NR 571 Complex Diagnosis and Management in
Acute Care Practicum | Chamberlain University
AGACNP Study Guide, Final Exam Review, Original
Practice Questions & Answers, Detailed Rationales,
Diagnostic Reasoning, Complex Acute Care Cases,
Clinical Decision-Making & Exam Prep
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, along with a pulse deficit in his left femoral artery. Which of the
following is the most appropriate immediate next step in management?
A. Administer sublingual nitroglycerin and obtain a 12-lead EKG
B. Emergent cardiac catheterization for suspected ST-elevation myocardial infarction
C. Immediate computed tomography angiography (CTA) of the chest, abdomen, and
pelvis
D. Administer a loading dose of clopidogrel and aspirin
CORRECT ANSWER: C. Immediate computed tomography angiography (CTA)
of the chest, abdomen, and pelvis
Rationale: The patient's presentation of tearing chest pain radiating to the back,
combined with a pulse deficit, is highly suspicious for an acute aortic dissection. The
diagnostic study of choice for suspected aortic dissection is a CTA, which can rapidly
identify the intimal flap and determine the extent of the dissection (Stanford Type A vs.
B). This is a time-sensitive emergency requiring immediate surgical or medical
intervention. Administering nitroglycerin or antiplatelet agents could be harmful if the
underlying cause is a dissection, and while an EKG is important, it should not delay
definitive imaging.
Question 2: A 72-year-old female with end-stage renal disease on hemodialysis
presents with worsening shortness of breath. Her vitals are HR 110, BP
160/90, RR 28, and SpO2 88% on room air. Lung auscultation reveals diffuse
crackles. A chest X-ray shows pulmonary edema. Which of the following
antihypertensive agents is most appropriate for acute afterload reduction in
this patient?
A. Labetalol
B. Enalaprilat
C. Sodium nitroprusside
D. Metoprolol
CORRECT ANSWER: C. Sodium nitroprusside
Rationale: Sodium nitroprusside is a potent, rapid-acting vasodilator that provides
acute afterload reduction, which is essential for managing hypertensive emergency with
acute pulmonary edema. While Enalaprilat is also an afterload reducer, sodium
,nitroprusside's immediate onset and ability to be carefully titrated in a critical care
setting make it the preferred agent for rapid blood pressure control in this scenario.
Labetalol and Metoprolol are beta-blockers and do not provide the necessary afterload
reduction and are not first-line for acute pulmonary edema in this setting.
Question 3: A 55-year-old male with a history of cirrhosis presents with
confusion, asterixis, and jaundice. His laboratory results reveal an ammonia
level of 150 µmol/L. Which of the following is the most appropriate first-line
pharmacological therapy to reduce ammonia production?
A. Lactulose
B. Neomycin
C. Rifaximin
D. Metronidazole
CORRECT ANSWER: A. Lactulose
Rationale: Lactulose is a non-absorbable disaccharide that acidifies the colonic lumen,
converting ammonia (NH3) to the non-absorbable ammonium ion (NH4+), promoting
its excretion in the stool. It is the first-line pharmacological treatment for hepatic
encephalopathy. While Rifaximin and Neomycin are also used, they are typically
considered second-line or adjunctive therapies to reduce ammonia-producing gut
bacteria, particularly in patients who do not respond adequately to lactulose alone.
Question 4: A 65-year-old female with a history of COPD is admitted with
acute exacerbation. Arterial blood gas shows: pH 7.25, PaCO2 70 mmHg, PaO2
55 mmHg, HCO3- 28 mEq/L. Which of the following non-invasive ventilation
settings is most appropriate to initiate?
A. CPAP of 10 cm H2O
B. BiPAP with IPAP 10/EPAP 5 cm H2O
C. BiPAP with IPAP 15/EPAP 5 cm H2O
D. CPAP of 5 cm H2O
CORRECT ANSWER: C. BiPAP with IPAP 15/EPAP 5 cm H2O
Rationale: The patient is in acute hypercapnic respiratory failure (pH < 7.35, PaCO2 >
45) due to COPD exacerbation. Bi-level positive airway pressure (BiPAP) is the preferred
non-invasive ventilation modality. The IPAP (Inspiratory Positive Airway Pressure)
provides pressure support to augment tidal volume and decrease work of breathing,
while the EPAP (Expiratory Positive Airway Pressure) helps to stent open airways and
recruit alveoli. An IPAP of 15 cm H2O is a typical and effective starting point for
pressure support in COPD to improve ventilation and lower PaCO2.
,Question 5: A 45-year-old male with a traumatic brain injury has an
intracranial pressure (ICP) monitor in place. His ICP is currently 28 mmHg.
Which of the following interventions should be initiated first to lower ICP?
A. Administer hypertonic saline (3% NaCl) bolus
B. Administer mannitol 1 g/kg IV
C. Elevate the head of the bed to 30 degrees
D. Initiate hyperventilation to a PaCO2 of 30 mmHg
CORRECT ANSWER: C. Elevate the head of the bed to 30 degrees
Rationale: The first-line, non-invasive, and rapid intervention to reduce elevated ICP is
to elevate the head of the bed to 30 degrees. This promotes venous drainage from the
brain, thereby reducing intracranial blood volume and pressure. While hypertonic saline
and mannitol are effective osmotic therapies, and hyperventilation is a temporizing
measure, they are secondary interventions. The head of bed elevation is a fundamental
and immediate nursing/medical intervention that should be performed before or
concurrently with pharmacological interventions.
Question 6: A 70-year-old male with a history of atrial fibrillation presents
with sudden onset of severe abdominal pain, vomiting, and bloody diarrhea.
Abdominal exam is benign. Serum lactate is 6.0 mmol/L. Which of the
following is the most likely diagnosis and most appropriate diagnostic test?
A. Mesenteric ischemia; CT angiography (CTA)
B. Diverticulitis; CT abdomen with contrast
C. Ischemic colitis; Colonoscopy
D. Acute pancreatitis; Serum lipase
CORRECT ANSWER: A. Mesenteric ischemia; CT angiography (CTA)
Rationale: The patient's history of atrial fibrillation puts him at high risk for an embolic
event. The presentation of sudden, severe abdominal pain out of proportion to physical
exam findings (benign abdomen) with bloody diarrhea and an elevated lactate is classic
for acute mesenteric ischemia. CTA of the abdomen is the diagnostic test of choice as it
can quickly identify vascular occlusion (e.g., superior mesenteric artery) and guide
urgent surgical or endovascular intervention.
Question 7: A 60-year-old female with a history of mitral stenosis presents
with acute onset of palpitations and lightheadedness. Her EKG shows an
irregularly irregular rhythm with a ventricular rate of 150. She is hypotensive
with a BP of 80/50 mmHg. Which of the following is the most appropriate
immediate management?
A. Amiodarone 150 mg IV push
B. Diltiazem 20 mg IV push
, C. Synchronized cardioversion
D. Digoxin 0.5 mg IV push
CORRECT ANSWER: C. Synchronized cardioversion
Rationale: This patient presents with unstable atrial fibrillation with rapid ventricular
response, evidenced by hypotension and lightheadedness. Synchronized cardioversion is
the immediate treatment of choice for any unstable tachyarrhythmia. Electrical
cardioversion is preferred over pharmacologic rate or rhythm control in the unstable
patient because it provides immediate restoration of sinus rhythm. Chemical
cardioversion (e.g., Amiodarone) or rate control (Diltiazem, Digoxin) are for
hemodynamically stable patients or as adjuncts after cardioversion.
Question 8: A 48-year-old male with a history of alcoholism presents with
severe epigastric pain radiating to the back, nausea, and vomiting. His serum
lipase is 1800 U/L. CT abdomen reveals pancreatic necrosis. Which of the
following antibiotic regimens is recommended for prophylaxis against infected
necrosis?
A. No prophylactic antibiotics are recommended
B. Vancomycin and Cefepime
C. Piperacillin-Tazobactam
D. Ciprofloxacin and Metronidazole
CORRECT ANSWER: A. No prophylactic antibiotics are recommended
Rationale: Current guidelines (e.g., American College of Gastroenterology) recommend
against the routine use of prophylactic antibiotics in acute pancreatitis, even in the
presence of necrosis. The use of prophylactic antibiotics has not been shown to reduce
mortality or the incidence of infected necrosis and can promote the development of
resistant organisms. Antibiotics should be reserved for patients with documented or
strongly suspected infected necrosis or other infectious complications.
Question 9: A 75-year-old male with a history of coronary artery disease
presents with progressive dyspnea and orthopnea. Echocardiogram shows an
ejection fraction of 25%. He is on optimal medical therapy for heart failure
with reduced ejection fraction (HFrEF). Which of the following medications
has been shown to provide a mortality benefit and should be added to his
regimen if not already prescribed?
A. Hydralazine and Isosorbide Dinitrate
B. Spironolactone
C. Ivabradine
D. Metolazone
CORRECT ANSWER: B. Spironolactone
Acute Care Practicum | Chamberlain University
AGACNP Study Guide, Final Exam Review, Original
Practice Questions & Answers, Detailed Rationales,
Diagnostic Reasoning, Complex Acute Care Cases,
Clinical Decision-Making & Exam Prep
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, along with a pulse deficit in his left femoral artery. Which of the
following is the most appropriate immediate next step in management?
A. Administer sublingual nitroglycerin and obtain a 12-lead EKG
B. Emergent cardiac catheterization for suspected ST-elevation myocardial infarction
C. Immediate computed tomography angiography (CTA) of the chest, abdomen, and
pelvis
D. Administer a loading dose of clopidogrel and aspirin
CORRECT ANSWER: C. Immediate computed tomography angiography (CTA)
of the chest, abdomen, and pelvis
Rationale: The patient's presentation of tearing chest pain radiating to the back,
combined with a pulse deficit, is highly suspicious for an acute aortic dissection. The
diagnostic study of choice for suspected aortic dissection is a CTA, which can rapidly
identify the intimal flap and determine the extent of the dissection (Stanford Type A vs.
B). This is a time-sensitive emergency requiring immediate surgical or medical
intervention. Administering nitroglycerin or antiplatelet agents could be harmful if the
underlying cause is a dissection, and while an EKG is important, it should not delay
definitive imaging.
Question 2: A 72-year-old female with end-stage renal disease on hemodialysis
presents with worsening shortness of breath. Her vitals are HR 110, BP
160/90, RR 28, and SpO2 88% on room air. Lung auscultation reveals diffuse
crackles. A chest X-ray shows pulmonary edema. Which of the following
antihypertensive agents is most appropriate for acute afterload reduction in
this patient?
A. Labetalol
B. Enalaprilat
C. Sodium nitroprusside
D. Metoprolol
CORRECT ANSWER: C. Sodium nitroprusside
Rationale: Sodium nitroprusside is a potent, rapid-acting vasodilator that provides
acute afterload reduction, which is essential for managing hypertensive emergency with
acute pulmonary edema. While Enalaprilat is also an afterload reducer, sodium
,nitroprusside's immediate onset and ability to be carefully titrated in a critical care
setting make it the preferred agent for rapid blood pressure control in this scenario.
Labetalol and Metoprolol are beta-blockers and do not provide the necessary afterload
reduction and are not first-line for acute pulmonary edema in this setting.
Question 3: A 55-year-old male with a history of cirrhosis presents with
confusion, asterixis, and jaundice. His laboratory results reveal an ammonia
level of 150 µmol/L. Which of the following is the most appropriate first-line
pharmacological therapy to reduce ammonia production?
A. Lactulose
B. Neomycin
C. Rifaximin
D. Metronidazole
CORRECT ANSWER: A. Lactulose
Rationale: Lactulose is a non-absorbable disaccharide that acidifies the colonic lumen,
converting ammonia (NH3) to the non-absorbable ammonium ion (NH4+), promoting
its excretion in the stool. It is the first-line pharmacological treatment for hepatic
encephalopathy. While Rifaximin and Neomycin are also used, they are typically
considered second-line or adjunctive therapies to reduce ammonia-producing gut
bacteria, particularly in patients who do not respond adequately to lactulose alone.
Question 4: A 65-year-old female with a history of COPD is admitted with
acute exacerbation. Arterial blood gas shows: pH 7.25, PaCO2 70 mmHg, PaO2
55 mmHg, HCO3- 28 mEq/L. Which of the following non-invasive ventilation
settings is most appropriate to initiate?
A. CPAP of 10 cm H2O
B. BiPAP with IPAP 10/EPAP 5 cm H2O
C. BiPAP with IPAP 15/EPAP 5 cm H2O
D. CPAP of 5 cm H2O
CORRECT ANSWER: C. BiPAP with IPAP 15/EPAP 5 cm H2O
Rationale: The patient is in acute hypercapnic respiratory failure (pH < 7.35, PaCO2 >
45) due to COPD exacerbation. Bi-level positive airway pressure (BiPAP) is the preferred
non-invasive ventilation modality. The IPAP (Inspiratory Positive Airway Pressure)
provides pressure support to augment tidal volume and decrease work of breathing,
while the EPAP (Expiratory Positive Airway Pressure) helps to stent open airways and
recruit alveoli. An IPAP of 15 cm H2O is a typical and effective starting point for
pressure support in COPD to improve ventilation and lower PaCO2.
,Question 5: A 45-year-old male with a traumatic brain injury has an
intracranial pressure (ICP) monitor in place. His ICP is currently 28 mmHg.
Which of the following interventions should be initiated first to lower ICP?
A. Administer hypertonic saline (3% NaCl) bolus
B. Administer mannitol 1 g/kg IV
C. Elevate the head of the bed to 30 degrees
D. Initiate hyperventilation to a PaCO2 of 30 mmHg
CORRECT ANSWER: C. Elevate the head of the bed to 30 degrees
Rationale: The first-line, non-invasive, and rapid intervention to reduce elevated ICP is
to elevate the head of the bed to 30 degrees. This promotes venous drainage from the
brain, thereby reducing intracranial blood volume and pressure. While hypertonic saline
and mannitol are effective osmotic therapies, and hyperventilation is a temporizing
measure, they are secondary interventions. The head of bed elevation is a fundamental
and immediate nursing/medical intervention that should be performed before or
concurrently with pharmacological interventions.
Question 6: A 70-year-old male with a history of atrial fibrillation presents
with sudden onset of severe abdominal pain, vomiting, and bloody diarrhea.
Abdominal exam is benign. Serum lactate is 6.0 mmol/L. Which of the
following is the most likely diagnosis and most appropriate diagnostic test?
A. Mesenteric ischemia; CT angiography (CTA)
B. Diverticulitis; CT abdomen with contrast
C. Ischemic colitis; Colonoscopy
D. Acute pancreatitis; Serum lipase
CORRECT ANSWER: A. Mesenteric ischemia; CT angiography (CTA)
Rationale: The patient's history of atrial fibrillation puts him at high risk for an embolic
event. The presentation of sudden, severe abdominal pain out of proportion to physical
exam findings (benign abdomen) with bloody diarrhea and an elevated lactate is classic
for acute mesenteric ischemia. CTA of the abdomen is the diagnostic test of choice as it
can quickly identify vascular occlusion (e.g., superior mesenteric artery) and guide
urgent surgical or endovascular intervention.
Question 7: A 60-year-old female with a history of mitral stenosis presents
with acute onset of palpitations and lightheadedness. Her EKG shows an
irregularly irregular rhythm with a ventricular rate of 150. She is hypotensive
with a BP of 80/50 mmHg. Which of the following is the most appropriate
immediate management?
A. Amiodarone 150 mg IV push
B. Diltiazem 20 mg IV push
, C. Synchronized cardioversion
D. Digoxin 0.5 mg IV push
CORRECT ANSWER: C. Synchronized cardioversion
Rationale: This patient presents with unstable atrial fibrillation with rapid ventricular
response, evidenced by hypotension and lightheadedness. Synchronized cardioversion is
the immediate treatment of choice for any unstable tachyarrhythmia. Electrical
cardioversion is preferred over pharmacologic rate or rhythm control in the unstable
patient because it provides immediate restoration of sinus rhythm. Chemical
cardioversion (e.g., Amiodarone) or rate control (Diltiazem, Digoxin) are for
hemodynamically stable patients or as adjuncts after cardioversion.
Question 8: A 48-year-old male with a history of alcoholism presents with
severe epigastric pain radiating to the back, nausea, and vomiting. His serum
lipase is 1800 U/L. CT abdomen reveals pancreatic necrosis. Which of the
following antibiotic regimens is recommended for prophylaxis against infected
necrosis?
A. No prophylactic antibiotics are recommended
B. Vancomycin and Cefepime
C. Piperacillin-Tazobactam
D. Ciprofloxacin and Metronidazole
CORRECT ANSWER: A. No prophylactic antibiotics are recommended
Rationale: Current guidelines (e.g., American College of Gastroenterology) recommend
against the routine use of prophylactic antibiotics in acute pancreatitis, even in the
presence of necrosis. The use of prophylactic antibiotics has not been shown to reduce
mortality or the incidence of infected necrosis and can promote the development of
resistant organisms. Antibiotics should be reserved for patients with documented or
strongly suspected infected necrosis or other infectious complications.
Question 9: A 75-year-old male with a history of coronary artery disease
presents with progressive dyspnea and orthopnea. Echocardiogram shows an
ejection fraction of 25%. He is on optimal medical therapy for heart failure
with reduced ejection fraction (HFrEF). Which of the following medications
has been shown to provide a mortality benefit and should be added to his
regimen if not already prescribed?
A. Hydralazine and Isosorbide Dinitrate
B. Spironolactone
C. Ivabradine
D. Metolazone
CORRECT ANSWER: B. Spironolactone
