Chamberlain University 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,
Respiratory, Neurological, Gastrointestinal, Renal,
Endocrine & Metabolic Disorders, Infectious Diseases,
Critical Care, Pharmacology, Diagnostic Testing, Clinical
Decision-Making, Patient Safety & Evidence-Based Acute
Care
Question 1: A 72-year-old male with a history of heart failure with reduced
ejection fraction (HFrEF) presents with acute respiratory distress. His blood
pressure is 85/50 mmHg, heart rate is 120 bpm, and oxygen saturation is 88%
on 15L non-rebreather mask. He is cool, clammy, and confused. An
electrocardiogram (ECG) shows sinus tachycardia. Which of the following is
the MOST appropriate immediate hemodynamic management strategy?
A. Administer a 500 mL normal saline bolus and initiate low-dose dobutamine
B. Initiate norepinephrine infusion and non-invasive positive pressure ventilation
C. Administer furosemide 40 mg IV push and titrate nitroglycerin infusion
D. Initiate milrinone infusion and an intra-aortic balloon pump (IABP)
CORRECT ANSWER: B. Initiate norepinephrine infusion and non-invasive
positive pressure ventilation
Rationale: This patient presents with cardiogenic shock (cool, clammy, hypotension,
tachycardia) with signs of acute pulmonary edema (low SpO2, respiratory distress).
Norepinephrine is the first-line vasopressor for cardiogenic shock to support perfusion
pressure without significantly increasing heart rate. Non-invasive positive pressure
ventilation (NIPPV) provides preload reduction and pulmonary support. Inotropes like
dobutamine or milrinone are not first-line in the presence of severe hypotension (SBP
<90) because they further reduce blood pressure. Furosemide and nitroglycerin are
contraindicated in this unstable, hypotensive state.
Question 2: A 65-year-old female with end-stage renal disease (ESRD) on
hemodialysis is admitted with altered mental status. Her serum potassium is
7.2 mEq/L, and her ECG shows peaked T-waves and a widened QRS complex.
Which of the following interventions should be administered FIRST to stabilize
the cardiac membrane?
A. Calcium gluconate 1 gram IV push
B. Insulin 10 units with D50% 1 amp IV push
C. Sodium bicarbonate 1 mEq/kg IV push
D. Albuterol 20 mg nebulized
,CORRECT ANSWER: A. Calcium gluconate 1 gram IV push
Rationale: In severe hyperkalemia with ECG changes (peaked T-waves, wide QRS), the
immediate priority is myocardial membrane stabilization with intravenous calcium
(gluconate or chloride) to prevent life-threatening arrhythmias. This does not lower
potassium but protects the heart. Insulin with dextrose, sodium bicarbonate, and
albuterol are treatments that shift potassium intracellularly, but they are secondary to
calcium administration in an acute, unstable situation.
Question 3: A 45-year-old male with a history of chronic pancreatitis is
brought to the emergency department with severe epigastric pain radiating to
his back. He is hypotensive and tachycardic. Abdominal examination reveals a
tender, distended abdomen with guarding. Laboratory results show a serum
lipase of 1,200 U/L and a hematocrit of 50%. What is the most appropriate
INITIAL fluid resuscitation strategy?
A. 250 mL boluses of normal saline every 15 minutes until urine output is >0.5
mL/kg/hr
B. 10-15 mL/kg bolus of normal saline or lactated Ringer's solution
C. 5% albumin solution at 100 mL/hr for the first 24 hours
D. Restrict fluids to 50 mL/hr to prevent pancreatic edema and acute respiratory
distress syndrome (ARDS)
CORRECT ANSWER: B. 10-15 mL/kg bolus of normal saline or lactated
Ringer's solution
Rationale: This patient is presenting with acute pancreatitis complicated by systemic
inflammatory response syndrome (SIRS) and hypovolemic shock. Aggressive fluid
resuscitation with isotonic crystalloids (10-15 mL/kg bolus) is critical in the first 24
hours to restore intravascular volume and prevent pancreatic necrosis. Lactated Ringer's
is preferred over normal saline in some guidelines due to lower risk of hyperchloremic
acidosis. Albumin is not first-line. Restricting fluids is harmful and increases mortality.
Question 4: A 68-year-old male with a history of coronary artery disease and
ischemic cardiomyopathy is admitted with acute decompensated heart failure
(ADHF). He is afebrile but has a white blood cell (WBC) count of 14,000/µL
with 90% neutrophils. A chest X-ray shows bilateral fluffy infiltrates. He is
started on diuretics and vasodilators but remains hypoxic. What is the most
likely cause of his leukocytosis and failure to improve, and what diagnostic
test is most appropriate?
A. Pulmonary embolism; CT pulmonary angiography
B. Acute coronary syndrome; high-sensitivity troponin
C. Occult pneumonia; sputum culture and procalcitonin
D. Drug-induced leukocytosis; monitor and continue diuresis
,CORRECT ANSWER: C. Occult pneumonia; sputum culture and procalcitonin
Rationale: This patient has ADHF but a significant leukocytosis with a neutrophilic
predominance, which is not typical for isolated heart failure. His failure to improve with
standard therapy suggests a superimposed infection. Pneumonia is a common
precipitant of ADHF and can present with subtle findings. A procalcitonin level can help
differentiate bacterial from non-bacterial causes of pulmonary infiltrates. Pulmonary
embolism is less likely without risk factors, and troponin elevation is not the primary
cause of his persistent hypoxia or leukocytosis.
Question 5: A 55-year-old female with cirrhosis and ascites is admitted with
altered mental status, jaundice, and fever. Her temperature is 38.8°C, heart
rate 110 bpm, and blood pressure 100/60 mmHg. Abdominal paracentesis
reveals a neutrophil count of 450 cells/mm³. What is the most appropriate
empirical antibiotic regimen for this patient's condition?
A. Cefotaxime 2 grams IV every 6 hours
B. Piperacillin-tazobactam 4.5 grams IV every 6 hours
C. Vancomycin 15 mg/kg IV every 12 hours
D. Metronidazole 500 mg IV every 8 hours
CORRECT ANSWER: A. Cefotaxime 2 grams IV every 6 hours
Rationale: This patient has spontaneous bacterial peritonitis (SBP), defined as ascitic
fluid neutrophil count ≥250 cells/mm³. The most common organisms are gram-negative
enteric bacteria (E. coli, Klebsiella). A third-generation cephalosporin like cefotaxime is
the first-line empirical therapy due to its excellent coverage against these pathogens and
its ability to achieve high ascitic fluid concentrations. Piperacillin-tazobactam is a
broader alternative but not first-line. Vancomycin is only indicated for MRSA or
penicillin-allergic patients. Metronidazole does not cover the predominant gram-
negative pathogens.
Question 6: A 78-year-old male with end-stage COPD and home oxygen is
admitted with worsening dyspnea and confusion. He is afebrile, but his
respiratory rate is 32 breaths/min, and his SpO₂ is 88% on a 50% Venturi
mask. Arterial blood gas (ABG) shows pH 7.28, PaCO₂ 72 mmHg, PaO₂ 55
mmHg, and HCO₃⁻ 28 mEq/L. What is the most appropriate next step in
managing his acute respiratory failure?
A. Intubate for invasive mechanical ventilation to achieve a PaCO₂ of 35 mmHg
B. Start bilevel positive airway pressure (BiPAP) with low inspiratory pressure
C. Administer sodium bicarbonate to correct the metabolic acidosis
D. Increase FiO₂ to 100% via non-rebreather mask
, CORRECT ANSWER: B. Start bilevel positive airway pressure (BiPAP) with low
inspiratory pressure
Rationale: This patient is in acute-on-chronic hypercapnic respiratory failure due to
COPD. BiPAP is the preferred initial intervention for acute hypercapnic exacerbations to
support ventilation, reduce work of breathing, and avoid intubation. Low inspiratory
pressures are started to minimize patient intolerance. Intubation is for failure of BiPAP or
severe encephalopathy. Sodium bicarbonate is contraindicated in hypercapnic acidosis
because it can worsen CO₂ retention and cause paradoxical intracellular acidosis.
Increasing FiO₂ alone will not address the hypercapnia.
Question 7: A 62-year-old female with a history of type 2 diabetes mellitus is
admitted with severe community-acquired pneumonia (CAP). She is
hypotensive despite 2 L of normal saline. Her lactate is 4.5 mmol/L. She is
started on broad-spectrum antibiotics. Which of the following hemodynamic
parameters is the BEST target for guiding her resuscitation to reduce
mortality?
A. Central venous pressure (CVP) of 12-15 mmHg
B. Urine output of 0.5 mL/kg/hr
C. Mean arterial pressure (MAP) ≥ 65 mmHg and lactate normalization
D. Pulmonary artery occlusion pressure (PAOP) of 18-24 mmHg
CORRECT ANSWER: C. Mean arterial pressure (MAP) ≥ 65 mmHg and lactate
normalization
Rationale: This patient has septic shock. The Surviving Sepsis Campaign guidelines
recommend targeting a MAP ≥ 65 mmHg and using lactate normalization (or
decreasing by >20% every 2 hours) as a primary marker of adequate resuscitation.
Static parameters like CVP and PAOP are no longer recommended for routine
resuscitation goals due to poor predictive value. Urine output is a useful secondary
marker but is not the best single target for early goal-directed therapy.
Question 8: A 50-year-old male with a history of alcohol use disorder is
admitted with severe epigastric pain, nausea, and vomiting. His amylase and
lipase are elevated. He develops periumbilical and flank ecchymoses. What is
the most likely diagnosis and its associated complication?
A. Peptic ulcer disease with retroperitoneal perforation
B. Necrotizing pancreatitis with retroperitoneal bleeding
C. Acute cholecystitis with biliary peritonitis
D. Mesenteric ischemia with bowel necrosis
CORRECT ANSWER: B. Necrotizing pancreatitis with retroperitoneal bleeding
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,
Respiratory, Neurological, Gastrointestinal, Renal,
Endocrine & Metabolic Disorders, Infectious Diseases,
Critical Care, Pharmacology, Diagnostic Testing, Clinical
Decision-Making, Patient Safety & Evidence-Based Acute
Care
Question 1: A 72-year-old male with a history of heart failure with reduced
ejection fraction (HFrEF) presents with acute respiratory distress. His blood
pressure is 85/50 mmHg, heart rate is 120 bpm, and oxygen saturation is 88%
on 15L non-rebreather mask. He is cool, clammy, and confused. An
electrocardiogram (ECG) shows sinus tachycardia. Which of the following is
the MOST appropriate immediate hemodynamic management strategy?
A. Administer a 500 mL normal saline bolus and initiate low-dose dobutamine
B. Initiate norepinephrine infusion and non-invasive positive pressure ventilation
C. Administer furosemide 40 mg IV push and titrate nitroglycerin infusion
D. Initiate milrinone infusion and an intra-aortic balloon pump (IABP)
CORRECT ANSWER: B. Initiate norepinephrine infusion and non-invasive
positive pressure ventilation
Rationale: This patient presents with cardiogenic shock (cool, clammy, hypotension,
tachycardia) with signs of acute pulmonary edema (low SpO2, respiratory distress).
Norepinephrine is the first-line vasopressor for cardiogenic shock to support perfusion
pressure without significantly increasing heart rate. Non-invasive positive pressure
ventilation (NIPPV) provides preload reduction and pulmonary support. Inotropes like
dobutamine or milrinone are not first-line in the presence of severe hypotension (SBP
<90) because they further reduce blood pressure. Furosemide and nitroglycerin are
contraindicated in this unstable, hypotensive state.
Question 2: A 65-year-old female with end-stage renal disease (ESRD) on
hemodialysis is admitted with altered mental status. Her serum potassium is
7.2 mEq/L, and her ECG shows peaked T-waves and a widened QRS complex.
Which of the following interventions should be administered FIRST to stabilize
the cardiac membrane?
A. Calcium gluconate 1 gram IV push
B. Insulin 10 units with D50% 1 amp IV push
C. Sodium bicarbonate 1 mEq/kg IV push
D. Albuterol 20 mg nebulized
,CORRECT ANSWER: A. Calcium gluconate 1 gram IV push
Rationale: In severe hyperkalemia with ECG changes (peaked T-waves, wide QRS), the
immediate priority is myocardial membrane stabilization with intravenous calcium
(gluconate or chloride) to prevent life-threatening arrhythmias. This does not lower
potassium but protects the heart. Insulin with dextrose, sodium bicarbonate, and
albuterol are treatments that shift potassium intracellularly, but they are secondary to
calcium administration in an acute, unstable situation.
Question 3: A 45-year-old male with a history of chronic pancreatitis is
brought to the emergency department with severe epigastric pain radiating to
his back. He is hypotensive and tachycardic. Abdominal examination reveals a
tender, distended abdomen with guarding. Laboratory results show a serum
lipase of 1,200 U/L and a hematocrit of 50%. What is the most appropriate
INITIAL fluid resuscitation strategy?
A. 250 mL boluses of normal saline every 15 minutes until urine output is >0.5
mL/kg/hr
B. 10-15 mL/kg bolus of normal saline or lactated Ringer's solution
C. 5% albumin solution at 100 mL/hr for the first 24 hours
D. Restrict fluids to 50 mL/hr to prevent pancreatic edema and acute respiratory
distress syndrome (ARDS)
CORRECT ANSWER: B. 10-15 mL/kg bolus of normal saline or lactated
Ringer's solution
Rationale: This patient is presenting with acute pancreatitis complicated by systemic
inflammatory response syndrome (SIRS) and hypovolemic shock. Aggressive fluid
resuscitation with isotonic crystalloids (10-15 mL/kg bolus) is critical in the first 24
hours to restore intravascular volume and prevent pancreatic necrosis. Lactated Ringer's
is preferred over normal saline in some guidelines due to lower risk of hyperchloremic
acidosis. Albumin is not first-line. Restricting fluids is harmful and increases mortality.
Question 4: A 68-year-old male with a history of coronary artery disease and
ischemic cardiomyopathy is admitted with acute decompensated heart failure
(ADHF). He is afebrile but has a white blood cell (WBC) count of 14,000/µL
with 90% neutrophils. A chest X-ray shows bilateral fluffy infiltrates. He is
started on diuretics and vasodilators but remains hypoxic. What is the most
likely cause of his leukocytosis and failure to improve, and what diagnostic
test is most appropriate?
A. Pulmonary embolism; CT pulmonary angiography
B. Acute coronary syndrome; high-sensitivity troponin
C. Occult pneumonia; sputum culture and procalcitonin
D. Drug-induced leukocytosis; monitor and continue diuresis
,CORRECT ANSWER: C. Occult pneumonia; sputum culture and procalcitonin
Rationale: This patient has ADHF but a significant leukocytosis with a neutrophilic
predominance, which is not typical for isolated heart failure. His failure to improve with
standard therapy suggests a superimposed infection. Pneumonia is a common
precipitant of ADHF and can present with subtle findings. A procalcitonin level can help
differentiate bacterial from non-bacterial causes of pulmonary infiltrates. Pulmonary
embolism is less likely without risk factors, and troponin elevation is not the primary
cause of his persistent hypoxia or leukocytosis.
Question 5: A 55-year-old female with cirrhosis and ascites is admitted with
altered mental status, jaundice, and fever. Her temperature is 38.8°C, heart
rate 110 bpm, and blood pressure 100/60 mmHg. Abdominal paracentesis
reveals a neutrophil count of 450 cells/mm³. What is the most appropriate
empirical antibiotic regimen for this patient's condition?
A. Cefotaxime 2 grams IV every 6 hours
B. Piperacillin-tazobactam 4.5 grams IV every 6 hours
C. Vancomycin 15 mg/kg IV every 12 hours
D. Metronidazole 500 mg IV every 8 hours
CORRECT ANSWER: A. Cefotaxime 2 grams IV every 6 hours
Rationale: This patient has spontaneous bacterial peritonitis (SBP), defined as ascitic
fluid neutrophil count ≥250 cells/mm³. The most common organisms are gram-negative
enteric bacteria (E. coli, Klebsiella). A third-generation cephalosporin like cefotaxime is
the first-line empirical therapy due to its excellent coverage against these pathogens and
its ability to achieve high ascitic fluid concentrations. Piperacillin-tazobactam is a
broader alternative but not first-line. Vancomycin is only indicated for MRSA or
penicillin-allergic patients. Metronidazole does not cover the predominant gram-
negative pathogens.
Question 6: A 78-year-old male with end-stage COPD and home oxygen is
admitted with worsening dyspnea and confusion. He is afebrile, but his
respiratory rate is 32 breaths/min, and his SpO₂ is 88% on a 50% Venturi
mask. Arterial blood gas (ABG) shows pH 7.28, PaCO₂ 72 mmHg, PaO₂ 55
mmHg, and HCO₃⁻ 28 mEq/L. What is the most appropriate next step in
managing his acute respiratory failure?
A. Intubate for invasive mechanical ventilation to achieve a PaCO₂ of 35 mmHg
B. Start bilevel positive airway pressure (BiPAP) with low inspiratory pressure
C. Administer sodium bicarbonate to correct the metabolic acidosis
D. Increase FiO₂ to 100% via non-rebreather mask
, CORRECT ANSWER: B. Start bilevel positive airway pressure (BiPAP) with low
inspiratory pressure
Rationale: This patient is in acute-on-chronic hypercapnic respiratory failure due to
COPD. BiPAP is the preferred initial intervention for acute hypercapnic exacerbations to
support ventilation, reduce work of breathing, and avoid intubation. Low inspiratory
pressures are started to minimize patient intolerance. Intubation is for failure of BiPAP or
severe encephalopathy. Sodium bicarbonate is contraindicated in hypercapnic acidosis
because it can worsen CO₂ retention and cause paradoxical intracellular acidosis.
Increasing FiO₂ alone will not address the hypercapnia.
Question 7: A 62-year-old female with a history of type 2 diabetes mellitus is
admitted with severe community-acquired pneumonia (CAP). She is
hypotensive despite 2 L of normal saline. Her lactate is 4.5 mmol/L. She is
started on broad-spectrum antibiotics. Which of the following hemodynamic
parameters is the BEST target for guiding her resuscitation to reduce
mortality?
A. Central venous pressure (CVP) of 12-15 mmHg
B. Urine output of 0.5 mL/kg/hr
C. Mean arterial pressure (MAP) ≥ 65 mmHg and lactate normalization
D. Pulmonary artery occlusion pressure (PAOP) of 18-24 mmHg
CORRECT ANSWER: C. Mean arterial pressure (MAP) ≥ 65 mmHg and lactate
normalization
Rationale: This patient has septic shock. The Surviving Sepsis Campaign guidelines
recommend targeting a MAP ≥ 65 mmHg and using lactate normalization (or
decreasing by >20% every 2 hours) as a primary marker of adequate resuscitation.
Static parameters like CVP and PAOP are no longer recommended for routine
resuscitation goals due to poor predictive value. Urine output is a useful secondary
marker but is not the best single target for early goal-directed therapy.
Question 8: A 50-year-old male with a history of alcohol use disorder is
admitted with severe epigastric pain, nausea, and vomiting. His amylase and
lipase are elevated. He develops periumbilical and flank ecchymoses. What is
the most likely diagnosis and its associated complication?
A. Peptic ulcer disease with retroperitoneal perforation
B. Necrotizing pancreatitis with retroperitoneal bleeding
C. Acute cholecystitis with biliary peritonitis
D. Mesenteric ischemia with bowel necrosis
CORRECT ANSWER: B. Necrotizing pancreatitis with retroperitoneal bleeding
