopamine while awaiting
PCI, but the immediate and most appropriate intervention overall for a STEMI with
shock is urgent revascularization.
Question 8: A 58-year-old patient with a history of chronic kidney disease
(CKD) is admitted with severe hyperkalemia (potassium 7.2 mEq/L) and
peaked T waves on ECG. Which of the following treatments is the most rapidly
acting to stabilize the cardiac membrane?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Intravenous insulin and dextrose
C. Intravenous calcium gluconate
D. Intravenous sodium bicarbonate
CORRECT ANSWER: C. Intravenous calcium gluconate
Rationale: In severe hyperkalemia with ECG changes, the most immediate life-
threatening concern is cardiac arrhythmias. Intravenous calcium gluconate does not
lower potassium levels but directly stabilizes the cardiac myocyte membrane, reducing
the risk of arrhythmias. It is the fastest-acting agent, working within minutes. Insulin and
dextrose, sodium bicarbonate, and Kayexalate all lower serum potassium but take longer
to have an effect.
Question 9: A 48-year-old female presents with a sudden onset of severe
headache and a seizure. Her blood pressure is 200/120 mmHg. She is known to
be non-compliant with her antihypertensive medications. Which of the
following is the most appropriate initial intravenous antihypertensive agent for
this hypertensive emergency?
A. Oral labetalol
B. Intravenous nitroprusside
C. Intravenous nicardipine
D. Intravenous hydralazine
CORRECT ANSWER: C. Intravenous nicardipine
Rationale: This is a hypertensive emergency with neurologic symptoms (headache,
seizure). The goal is to reduce blood pressure by no more than 25% within the first hour.
Intravenous nicardipine (a calcium channel blocker) is a first-line agent due to its ease of
titration, predictable response, and fewer adverse effects compared to nitroprusside
(which can cause cyanide toxicity). Oral labetalol is not appropriate for acute
management, and hydralazine can cause reflex tachycardia and is not a first-line agent.
