Chamberlain University NR-571 Complex Diagnosis and
Management in Acute Care Practicum – NR 571 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 with acute onset of severe, tearing chest pain radiating to his
back. His blood pressure is 180/110 mmHg in the right arm and 100/70 mmHg
in the left arm. Which diagnostic study is the most appropriate initial imaging
modality to confirm the suspected diagnosis?
A. Transthoracic echocardiogram
B. Computed tomography angiography of the chest
C. Magnetic resonance angiography
D. Standard chest radiograph
CORRECT ANSWER: B. Computed tomography angiography of the chest
Rationale: The patient's presentation of acute tearing chest pain radiating to the back,
along with a significant blood pressure differential between arms, is highly suspicious for
an acute aortic dissection. Computed tomography angiography (CTA) of the chest is the
diagnostic modality of choice due to its high sensitivity and specificity, rapid acquisition
time, and wide availability in emergency settings. It allows for precise visualization of
the intimal flap and extent of the dissection, which is critical for surgical planning.
Question 2: A 55-year-old female with a history of cirrhosis presents with
altered mental status, asterixis, and a serum ammonia level of 150 µmol/L.
Which medication is the primary treatment for reducing ammonia production
in this patient?
A. Lactulose
B. Rifaximin
C. Neomycin
D. Spironolactone
CORRECT ANSWER: A. Lactulose
Rationale: This patient is exhibiting signs of hepatic encephalopathy. Lactulose is a
non-absorbable disaccharide that acidifies the colon, converting ammonia (NH3) to
ammonium (NH4+), which is less readily absorbed. This promotes the excretion of
ammonia in the stool. While rifaximin is used as an adjunctive therapy to alter gut flora
,and reduce ammonia production, lactulose is considered the first-line and primary
treatment for reducing ammonia levels in acute hepatic encephalopathy.
Question 3: A 72-year-old man is admitted to the ICU with septic shock
secondary to pneumonia. He is on a norepinephrine infusion at 0.5
mcg/kg/min. His mean arterial pressure (MAP) is 58 mmHg. Which of the
following is the most appropriate next step in managing his vasopressor-
resistant shock?
A. Increase the norepinephrine infusion rate
B. Initiate an infusion of phenylephrine
C. Initiate an infusion of vasopressin
D. Administer a fluid bolus of 500 mL of normal saline
CORRECT ANSWER: C. Initiate an infusion of vasopressin
Rationale: In septic shock, norepinephrine is the first-line vasopressor. When a patient
remains hypotensive with a MAP < 65 mmHg despite moderate to high doses of
norepinephrine, a second-line agent should be added. Vasopressin (0.03 units/min) is
the preferred adjunctive vasopressor in this scenario. It acts on V1 receptors to cause
vasoconstriction and its effects are often augmented in the presence of acidosis.
Increasing the norepinephrine further would increase the risk of adverse effects such as
dysrhythmias, and a fluid bolus is less likely to be effective if the patient is already
volume-resuscitated and remains pressor-dependent.
Question 4: A 45-year-old female with a history of systemic lupus
erythematosus presents with acute onset of severe, pleuritic chest pain and
shortness of breath. She is tachypneic and hypoxic. A CT pulmonary
angiography is positive for a large pulmonary embolism. Her blood pressure is
85/55 mmHg. Which of the following is the most appropriate immediate
management strategy?
A. Initiate therapeutic unfractionated heparin infusion
B. Administer a weight-based bolus of low molecular weight heparin
C. Administer systemic thrombolytic therapy
D. Perform an emergency catheter-directed embolectomy
CORRECT ANSWER: C. Administer systemic thrombolytic therapy
Rationale: This patient has a massive pulmonary embolism (PE) defined by the
presence of hypotension (systolic BP < 90 mmHg or a drop of >40 mmHg). In patients
with a massive PE, immediate reperfusion via systemic thrombolytic therapy is the
standard of care and can be life-saving. Heparin alone is insufficient for managing the
hemodynamic instability associated with a massive PE, and catheter-directed therapies
,are usually considered when there is a contraindication to thrombolysis or if
thrombolysis fails.
Question 5: A 60-year-old male with a history of coronary artery disease
presents with progressive dyspnea and orthopnea. Physical examination
reveals jugular venous distension, an S3 gallop, and bilateral crackles. His BNP
level is 1,200 pg/mL. Which of the following is the most appropriate initial
pharmacologic intervention to reduce preload and relieve symptoms of
pulmonary congestion in this patient?
A. Metoprolol succinate
B. Furosemide
C. Spironolactone
D. Dobutamine
CORRECT ANSWER: B. Furosemide
Rationale: The patient is presenting with acute decompensated heart failure with
significant volume overload, as evidenced by his signs and symptoms. Loop diuretics
like furosemide are the mainstay of initial therapy in this scenario. They work by
inhibiting the Na-K-2Cl cotransporter in the thick ascending limb of the loop of Henle,
promoting diuresis and reducing preload, which alleviates pulmonary congestion. While
other medications like beta-blockers and dobutamine may have roles in heart failure
management, furosemide is the most appropriate first-line for acute volume overload.
Question 6: A 50-year-old male with a history of alcohol abuse is admitted
with severe epigastric pain radiating to the back, nausea, and vomiting. His
serum amylase is 1,200 U/L. An abdominal CT reveals pancreatic necrosis.
Antibiotic therapy is being considered. Which of the following antibiotics is
most appropriate for prophylaxis in patients with suspected necrotizing
pancreatitis?
A. Ciprofloxacin
B. Metronidazole
C. Imipenem
D. Vancomycin
CORRECT ANSWER: C. Imipenem
Rationale: In patients with necrotizing pancreatitis, prophylactic antibiotics should be
used cautiously and only in cases of documented infection, though guidelines have
shifted away from routine prophylaxis. If antibiotics are indicated, the choice should
target organisms that penetrate pancreatic tissue effectively, such as carbapenems (e.g.,
imipenem) or fluoroquinolones in combination with metronidazole. Imipenem has
, excellent penetration into pancreatic tissue and covers aerobic and anaerobic organisms
commonly associated with infected necrosis.
Question 7: A 65-year-old female with a history of chronic obstructive
pulmonary disease is admitted with acute respiratory failure. She is placed on
bilevel positive airway pressure (BiPAP). She becomes increasingly somnolent
and has a respiratory rate of 6 breaths per minute. Her arterial blood gas
shows pH 7.15, PaCO2 85 mmHg, and PaO2 55 mmHg. Which of the following
is the most appropriate next step in management?
A. Increase the inspiratory positive airway pressure (IPAP) on BiPAP
B. Administer naloxone
C. Administer sodium bicarbonate
D. Proceed with endotracheal intubation and mechanical ventilation
CORRECT ANSWER: D. Proceed with endotracheal intubation and mechanical
ventilation
Rationale: This patient is experiencing respiratory failure with severe hypercapnia and
respiratory acidosis, which has not been corrected by non-invasive ventilation (BiPAP).
Her increasing somnolence and decreased respiratory rate indicate impending
respiratory arrest and an inability to protect her airway. The most appropriate next step
is to secure the airway via endotracheal intubation and initiate mechanical ventilation.
Increasing BiPAP settings at this point would be unsafe, and sodium bicarbonate is not
indicated as it may worsen intracellular acidosis.
Question 8: A 75-year-old male with atrial fibrillation is on warfarin therapy
for stroke prophylaxis. His INR is currently 6.5. He is not bleeding. Which of
the following is the most appropriate management strategy?
A. Administer vitamin K 10 mg IV
B. Administer fresh frozen plasma
C. Withhold warfarin and monitor INR
D. Administer prothrombin complex concentrate
CORRECT ANSWER: C. Withhold warfarin and monitor INR
Rationale: The management of a supratherapeutic INR depends on the INR level and
presence of bleeding. For an asymptomatic patient with an INR between 5.0 and 9.0, the
standard of care is to hold warfarin and monitor the INR. Vitamin K is generally
reserved for INRs > 10 or for patients with bleeding. Fresh frozen plasma and
prothrombin complex concentrate are used for urgent reversal in cases of active
bleeding or need for emergent surgery.
Management in Acute Care Practicum – NR 571 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 with acute onset of severe, tearing chest pain radiating to his
back. His blood pressure is 180/110 mmHg in the right arm and 100/70 mmHg
in the left arm. Which diagnostic study is the most appropriate initial imaging
modality to confirm the suspected diagnosis?
A. Transthoracic echocardiogram
B. Computed tomography angiography of the chest
C. Magnetic resonance angiography
D. Standard chest radiograph
CORRECT ANSWER: B. Computed tomography angiography of the chest
Rationale: The patient's presentation of acute tearing chest pain radiating to the back,
along with a significant blood pressure differential between arms, is highly suspicious for
an acute aortic dissection. Computed tomography angiography (CTA) of the chest is the
diagnostic modality of choice due to its high sensitivity and specificity, rapid acquisition
time, and wide availability in emergency settings. It allows for precise visualization of
the intimal flap and extent of the dissection, which is critical for surgical planning.
Question 2: A 55-year-old female with a history of cirrhosis presents with
altered mental status, asterixis, and a serum ammonia level of 150 µmol/L.
Which medication is the primary treatment for reducing ammonia production
in this patient?
A. Lactulose
B. Rifaximin
C. Neomycin
D. Spironolactone
CORRECT ANSWER: A. Lactulose
Rationale: This patient is exhibiting signs of hepatic encephalopathy. Lactulose is a
non-absorbable disaccharide that acidifies the colon, converting ammonia (NH3) to
ammonium (NH4+), which is less readily absorbed. This promotes the excretion of
ammonia in the stool. While rifaximin is used as an adjunctive therapy to alter gut flora
,and reduce ammonia production, lactulose is considered the first-line and primary
treatment for reducing ammonia levels in acute hepatic encephalopathy.
Question 3: A 72-year-old man is admitted to the ICU with septic shock
secondary to pneumonia. He is on a norepinephrine infusion at 0.5
mcg/kg/min. His mean arterial pressure (MAP) is 58 mmHg. Which of the
following is the most appropriate next step in managing his vasopressor-
resistant shock?
A. Increase the norepinephrine infusion rate
B. Initiate an infusion of phenylephrine
C. Initiate an infusion of vasopressin
D. Administer a fluid bolus of 500 mL of normal saline
CORRECT ANSWER: C. Initiate an infusion of vasopressin
Rationale: In septic shock, norepinephrine is the first-line vasopressor. When a patient
remains hypotensive with a MAP < 65 mmHg despite moderate to high doses of
norepinephrine, a second-line agent should be added. Vasopressin (0.03 units/min) is
the preferred adjunctive vasopressor in this scenario. It acts on V1 receptors to cause
vasoconstriction and its effects are often augmented in the presence of acidosis.
Increasing the norepinephrine further would increase the risk of adverse effects such as
dysrhythmias, and a fluid bolus is less likely to be effective if the patient is already
volume-resuscitated and remains pressor-dependent.
Question 4: A 45-year-old female with a history of systemic lupus
erythematosus presents with acute onset of severe, pleuritic chest pain and
shortness of breath. She is tachypneic and hypoxic. A CT pulmonary
angiography is positive for a large pulmonary embolism. Her blood pressure is
85/55 mmHg. Which of the following is the most appropriate immediate
management strategy?
A. Initiate therapeutic unfractionated heparin infusion
B. Administer a weight-based bolus of low molecular weight heparin
C. Administer systemic thrombolytic therapy
D. Perform an emergency catheter-directed embolectomy
CORRECT ANSWER: C. Administer systemic thrombolytic therapy
Rationale: This patient has a massive pulmonary embolism (PE) defined by the
presence of hypotension (systolic BP < 90 mmHg or a drop of >40 mmHg). In patients
with a massive PE, immediate reperfusion via systemic thrombolytic therapy is the
standard of care and can be life-saving. Heparin alone is insufficient for managing the
hemodynamic instability associated with a massive PE, and catheter-directed therapies
,are usually considered when there is a contraindication to thrombolysis or if
thrombolysis fails.
Question 5: A 60-year-old male with a history of coronary artery disease
presents with progressive dyspnea and orthopnea. Physical examination
reveals jugular venous distension, an S3 gallop, and bilateral crackles. His BNP
level is 1,200 pg/mL. Which of the following is the most appropriate initial
pharmacologic intervention to reduce preload and relieve symptoms of
pulmonary congestion in this patient?
A. Metoprolol succinate
B. Furosemide
C. Spironolactone
D. Dobutamine
CORRECT ANSWER: B. Furosemide
Rationale: The patient is presenting with acute decompensated heart failure with
significant volume overload, as evidenced by his signs and symptoms. Loop diuretics
like furosemide are the mainstay of initial therapy in this scenario. They work by
inhibiting the Na-K-2Cl cotransporter in the thick ascending limb of the loop of Henle,
promoting diuresis and reducing preload, which alleviates pulmonary congestion. While
other medications like beta-blockers and dobutamine may have roles in heart failure
management, furosemide is the most appropriate first-line for acute volume overload.
Question 6: A 50-year-old male with a history of alcohol abuse is admitted
with severe epigastric pain radiating to the back, nausea, and vomiting. His
serum amylase is 1,200 U/L. An abdominal CT reveals pancreatic necrosis.
Antibiotic therapy is being considered. Which of the following antibiotics is
most appropriate for prophylaxis in patients with suspected necrotizing
pancreatitis?
A. Ciprofloxacin
B. Metronidazole
C. Imipenem
D. Vancomycin
CORRECT ANSWER: C. Imipenem
Rationale: In patients with necrotizing pancreatitis, prophylactic antibiotics should be
used cautiously and only in cases of documented infection, though guidelines have
shifted away from routine prophylaxis. If antibiotics are indicated, the choice should
target organisms that penetrate pancreatic tissue effectively, such as carbapenems (e.g.,
imipenem) or fluoroquinolones in combination with metronidazole. Imipenem has
, excellent penetration into pancreatic tissue and covers aerobic and anaerobic organisms
commonly associated with infected necrosis.
Question 7: A 65-year-old female with a history of chronic obstructive
pulmonary disease is admitted with acute respiratory failure. She is placed on
bilevel positive airway pressure (BiPAP). She becomes increasingly somnolent
and has a respiratory rate of 6 breaths per minute. Her arterial blood gas
shows pH 7.15, PaCO2 85 mmHg, and PaO2 55 mmHg. Which of the following
is the most appropriate next step in management?
A. Increase the inspiratory positive airway pressure (IPAP) on BiPAP
B. Administer naloxone
C. Administer sodium bicarbonate
D. Proceed with endotracheal intubation and mechanical ventilation
CORRECT ANSWER: D. Proceed with endotracheal intubation and mechanical
ventilation
Rationale: This patient is experiencing respiratory failure with severe hypercapnia and
respiratory acidosis, which has not been corrected by non-invasive ventilation (BiPAP).
Her increasing somnolence and decreased respiratory rate indicate impending
respiratory arrest and an inability to protect her airway. The most appropriate next step
is to secure the airway via endotracheal intubation and initiate mechanical ventilation.
Increasing BiPAP settings at this point would be unsafe, and sodium bicarbonate is not
indicated as it may worsen intracellular acidosis.
Question 8: A 75-year-old male with atrial fibrillation is on warfarin therapy
for stroke prophylaxis. His INR is currently 6.5. He is not bleeding. Which of
the following is the most appropriate management strategy?
A. Administer vitamin K 10 mg IV
B. Administer fresh frozen plasma
C. Withhold warfarin and monitor INR
D. Administer prothrombin complex concentrate
CORRECT ANSWER: C. Withhold warfarin and monitor INR
Rationale: The management of a supratherapeutic INR depends on the INR level and
presence of bleeding. For an asymptomatic patient with an INR between 5.0 and 9.0, the
standard of care is to hold warfarin and monitor the INR. Vitamin K is generally
reserved for INRs > 10 or for patients with bleeding. Fresh frozen plasma and
prothrombin complex concentrate are used for urgent reversal in cases of active
bleeding or need for emergent surgery.
