NR-571 Complex Diagnosis and Management in
Acute Care Practicum – NR571 Study Guide,
Original Practice Questions & Answers,
Comprehensive AGACNP Exam Preparation,
Advanced Acute-Care Diagnosis & Management
Review, Differential Diagnosis, Clinical Reasoning,
Cardiovascular, Pulmonary & Respiratory,
Neurological, Renal, Gastrointestinal, Endocrine &
Metabolic, Infectious & Multisystem Disorders,
Diagnostic Testing, Pharmacology, Critical Care,
Patient Safety & Clinical Decision-Making
Question 1: A 68-year-old male with a history of hypertension and type 2
diabetes presents to the emergency department with acute onset of severe,
tearing chest pain radiating to his back. His blood pressure is 180/110 mmHg
in the right arm and 140/90 mmHg in the left arm. Which diagnostic study is
the most appropriate initial imaging modality to confirm the suspected
diagnosis?
A. Chest X-ray
B. Computed tomography angiography (CTA) of the chest
C. Transthoracic echocardiogram (TTE)
D. Magnetic resonance angiography (MRA)
CORRECT ANSWER: B. Computed tomography angiography (CTA) of the chest
Rationale: The patient's presentation is classic for an acute aortic dissection. CTA of
the chest is the gold standard and most readily available imaging modality for the rapid
diagnosis of aortic dissection, as it accurately identifies the intimal flap and the extent of
the dissection. While a chest X-ray may show a widened mediastinum, it is not
diagnostic. TTE can visualize the aortic root but is not as comprehensive for the entire
thoracic aorta, and MRA is time-consuming and not readily available in an emergency
setting.
Question 2: A 72-year-old female with end-stage renal disease on hemodialysis
is admitted with shortness of breath. Her chest X-ray shows pulmonary
edema. Despite receiving a 40 mg IV dose of furosemide, she remains oliguric.
Her serum potassium is 6.8 mEq/L. Which of the following is the most
appropriate next step in management?
A. Administer a second dose of furosemide 80 mg IV push
B. Start a continuous infusion of insulin and dextrose
C. Initiate emergent hemodialysis
D. Administer sodium polystyrene sulfonate (Kayexalate) orally
CORRECT ANSWER: C. Initiate emergent hemodialysis
,Rationale: This patient has hyperkalemia (potassium 6.8 mEq/L) with severe volume
overload (pulmonary edema) and is oliguric in the setting of end-stage renal disease.
Emergent hemodialysis is the definitive treatment as it will simultaneously correct the
life-threatening hyperkalemia and remove excess fluid. While insulin and dextrose are
temporizing measures for hyperkalemia, they do not remove potassium from the body.
Kayexalate is slow-acting and not appropriate in an acute, life-threatening situation.
Additional furosemide is unlikely to be effective in an anuric patient.
Question 3: A 55-year-old male with a history of alcoholic cirrhosis is admitted
with hematemesis. He is tachycardic and hypotensive. An emergent upper
endoscopy reveals bleeding esophageal varices. What is the most appropriate
initial pharmacological therapy in conjunction with endoscopic band ligation?
A. Propranolol
B. Octreotide
C. Omeprazole
D. Vasopressin
CORRECT ANSWER: B. Octreotide
Rationale: Octreotide, a somatostatin analogue, is the pharmacological agent of choice
for acute variceal hemorrhage. It reduces splanchnic blood flow and portal pressure
without the significant systemic side effects of vasopressin. It is used as an adjunct to
endoscopic therapy (band ligation or sclerotherapy). Propranolol is a non-selective beta-
blocker used for primary prophylaxis, not acute management. Omeprazole is used for
peptic ulcer disease, not variceal bleeding.
Question 4: A 60-year-old male is post-operative day 2 following a CABG. He
becomes acutely confused and agitated. His vital signs are: HR 110, BP 160/90,
RR 22, T 37.0°C. His oxygen saturation is 94% on 2L NC. Which of the
following is the most likely cause of his delirium?
A. Pain
B. Hypoxia
C. Alcohol withdrawal
D. Urinary tract infection
CORRECT ANSWER: C. Alcohol withdrawal
Rationale: Post-operative delirium in a patient who is hypertensive and tachycardic on
post-op day 2 is highly suspicious for alcohol withdrawal, as the timeline of 48-72 hours
post-cessation of intake is classic. While pain and hypoxia can contribute to delirium, his
vital signs and the timeline most strongly suggest withdrawal. A UTI is less likely to
cause such acute agitation without other signs of infection (fever, leukocytosis) so early
post-op.
Question 5: A 45-year-old female with a history of systemic lupus
erythematosus (SLE) presents with pleuritic chest pain and shortness of
breath. Her ECG shows diffuse ST-segment elevation and PR depression. A
,chest X-ray shows a small pericardial effusion. Which of the following is the
most appropriate initial management?
A. High-dose corticosteroids
B. Colchicine and NSAIDs
C. Pericardiocentesis
D. Intravenous immunoglobulin
CORRECT ANSWER: B. Colchicine and NSAIDs
Rationale: The patient presents with acute pericarditis, a known complication of SLE.
The initial management for acute pericarditis, especially in the absence of hemodynamic
compromise or a large effusion causing tamponade, involves anti-inflammatory therapy.
A combination of NSAIDs and colchicine is recommended for initial treatment to reduce
inflammation and prevent recurrence. High-dose corticosteroids are generally reserved
for refractory cases due to the risk of exacerbating SLE and increasing the risk of
recurrence. Pericardiocentesis is indicated for large effusions or suspected tamponade.
Question 6: A 78-year-old male is admitted with a severe community-acquired
pneumonia. He is started on levofloxacin. On day 2, he develops a sudden
onset of palpitations and dizziness. His ECG shows a corrected QT interval
(QTc) of 520 msec. Which of the following is the most appropriate next step?
A. Continue levofloxacin and monitor QTc daily
B. Discontinue levofloxacin and initiate azithromycin
C. Discontinue levofloxacin and initiate a beta-lactam antibiotic
D. Administer IV magnesium sulfate
CORRECT ANSWER: C. Discontinue levofloxacin and initiate a beta-lactam
antibiotic
Rationale: Levofloxacin is a fluoroquinolone known to prolong the QT interval, which
can predispose patients to potentially fatal arrhythmias like Torsades de Pointes. A QTc
> 500 msec is a significant risk factor. The safest course of action is to discontinue the
offending agent and switch to an appropriate alternative antibiotic class with a lower risk
of QT prolongation, such as a beta-lactam (e.g., ceftriaxone). Continuing the drug or
switching to azithromycin (another QT-prolonging agent) is inappropriate. Magnesium is
a treatment for Torsades but does not address the source of the problem (the drug).
Question 7: A 65-year-old female with a history of chronic heart failure
(HFrEF) is admitted with increasing dyspnea and weight gain. She is on a
regimen of lisinopril, carvedilol, and furosemide. Her blood pressure is 100/70
mmHg, and her heart rate is 80. Her labs show a creatinine of 2.1 mg/dL
(baseline 1.5). Which medication is most likely contributing to the worsening
renal function?
A. Lisinopril
B. Carvedilol
, C. Furosemide
D. All of the above
CORRECT ANSWER: A. Lisinopril
Rationale: Lisinopril, an ACE inhibitor, can cause a reversible increase in serum
creatinine due to its effect on efferent arteriolar vasodilation, which decreases
glomerular filtration pressure. In the setting of heart failure, this effect can be
pronounced, especially if the patient is volume-depleted. While furosemide can cause
pre-renal azotemia, the rise in creatinine is most classically associated with the initiation
or up-titration of an ACE inhibitor. Carvedilol does not typically cause an acute rise in
creatinine.
Question 8: A 50-year-old obese male with a history of obstructive sleep apnea
is admitted with acute respiratory failure. He is drowsy and has a PaCO2 of 75
mmHg. He is started on BiPAP. Which of the following is the most important
parameter to monitor to assess the effectiveness of non-invasive ventilation?
A. Respiratory rate
B. Oxygen saturation
C. Arterial blood gas analysis
D. Mental status
CORRECT ANSWER: D. Mental status
Rationale: In a patient with acute respiratory failure and hypercapnia, the most critical
parameter to monitor for non-invasive ventilation (NIV) success is the patient's mental
status. A deteriorating level of consciousness indicates worsening hypercapnia, CNS
depression, and an inability to protect the airway, which is a primary indicator for
intubation. While ABG, SpO2, and respiratory rate are important, they are secondary to
the patient's neurological status in determining the need for escalation of care.
Question 9: A 40-year-old female with a history of asthma is admitted for an
acute exacerbation. She is not responding to nebulized albuterol and
ipratropium. On exam, she is diaphoretic, has a silent chest, and is using
accessory muscles. Her ABG shows pH 7.20, PaCO2 65, PaO2 55. What is the
most appropriate next step in management?
A. Increase the frequency of albuterol nebulizations
B. Start IV magnesium sulfate
C. Initiate heliox therapy
D. Prepare for immediate endotracheal intubation and mechanical ventilation
CORRECT ANSWER: D. Prepare for immediate endotracheal intubation and
mechanical ventilation
Rationale: This patient is in a life-threatening, near-fatal asthma exacerbation. The
presence of a "silent chest," diaphoresis, accessory muscle use, and the ABG showing
respiratory acidosis (pH 7.20, PaCO2 65) indicate severe respiratory muscle fatigue and
Acute Care Practicum – NR571 Study Guide,
Original Practice Questions & Answers,
Comprehensive AGACNP Exam Preparation,
Advanced Acute-Care Diagnosis & Management
Review, Differential Diagnosis, Clinical Reasoning,
Cardiovascular, Pulmonary & Respiratory,
Neurological, Renal, Gastrointestinal, Endocrine &
Metabolic, Infectious & Multisystem Disorders,
Diagnostic Testing, Pharmacology, Critical Care,
Patient Safety & Clinical Decision-Making
Question 1: A 68-year-old male with a history of hypertension and type 2
diabetes presents to the emergency department with acute onset of severe,
tearing chest pain radiating to his back. His blood pressure is 180/110 mmHg
in the right arm and 140/90 mmHg in the left arm. Which diagnostic study is
the most appropriate initial imaging modality to confirm the suspected
diagnosis?
A. Chest X-ray
B. Computed tomography angiography (CTA) of the chest
C. Transthoracic echocardiogram (TTE)
D. Magnetic resonance angiography (MRA)
CORRECT ANSWER: B. Computed tomography angiography (CTA) of the chest
Rationale: The patient's presentation is classic for an acute aortic dissection. CTA of
the chest is the gold standard and most readily available imaging modality for the rapid
diagnosis of aortic dissection, as it accurately identifies the intimal flap and the extent of
the dissection. While a chest X-ray may show a widened mediastinum, it is not
diagnostic. TTE can visualize the aortic root but is not as comprehensive for the entire
thoracic aorta, and MRA is time-consuming and not readily available in an emergency
setting.
Question 2: A 72-year-old female with end-stage renal disease on hemodialysis
is admitted with shortness of breath. Her chest X-ray shows pulmonary
edema. Despite receiving a 40 mg IV dose of furosemide, she remains oliguric.
Her serum potassium is 6.8 mEq/L. Which of the following is the most
appropriate next step in management?
A. Administer a second dose of furosemide 80 mg IV push
B. Start a continuous infusion of insulin and dextrose
C. Initiate emergent hemodialysis
D. Administer sodium polystyrene sulfonate (Kayexalate) orally
CORRECT ANSWER: C. Initiate emergent hemodialysis
,Rationale: This patient has hyperkalemia (potassium 6.8 mEq/L) with severe volume
overload (pulmonary edema) and is oliguric in the setting of end-stage renal disease.
Emergent hemodialysis is the definitive treatment as it will simultaneously correct the
life-threatening hyperkalemia and remove excess fluid. While insulin and dextrose are
temporizing measures for hyperkalemia, they do not remove potassium from the body.
Kayexalate is slow-acting and not appropriate in an acute, life-threatening situation.
Additional furosemide is unlikely to be effective in an anuric patient.
Question 3: A 55-year-old male with a history of alcoholic cirrhosis is admitted
with hematemesis. He is tachycardic and hypotensive. An emergent upper
endoscopy reveals bleeding esophageal varices. What is the most appropriate
initial pharmacological therapy in conjunction with endoscopic band ligation?
A. Propranolol
B. Octreotide
C. Omeprazole
D. Vasopressin
CORRECT ANSWER: B. Octreotide
Rationale: Octreotide, a somatostatin analogue, is the pharmacological agent of choice
for acute variceal hemorrhage. It reduces splanchnic blood flow and portal pressure
without the significant systemic side effects of vasopressin. It is used as an adjunct to
endoscopic therapy (band ligation or sclerotherapy). Propranolol is a non-selective beta-
blocker used for primary prophylaxis, not acute management. Omeprazole is used for
peptic ulcer disease, not variceal bleeding.
Question 4: A 60-year-old male is post-operative day 2 following a CABG. He
becomes acutely confused and agitated. His vital signs are: HR 110, BP 160/90,
RR 22, T 37.0°C. His oxygen saturation is 94% on 2L NC. Which of the
following is the most likely cause of his delirium?
A. Pain
B. Hypoxia
C. Alcohol withdrawal
D. Urinary tract infection
CORRECT ANSWER: C. Alcohol withdrawal
Rationale: Post-operative delirium in a patient who is hypertensive and tachycardic on
post-op day 2 is highly suspicious for alcohol withdrawal, as the timeline of 48-72 hours
post-cessation of intake is classic. While pain and hypoxia can contribute to delirium, his
vital signs and the timeline most strongly suggest withdrawal. A UTI is less likely to
cause such acute agitation without other signs of infection (fever, leukocytosis) so early
post-op.
Question 5: A 45-year-old female with a history of systemic lupus
erythematosus (SLE) presents with pleuritic chest pain and shortness of
breath. Her ECG shows diffuse ST-segment elevation and PR depression. A
,chest X-ray shows a small pericardial effusion. Which of the following is the
most appropriate initial management?
A. High-dose corticosteroids
B. Colchicine and NSAIDs
C. Pericardiocentesis
D. Intravenous immunoglobulin
CORRECT ANSWER: B. Colchicine and NSAIDs
Rationale: The patient presents with acute pericarditis, a known complication of SLE.
The initial management for acute pericarditis, especially in the absence of hemodynamic
compromise or a large effusion causing tamponade, involves anti-inflammatory therapy.
A combination of NSAIDs and colchicine is recommended for initial treatment to reduce
inflammation and prevent recurrence. High-dose corticosteroids are generally reserved
for refractory cases due to the risk of exacerbating SLE and increasing the risk of
recurrence. Pericardiocentesis is indicated for large effusions or suspected tamponade.
Question 6: A 78-year-old male is admitted with a severe community-acquired
pneumonia. He is started on levofloxacin. On day 2, he develops a sudden
onset of palpitations and dizziness. His ECG shows a corrected QT interval
(QTc) of 520 msec. Which of the following is the most appropriate next step?
A. Continue levofloxacin and monitor QTc daily
B. Discontinue levofloxacin and initiate azithromycin
C. Discontinue levofloxacin and initiate a beta-lactam antibiotic
D. Administer IV magnesium sulfate
CORRECT ANSWER: C. Discontinue levofloxacin and initiate a beta-lactam
antibiotic
Rationale: Levofloxacin is a fluoroquinolone known to prolong the QT interval, which
can predispose patients to potentially fatal arrhythmias like Torsades de Pointes. A QTc
> 500 msec is a significant risk factor. The safest course of action is to discontinue the
offending agent and switch to an appropriate alternative antibiotic class with a lower risk
of QT prolongation, such as a beta-lactam (e.g., ceftriaxone). Continuing the drug or
switching to azithromycin (another QT-prolonging agent) is inappropriate. Magnesium is
a treatment for Torsades but does not address the source of the problem (the drug).
Question 7: A 65-year-old female with a history of chronic heart failure
(HFrEF) is admitted with increasing dyspnea and weight gain. She is on a
regimen of lisinopril, carvedilol, and furosemide. Her blood pressure is 100/70
mmHg, and her heart rate is 80. Her labs show a creatinine of 2.1 mg/dL
(baseline 1.5). Which medication is most likely contributing to the worsening
renal function?
A. Lisinopril
B. Carvedilol
, C. Furosemide
D. All of the above
CORRECT ANSWER: A. Lisinopril
Rationale: Lisinopril, an ACE inhibitor, can cause a reversible increase in serum
creatinine due to its effect on efferent arteriolar vasodilation, which decreases
glomerular filtration pressure. In the setting of heart failure, this effect can be
pronounced, especially if the patient is volume-depleted. While furosemide can cause
pre-renal azotemia, the rise in creatinine is most classically associated with the initiation
or up-titration of an ACE inhibitor. Carvedilol does not typically cause an acute rise in
creatinine.
Question 8: A 50-year-old obese male with a history of obstructive sleep apnea
is admitted with acute respiratory failure. He is drowsy and has a PaCO2 of 75
mmHg. He is started on BiPAP. Which of the following is the most important
parameter to monitor to assess the effectiveness of non-invasive ventilation?
A. Respiratory rate
B. Oxygen saturation
C. Arterial blood gas analysis
D. Mental status
CORRECT ANSWER: D. Mental status
Rationale: In a patient with acute respiratory failure and hypercapnia, the most critical
parameter to monitor for non-invasive ventilation (NIV) success is the patient's mental
status. A deteriorating level of consciousness indicates worsening hypercapnia, CNS
depression, and an inability to protect the airway, which is a primary indicator for
intubation. While ABG, SpO2, and respiratory rate are important, they are secondary to
the patient's neurological status in determining the need for escalation of care.
Question 9: A 40-year-old female with a history of asthma is admitted for an
acute exacerbation. She is not responding to nebulized albuterol and
ipratropium. On exam, she is diaphoretic, has a silent chest, and is using
accessory muscles. Her ABG shows pH 7.20, PaCO2 65, PaO2 55. What is the
most appropriate next step in management?
A. Increase the frequency of albuterol nebulizations
B. Start IV magnesium sulfate
C. Initiate heliox therapy
D. Prepare for immediate endotracheal intubation and mechanical ventilation
CORRECT ANSWER: D. Prepare for immediate endotracheal intubation and
mechanical ventilation
Rationale: This patient is in a life-threatening, near-fatal asthma exacerbation. The
presence of a "silent chest," diaphoresis, accessory muscle use, and the ABG showing
respiratory acidosis (pH 7.20, PaCO2 65) indicate severe respiratory muscle fatigue and
