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 68-year-old male with a history of hypertension and type 2
diabetes presents with acute onset of severe, tearing chest pain radiating 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
diagnostic study?
A. Transthoracic echocardiogram
B. Computed tomography angiography of the chest
C. Standard 12-lead electrocardiogram
D. Chest X-ray
CORRECT ANSWER: B. Computed tomography angiography of the chest
Rationale: The patient's presentation of tearing chest pain with a significant blood
pressure differential between arms is classic for an acute aortic dissection. CT
angiography is the gold standard for diagnosis in the acute setting due to its high
sensitivity and specificity, rapid acquisition, and ability to assess the entire aorta and
branch involvement. An ECG (C) is important to rule out MI but is not diagnostic for
dissection. A chest X-ray (D) may show a widened mediastinum but is neither sensitive
nor specific. A TTE (A) is not the primary diagnostic tool for aortic dissection.
Question 2: A 72-year-old female is post-operative day 1 following a coronary
artery bypass graft. She becomes acutely hypoxic, tachypneic, and complains
of pleuritic chest pain. Her heart rate is 110 bpm, respiratory rate 28/min, and
oxygen saturation 88% on 4L nasal cannula. An ECG reveals sinus tachycardia
with a right ventricular strain pattern. What is the most appropriate next step?
A. Administer a therapeutic dose of low molecular weight heparin
B. Obtain a CT pulmonary angiography
C. Perform a transthoracic echocardiogram
D. Begin high-flow oxygen and monitor
,CORRECT ANSWER: B. Obtain a CT pulmonary angiography
Rationale: The patient is at high risk for a pulmonary embolism (PE) post-operatively
with acute hypoxia, tachycardia, and ECG changes indicative of right heart strain. CT
pulmonary angiography (CTPA) is the diagnostic test of choice in a hemodynamically
stable patient with suspected PE. While administering heparin (A) is a treatment, it is
critical to confirm the diagnosis before initiating therapy in a post-op patient due to
bleeding risks. TTE (C) is useful for assessing right heart function but does not confirm
PE. High-flow oxygen (D) is supportive but does not address the diagnostic need.
Question 3: A 45-year-old male with a history of alcohol use disorder is
admitted with severe epigastric pain radiating to the back, nausea, and
vomiting. Serum amylase and lipase are elevated greater than three times the
upper limit of normal. He is tachycardic and hypotensive. Which of the
following findings on a CT scan of the abdomen would best indicate the
development of pancreatic necrosis?
A. Peripancreatic fluid collections
B. Diffuse pancreatic enlargement
C. Non-enhancement of pancreatic parenchyma after contrast administration
D. Presence of pseudocysts
CORRECT ANSWER: C. Non-enhancement of pancreatic parenchyma after
contrast administration
Rationale: Contrast-enhanced CT is the imaging modality of choice for detecting
pancreatic necrosis. Necrotic tissue will not enhance due to lack of perfusion.
Peripancreatic fluid collections (A) and diffuse enlargement (B) are common in acute
pancreatitis but do not specifically indicate necrosis. Pseudocysts (D) typically develop
weeks after the initial attack and are not acute markers of necrosis.
Question 4: A 60-year-old female with end-stage renal disease on hemodialysis
presents with a fever of 102°F and chills. She has a palpable, tender, and
erythematous area over her arteriovenous fistula. Blood cultures are drawn.
What is the most appropriate initial management?
A. Administer oral cephalexin and discharge home
B. Obtain a fistulogram
C. Start empiric intravenous vancomycin and gentamicin
D. Remove the AV fistula immediately
CORRECT ANSWER: C. Start empiric intravenous vancomycin and gentamicin
Rationale: The patient presents with signs of an AV fistula infection, which is a serious
complication. Empiric broad-spectrum antibiotics with coverage for Gram-positive
organisms (including MRSA) and Gram-negative organisms are required immediately
,due to the risk of sepsis and endocarditis. A fistulogram (B) may be indicated later but
should not delay antibiotics. Oral antibiotics (A) are insufficient for a serious bacteremia.
Removal of the fistula (D) is not the first step and is only considered if the infection is
unresponsive to medical therapy or if there is a mycotic aneurysm.
Question 5: A 78-year-old male is admitted with a massive upper GI bleed. He
is confused, diaphoretic, and has a heart rate of 130 bpm and a blood pressure
of 85/50 mmHg. Which of the following is the most appropriate initial fluid
resuscitation strategy?
A. 500 mL of 0.9% normal saline bolus
B. 1 Liter of Lactated Ringer's solution over 2 hours
C. 2 Units of packed red blood cells followed by a 500 mL bolus of normal saline
D. 1 Liter of 0.9% normal saline bolus wide open
CORRECT ANSWER: D. 1 Liter of 0.9% normal saline bolus wide open
Rationale: The patient is in hemorrhagic shock (class III/IV) due to an active GI bleed.
The initial management of severe hemorrhagic shock involves rapid administration of
isotonic crystalloids (e.g., 1L NS wide open) to restore intravascular volume while
preparing for blood transfusion. A 500 mL bolus (A) is insufficient for this presentation.
Lactated Ringer's (B) is acceptable but should be given rapidly, not over 2 hours. While
blood (C) is needed, the immediate priority is volume expansion with a large-bore
crystalloid bolus.
Question 6: A 55-year-old male with a history of COPD presents with acute
respiratory distress. He is unable to speak in full sentences, using accessory
muscles, and has a respiratory rate of 34/min. Arterial blood gas shows pH
7.25, PaCO2 65 mmHg, PaO2 55 mmHg, and HCO3 28 mEq/L. What is the most
appropriate next step?
A. Start BiPAP ventilation
B. Intubate and mechanically ventilate
C. Administer 100% oxygen via non-rebreather mask
D. Administer nebulized albuterol
CORRECT ANSWER: B. Intubate and mechanically ventilate
Rationale: The patient is in acute hypercapnic respiratory failure with a significantly
elevated PaCO2 (65 mmHg) and severe acidosis (pH 7.25). He is exhibiting signs of
respiratory muscle fatigue and is unable to maintain ventilation. Immediate intubation
and mechanical ventilation are indicated to reduce the work of breathing and correct
the acidosis. BiPAP (A) is an option for less severe hypercapnia in a more stable patient.
High-flow oxygen (C) without ventilatory support will not correct the hypercapnia.
Nebulized albuterol (D) is supportive but will not address the acute ventilatory failure.
, Question 7: A 32-year-old female presents with acute severe headache,
photophobia, and fever. A lumbar puncture is performed, and the
cerebrospinal fluid (CSF) analysis reveals cloudy fluid, elevated protein,
decreased glucose, and a white blood cell count of 1,500/mm³ with 90%
neutrophils. Which of the following is the most appropriate empiric antibiotic
regimen?
A. Ceftriaxone, Vancomycin, and Ampicillin
B. Ceftazidime and Gentamicin
C. Ceftriaxone and Doxycycline
D. Acyclovir
CORRECT ANSWER: A. Ceftriaxone, Vancomycin, and Ampicillin
Rationale: The patient has acute bacterial meningitis based on CSF findings
(neutrophilic pleocytosis, high protein, low glucose). Empiric therapy must cover the
most common pathogens: Streptococcus pneumoniae and Neisseria meningitidis.
Vancomycin and a third-generation cephalosporin (Ceftriaxone) are the mainstay.
Ampicillin is added for coverage of Listeria monocytogenes, especially in patients over 50,
immunocompromised, or with altered mental status. The other regimens (B, C, D) do
not provide broad enough coverage for typical community-acquired bacterial meningitis.
Question 8: A 68-year-old male post-operative day 3 after a colectomy
develops a sudden onset of chest pain and shortness of breath. He is febrile
and has a productive cough with purulent sputum. What is the most likely
complication?
A. Pulmonary embolism
B. Atelectasis
C. Hospital-acquired pneumonia
D. Myocardial infarction
CORRECT ANSWER: C. Hospital-acquired pneumonia
Rationale: Post-operative day 3 with fever, productive cough, and purulent sputum is
characteristic of hospital-acquired pneumonia. While pulmonary embolism (A) is a
concern, the presence of purulent sputum and fever points more to an infectious
process. Atelectasis (B) is common early post-op but typically presents with decreased
breath sounds and resolves quickly. Myocardial infarction (D) is possible but less likely
without ECG changes.
Question 9: A 40-year-old male presents with severe right lower quadrant pain,
vomiting, and fever. A CT scan of the abdomen suggests acute appendicitis
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 68-year-old male with a history of hypertension and type 2
diabetes presents with acute onset of severe, tearing chest pain radiating 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
diagnostic study?
A. Transthoracic echocardiogram
B. Computed tomography angiography of the chest
C. Standard 12-lead electrocardiogram
D. Chest X-ray
CORRECT ANSWER: B. Computed tomography angiography of the chest
Rationale: The patient's presentation of tearing chest pain with a significant blood
pressure differential between arms is classic for an acute aortic dissection. CT
angiography is the gold standard for diagnosis in the acute setting due to its high
sensitivity and specificity, rapid acquisition, and ability to assess the entire aorta and
branch involvement. An ECG (C) is important to rule out MI but is not diagnostic for
dissection. A chest X-ray (D) may show a widened mediastinum but is neither sensitive
nor specific. A TTE (A) is not the primary diagnostic tool for aortic dissection.
Question 2: A 72-year-old female is post-operative day 1 following a coronary
artery bypass graft. She becomes acutely hypoxic, tachypneic, and complains
of pleuritic chest pain. Her heart rate is 110 bpm, respiratory rate 28/min, and
oxygen saturation 88% on 4L nasal cannula. An ECG reveals sinus tachycardia
with a right ventricular strain pattern. What is the most appropriate next step?
A. Administer a therapeutic dose of low molecular weight heparin
B. Obtain a CT pulmonary angiography
C. Perform a transthoracic echocardiogram
D. Begin high-flow oxygen and monitor
,CORRECT ANSWER: B. Obtain a CT pulmonary angiography
Rationale: The patient is at high risk for a pulmonary embolism (PE) post-operatively
with acute hypoxia, tachycardia, and ECG changes indicative of right heart strain. CT
pulmonary angiography (CTPA) is the diagnostic test of choice in a hemodynamically
stable patient with suspected PE. While administering heparin (A) is a treatment, it is
critical to confirm the diagnosis before initiating therapy in a post-op patient due to
bleeding risks. TTE (C) is useful for assessing right heart function but does not confirm
PE. High-flow oxygen (D) is supportive but does not address the diagnostic need.
Question 3: A 45-year-old male with a history of alcohol use disorder is
admitted with severe epigastric pain radiating to the back, nausea, and
vomiting. Serum amylase and lipase are elevated greater than three times the
upper limit of normal. He is tachycardic and hypotensive. Which of the
following findings on a CT scan of the abdomen would best indicate the
development of pancreatic necrosis?
A. Peripancreatic fluid collections
B. Diffuse pancreatic enlargement
C. Non-enhancement of pancreatic parenchyma after contrast administration
D. Presence of pseudocysts
CORRECT ANSWER: C. Non-enhancement of pancreatic parenchyma after
contrast administration
Rationale: Contrast-enhanced CT is the imaging modality of choice for detecting
pancreatic necrosis. Necrotic tissue will not enhance due to lack of perfusion.
Peripancreatic fluid collections (A) and diffuse enlargement (B) are common in acute
pancreatitis but do not specifically indicate necrosis. Pseudocysts (D) typically develop
weeks after the initial attack and are not acute markers of necrosis.
Question 4: A 60-year-old female with end-stage renal disease on hemodialysis
presents with a fever of 102°F and chills. She has a palpable, tender, and
erythematous area over her arteriovenous fistula. Blood cultures are drawn.
What is the most appropriate initial management?
A. Administer oral cephalexin and discharge home
B. Obtain a fistulogram
C. Start empiric intravenous vancomycin and gentamicin
D. Remove the AV fistula immediately
CORRECT ANSWER: C. Start empiric intravenous vancomycin and gentamicin
Rationale: The patient presents with signs of an AV fistula infection, which is a serious
complication. Empiric broad-spectrum antibiotics with coverage for Gram-positive
organisms (including MRSA) and Gram-negative organisms are required immediately
,due to the risk of sepsis and endocarditis. A fistulogram (B) may be indicated later but
should not delay antibiotics. Oral antibiotics (A) are insufficient for a serious bacteremia.
Removal of the fistula (D) is not the first step and is only considered if the infection is
unresponsive to medical therapy or if there is a mycotic aneurysm.
Question 5: A 78-year-old male is admitted with a massive upper GI bleed. He
is confused, diaphoretic, and has a heart rate of 130 bpm and a blood pressure
of 85/50 mmHg. Which of the following is the most appropriate initial fluid
resuscitation strategy?
A. 500 mL of 0.9% normal saline bolus
B. 1 Liter of Lactated Ringer's solution over 2 hours
C. 2 Units of packed red blood cells followed by a 500 mL bolus of normal saline
D. 1 Liter of 0.9% normal saline bolus wide open
CORRECT ANSWER: D. 1 Liter of 0.9% normal saline bolus wide open
Rationale: The patient is in hemorrhagic shock (class III/IV) due to an active GI bleed.
The initial management of severe hemorrhagic shock involves rapid administration of
isotonic crystalloids (e.g., 1L NS wide open) to restore intravascular volume while
preparing for blood transfusion. A 500 mL bolus (A) is insufficient for this presentation.
Lactated Ringer's (B) is acceptable but should be given rapidly, not over 2 hours. While
blood (C) is needed, the immediate priority is volume expansion with a large-bore
crystalloid bolus.
Question 6: A 55-year-old male with a history of COPD presents with acute
respiratory distress. He is unable to speak in full sentences, using accessory
muscles, and has a respiratory rate of 34/min. Arterial blood gas shows pH
7.25, PaCO2 65 mmHg, PaO2 55 mmHg, and HCO3 28 mEq/L. What is the most
appropriate next step?
A. Start BiPAP ventilation
B. Intubate and mechanically ventilate
C. Administer 100% oxygen via non-rebreather mask
D. Administer nebulized albuterol
CORRECT ANSWER: B. Intubate and mechanically ventilate
Rationale: The patient is in acute hypercapnic respiratory failure with a significantly
elevated PaCO2 (65 mmHg) and severe acidosis (pH 7.25). He is exhibiting signs of
respiratory muscle fatigue and is unable to maintain ventilation. Immediate intubation
and mechanical ventilation are indicated to reduce the work of breathing and correct
the acidosis. BiPAP (A) is an option for less severe hypercapnia in a more stable patient.
High-flow oxygen (C) without ventilatory support will not correct the hypercapnia.
Nebulized albuterol (D) is supportive but will not address the acute ventilatory failure.
, Question 7: A 32-year-old female presents with acute severe headache,
photophobia, and fever. A lumbar puncture is performed, and the
cerebrospinal fluid (CSF) analysis reveals cloudy fluid, elevated protein,
decreased glucose, and a white blood cell count of 1,500/mm³ with 90%
neutrophils. Which of the following is the most appropriate empiric antibiotic
regimen?
A. Ceftriaxone, Vancomycin, and Ampicillin
B. Ceftazidime and Gentamicin
C. Ceftriaxone and Doxycycline
D. Acyclovir
CORRECT ANSWER: A. Ceftriaxone, Vancomycin, and Ampicillin
Rationale: The patient has acute bacterial meningitis based on CSF findings
(neutrophilic pleocytosis, high protein, low glucose). Empiric therapy must cover the
most common pathogens: Streptococcus pneumoniae and Neisseria meningitidis.
Vancomycin and a third-generation cephalosporin (Ceftriaxone) are the mainstay.
Ampicillin is added for coverage of Listeria monocytogenes, especially in patients over 50,
immunocompromised, or with altered mental status. The other regimens (B, C, D) do
not provide broad enough coverage for typical community-acquired bacterial meningitis.
Question 8: A 68-year-old male post-operative day 3 after a colectomy
develops a sudden onset of chest pain and shortness of breath. He is febrile
and has a productive cough with purulent sputum. What is the most likely
complication?
A. Pulmonary embolism
B. Atelectasis
C. Hospital-acquired pneumonia
D. Myocardial infarction
CORRECT ANSWER: C. Hospital-acquired pneumonia
Rationale: Post-operative day 3 with fever, productive cough, and purulent sputum is
characteristic of hospital-acquired pneumonia. While pulmonary embolism (A) is a
concern, the presence of purulent sputum and fever points more to an infectious
process. Atelectasis (B) is common early post-op but typically presents with decreased
breath sounds and resolves quickly. Myocardial infarction (D) is possible but less likely
without ECG changes.
Question 9: A 40-year-old male presents with severe right lower quadrant pain,
vomiting, and fever. A CT scan of the abdomen suggests acute appendicitis
