APRN ACNPC(AG)
Final Test Review
(Questions & Solutions)
2025
1
, 1. STEMI + CKD
A 78-year-old man (eGFR 28 mL/min/1.73 m²) presents 90 min after
chest-pain onset. ECG shows an anterior STEMI; PCI lab is 40 min away.
Which medication sequence is most appropriate before transfer?
A. Aspirin 325 mg PO + ticagrelor 180 mg PO + half-dose tenecteplase IV
B. Aspirin 325 mg PO + clopidogrel 600 mg PO + full-dose tenecteplase IV
C. Aspirin 325 mg PO + prasugrel 60 mg PO + abciximab IV bolus
D. Aspirin 325 mg PO only; defer all other antithrombotics to cath lab
ANS A
Rationale — Guidelines favor fibrinolysis when door-to-balloon will
exceed 120 min. CKD heightens bleeding risk, so weight- and renal-
adjusted (half-dose) tenecteplase is recommended; ticagrelor’s renal
safety profile is superior to prasugrel. Abciximab adds little benefit pre-
transfer.
---
2. Rapid-AF in Decompensated HFpEF
An 82-year-old woman with EF 60 % and pulmonary edema is in AF at
160 bpm. BP 94/56 mmHg; she is mildly confused. Optimal first
intervention?
A. IV amiodarone 150 mg bolus
B. IV metoprolol 5 mg q5 min ×3
C. Synchronized cardioversion 200 J
D. IV diltiazem 20 mg bolus
ANS C
Rationale — Unstable tachyarrhythmia (hypotension, altered
mentation) mandates immediate synchronized cardioversion; negative
inotropes (β-blocker, calcium-channel blocker) can precipitate shock in
acutely decompensated HF.
2
,---
3. Vasopressor Choice in Septic Shock + A-fib
An 85-year-old with septic shock remains MAP 55 mmHg on
norepinephrine 0.25 µg/kg/min; she develops new AF at 140 bpm. Best
vasopressor adjunct?
A. Add epinephrine
B. Add vasopressin 0.03 U/min
C. Switch to phenylephrine infusion
D. Start dopamine 10 µg/kg/min
ANS B
Rationale — Vasopressin raises MAP via V1 receptors without β-
adrenergic chronotropy, benefiting hypotension and permitting
norepinephrine dose-sparing while avoiding further rate acceleration.
---
4. Hyperactive Delirium
A 79-year-old post-op hip-fracture patient is agitated, pulling lines. CAM-
ICU positive; QTc 460 ms. Optimal pharmacologic rescue?
A. Haloperidol 5 mg IV push
B. Quetiapine 50 mg PO
C. Dexmedetomidine IV infusion
D. Lorazepam 1 mg IV
ANS C
Rationale — Dexmedetomidine provides rapid sedation with minimal
respiratory depression and no QT prolongation; haloperidol and
quetiapine risk torsades; benzodiazepines exacerbate delirium.
---
5. Parkinsonian Crisis
An 81-year-old with Parkinson disease is NPO for bowel surgery and
3
, develops rigid muscles and hyperthermia. Which agent should be infused
emergently?
A. IV lorazepam
B. IV bromocriptine
C. IV dantrolene
D. IV amantadine
ANS B
Rationale — Acute withdrawal of dopaminergic therapy provokes
parkinsonism-hyperpyrexia syndrome; bromocriptine (dopamine agonist)
reverses dopamine deficiency, while dantrolene addresses malignant
hyperthermia, not dopaminergic crisis.
---
6. Myasthenic vs Cholinergic Crisis
A 70-year-old with myasthenia gravis on pyridostigmine develops
respiratory distress. Ice-pack test equivocal. Giving 1 mg IV edrophonium
improves strength for 3 min. Interpretation?
A. Cholinergic crisis; stop anticholinesterase
B. Myasthenic crisis; escalate immunotherapy
C. Insufficient dose; repeat at 3 mg
D. Test invalid in older adults
ANS B
Rationale — Transient improvement after edrophonium confirms
myasthenic crisis (acetylcholine deficit). Cholinergic crisis would worsen.
---
7. Intracerebral Hemorrhage Blood-Pressure Target
An 84-year-old with lobar ICH (CT volume 35 mL) presents BP 198/104
mmHg. According to latest AHA/ASA guidance, target SBP in first hour?
A. <140 mmHg
B. 140–160 mmHg
4
Final Test Review
(Questions & Solutions)
2025
1
, 1. STEMI + CKD
A 78-year-old man (eGFR 28 mL/min/1.73 m²) presents 90 min after
chest-pain onset. ECG shows an anterior STEMI; PCI lab is 40 min away.
Which medication sequence is most appropriate before transfer?
A. Aspirin 325 mg PO + ticagrelor 180 mg PO + half-dose tenecteplase IV
B. Aspirin 325 mg PO + clopidogrel 600 mg PO + full-dose tenecteplase IV
C. Aspirin 325 mg PO + prasugrel 60 mg PO + abciximab IV bolus
D. Aspirin 325 mg PO only; defer all other antithrombotics to cath lab
ANS A
Rationale — Guidelines favor fibrinolysis when door-to-balloon will
exceed 120 min. CKD heightens bleeding risk, so weight- and renal-
adjusted (half-dose) tenecteplase is recommended; ticagrelor’s renal
safety profile is superior to prasugrel. Abciximab adds little benefit pre-
transfer.
---
2. Rapid-AF in Decompensated HFpEF
An 82-year-old woman with EF 60 % and pulmonary edema is in AF at
160 bpm. BP 94/56 mmHg; she is mildly confused. Optimal first
intervention?
A. IV amiodarone 150 mg bolus
B. IV metoprolol 5 mg q5 min ×3
C. Synchronized cardioversion 200 J
D. IV diltiazem 20 mg bolus
ANS C
Rationale — Unstable tachyarrhythmia (hypotension, altered
mentation) mandates immediate synchronized cardioversion; negative
inotropes (β-blocker, calcium-channel blocker) can precipitate shock in
acutely decompensated HF.
2
,---
3. Vasopressor Choice in Septic Shock + A-fib
An 85-year-old with septic shock remains MAP 55 mmHg on
norepinephrine 0.25 µg/kg/min; she develops new AF at 140 bpm. Best
vasopressor adjunct?
A. Add epinephrine
B. Add vasopressin 0.03 U/min
C. Switch to phenylephrine infusion
D. Start dopamine 10 µg/kg/min
ANS B
Rationale — Vasopressin raises MAP via V1 receptors without β-
adrenergic chronotropy, benefiting hypotension and permitting
norepinephrine dose-sparing while avoiding further rate acceleration.
---
4. Hyperactive Delirium
A 79-year-old post-op hip-fracture patient is agitated, pulling lines. CAM-
ICU positive; QTc 460 ms. Optimal pharmacologic rescue?
A. Haloperidol 5 mg IV push
B. Quetiapine 50 mg PO
C. Dexmedetomidine IV infusion
D. Lorazepam 1 mg IV
ANS C
Rationale — Dexmedetomidine provides rapid sedation with minimal
respiratory depression and no QT prolongation; haloperidol and
quetiapine risk torsades; benzodiazepines exacerbate delirium.
---
5. Parkinsonian Crisis
An 81-year-old with Parkinson disease is NPO for bowel surgery and
3
, develops rigid muscles and hyperthermia. Which agent should be infused
emergently?
A. IV lorazepam
B. IV bromocriptine
C. IV dantrolene
D. IV amantadine
ANS B
Rationale — Acute withdrawal of dopaminergic therapy provokes
parkinsonism-hyperpyrexia syndrome; bromocriptine (dopamine agonist)
reverses dopamine deficiency, while dantrolene addresses malignant
hyperthermia, not dopaminergic crisis.
---
6. Myasthenic vs Cholinergic Crisis
A 70-year-old with myasthenia gravis on pyridostigmine develops
respiratory distress. Ice-pack test equivocal. Giving 1 mg IV edrophonium
improves strength for 3 min. Interpretation?
A. Cholinergic crisis; stop anticholinesterase
B. Myasthenic crisis; escalate immunotherapy
C. Insufficient dose; repeat at 3 mg
D. Test invalid in older adults
ANS B
Rationale — Transient improvement after edrophonium confirms
myasthenic crisis (acetylcholine deficit). Cholinergic crisis would worsen.
---
7. Intracerebral Hemorrhage Blood-Pressure Target
An 84-year-old with lobar ICH (CT volume 35 mL) presents BP 198/104
mmHg. According to latest AHA/ASA guidance, target SBP in first hour?
A. <140 mmHg
B. 140–160 mmHg
4
