AGACNP Spring 2025 Exam 2
(POCUS) and deep venous thrombosis (DVT) and pulmonary embolism (PE)?
Which of the following is true regarding ICU point-of-care ultrasound
A. Evaluation for DVT is best done with a phased array probe without compression
B. The combination of DVT and findings consistent with acute right- sided heart strain has
high diagnostic accuracy for PE
C. The lower extremity source of an embolism as well as the embolism in the pulmonary
vasculature are commonly visualized together
D. Ultrasonographic images of right-sided heart findings definitively diagnosis PE - ANS-The
correct answer is B.
Rationale: The combination of a lower extremity source of an embolism
(DVT) and findings consistent with acute right-sided heart strain in an at-risk patient has
sufficient diagnostic accuracy for VTE to justify emergent treatment (choice B is correct).
While lower extremity source of an embolism is often imaged, only the relatively uncommon
thrombus in transit can be visualized through the heart or in the main pulmonary artery by
POCUS (choice C is incorrect). Acute right-sided heart strain is suggestive of pulmonary
embolism but by itself should not be taken as definitive proof (choice D is incorrect).
Compression studies for a lower extremity source of VTE are best done with a linear
vascular probe (7.5 MHz) used for vascular access studies (choice A is incorrect).
A 19-year-old woman with history of depression is found unresponsive on the floor of her
grandparent's bathroom with an empty bottle of pills. She is
breathing spontaneously and is transported to the nearest hospital. After the patient is put on
cardiac telemetry she suddenly goes into pulseless bidirectional ventricular tachycardia.
Cardiopulmonary resuscitation is initiated. Emergency medical personnel do not know what
the empty pill bottle contained but you suspect digoxin. What is the digoxin-specific antibody
fragments dose to administer to the patient?
A, 1 to 2 vials
B. 5 to 10 vials
C. 20 to 30 vials
D. Calculate once serum digoxin level is known - ANS-The correct answer is B.
Rationale: The empiric dose of digoxin-specific antibody fragments to
administer to a hemodynamically unstable patient following an acute overdose is 5 to 10
vials (choice B is correct). This dose should be given as a bolus in the setting of imminent or
active cardiac arrest. One or two vials may be appropriate in the setting of chronic digoxin
poisoning without impending cardiac arrest, but not in this emergent acute case (choice A is
incorrect). Twenty to 30 vials is more than required as initial dose for most acute overdoses,
though a patient may end up needing 20 or more vials throughout their hospitalization
(choice C is incorrect). During cardiac arrest or imminent arrest, patients should receive
empirical treatment. Physicians should not wait to calculate total body burden of digoxin
(choice D is incorrect).
,A 2-year old healthy child on no medications presents to Arizona emergency department. He
has been inconsolable, agitated, and hysterical for the last hour. Initial vital signs are positive
for tachycardia and tachypnea, but no fever. Exam demonstrates clear lungs, normal eye
exam, and all four extremities are normal with no skin lesions. The tap test is impossible to
conduct due to the child's nature. What is the most appropriate next step in management?
A. Benzodiazepine
B. Centruroides immune F(ab')2 antivenom
C. Crotalid Antivenom FabAV—10 vials
D. Cr otalid Antivenom F(ab')2AV—10 vials - ANS-The correct answer is A.
Rationale: While some of the symptoms this child is having are consistent with Centruroides
(bark scorpion) envenomation, with no increase in secretions and no ocular findings (no
opsoclonus) that diagnosis should be questioned. The tap test or tapping in the area of a
suspected scorpion sting to see if pain gets worse, will be impossible to conduct with this
child. Initial treatment for a Centruroides sting would be benzodiazepines (choice A is
correct) with antivenom reserved for systemic symptoms. Acute amphetamine toxicity can
appear similar and would initially be treated with benzodiazepines and potentially
antipsychotics depending on the response.
A 2-year-old child presents to the emergency department at 6pm after being bitten by a
copperhead. The bite is to the calf, and there are two oozing puncture wounds about 1.5 cm
apart with some mild local erythema. The calf is soft, and there is no swelling. Vitals are
normal, and physical exam is otherwise unremarkable. Over the first few hours of
observation the patient has minimal pain. What is the most appropriate management?
A. Administer IV Crotalid Antivenom
B. Admit for observation overnight
C. Discharge now with follow-up in 3 days
D. Observe for a total of 6 hours, if no progression, then follow up in
3 days - ANS-The correct answer is B.
Rationale: Lower extremity bites from copperheads especially to ankle or calf
can have significant delay in progression of swelling, so admission is warranted (choice B is
correct). Children may also have greater extremity injury from a copperhead bite relative to
adults as their limbs are smaller and the venom load is larger per unit weight. With a full 8
hours observation this patient could be discharged if he has an excellent support network,
negative/normal laboratories at 6 hours, and a follow-up 8 hours after discharge (usually by
phone) but waiting 3 days is too long (choices C and D are incorrect). For this patient who
has what looks to be a "dry" bite (a bite without venom administration), antivenom should not
be used at this point (choice A is incorrect).
A 20-year-old woman has taken an unknown medication during a suicide attempt. She
presents complaining of chest pain with her heart racing and pounding. Her vital signs are
blood pressure 150/90, heart rate 130 bpm, respiratory rate 18 breaths/min, and temperature
100.4 °F. Her physical examination is notable for anxious appearance with tremulousness,
but her mental status is oriented to person, place, and time. Her pupils are dilated
symmetrically. Mucous membranes are moist. Cardiac examination is notable for a rapid rate
without murmurs, lungs are clear, abdomen is nondistended with active bowel sounds, and
neurological exam shows a slight tremor and hyperreflexia but no ankle clonus. Which of the
following medications did this patient most likely overdose?
A. Dextromethorphan
,B. Diphenhydramine
C. Donepezil
D. Pseudoephedrine - ANS-The correct answer is D.
Rationale: This presentation is consistent with a sympathomimetic toxidrome
(tachycardia, hypertension, anxiety, mydriasis, and tremor), making pseudoephedrine the
right answer (choice D is correct). Dextromethorphan enhances central serotonergic tone by
blocking its reuptake as well as increasing its release and is an N-methyl-D-aspartate
receptor antagonist that is associated with postsynaptic 5-HT stimulation. Dextromethorphan
administrated at supratherapeutic doses or in combination with serotonergic agents could
induce a serotonin syndrome that also has overlapping signs and symptoms of
anticholinergic toxicity including hypertension, tachycardia, fever, and agitated delirium. The
major distinguishing feature is often muscle rigidity and sustained clonus (choice A is
incorrect). Diphenhydramine would produce an anticholinergic syndrome (choice B is
incorrect). There are many overlapping features with the sympathomimetic and
anticholinergic syndromes. They both may cause tachycardia, hypertension, temperature
elevation, mydriasis, and seizures and motor signs with tremor common in the
sympathomimetic syndrome and myoclonus in the anticholinergic syndrome. The major
distinguishing features for anticholinergic toxicity are altered mental status changes, that
may include agitated delirium and garbled speech, and dry mucous membranes with
diminished bowel sounds. Donepezil would produce a cholinergic syndrome with
bradycardia and hypotension (choice C is incorrect).
A 21-year-old man presents with a chief complaint of a spider bite 1 day ago that he says
was a brown recluse. On examination, there is an erythematous, raised, warm lesion on the
left forearm. His vitals are normal, he has no systemic symptoms, his urine is pale in color,
and his pain is controlled with minimal analgesia. What is the most appropriate
management?
A. Administer recluse antivenom, half around the site, half intravenously
B. Administer black widow antivenom, 1 vial
C. Check CBC with diff, Type and cross, LDH, U/A and admit for
observation
D. Evaluate for methicillin-resistant Staphylococcus aureus (MRSA) - ANS-The correct
answer is D.
Rationale: While brown recluses can cause necrotic lesions in adults, their
evolution is over several days and often the spider bite is unrecognized. Most often with this
initial presentation the lesion turns out to be a skin MRSA infection (choice D is correct).
There is no antivenom for brown recluse bites. The laboratories suggested might be
appropriate for a child where the history was concerning for a recluse bite with systemic
effects such as fever, weakness, and malaise.
A 21-year-old previously healthy man is being admitted with fatigue and abdominal pain
without diarrhea for the past week. Vital signs are normal except for a heart rate of 102
beats/min. There is no bleeding, and his mental status is normal. Laboratory studies are
significant for the following:
Leukocyte count 6600/μL
Hemoglobin 7.9 g/dL
Platelet count 34,000/μL
Creatinine 6.3 mg/dL
, Serum lactate dehydrogenase 1600 U/L
Coagulation studies and fibrinogen Normal
ADAMTS-13 49% activity
The peripheral blood smear shows many schistocytes, decreased platelets, and normal
white blood cells without blast forms.What is the most appropriate therapy?
A. Cryoprecipitate
B. Eculizumab
C. Platelet transfusion
D. Therapeutic plasma exchange - ANS-The correct answer is B.
Rationale: This patient presents with severe acute renal failure,
thrombocytopenia, and hemolytic anemia. Schistocytes are seen on the peripheral blood
smear consistent with a thrombotic microangiopathy. The clinical presentation and laboratory
data are consistent with atypical HUS (aHUS) and the terminal complement inhibitor
eculizumab is the recommended first-line treatment (choice B is correct). In thrombotic
thrombocytopenia purpura (TTP), the ADAMTS-13 level is typically below 5% to 10% and
the degree of renal dysfunction is mild, thus therapeutic plasma exchange is not indicated
(choice D is incorrect). Coagulation studies and fibrinogen are normal, so there is no
indication for cryoprecipitate replacement (choice A is incorrect). At the current platelet count
and without bleeding, platelet transfusion is also not indicated (choice C is incorrect).
A 22-year-old woman with HIV, tuberculosis, and depression who recently immigrated from
Bangladesh is brought to the hospital in status epilepticus. On arrival her vital signs are heart
rate 120 beats per minute, blood pressure150/90 mmHg, respirations 20 per minute, and
temperature 38 °C. Initial laboratory studies with normal values in parentheses are shown:
Serum sodium: 138 mEq/L (136-144 mEq/L). Serum potassium: 5.8 mEq/L (3.7-5.2 mEq/L).
Serum chloride: 99 mEq/L (96-106 mEq/L). CO2 (carbon dioxide): 13 mEq/L (22-28 mEq/L).
BUN: 11 mg/dL (8-23 mg/L).
Creatinine: 0.9 mg/dL (0.3-0.9 mg/L).Glucose: 220 mg/dL (70-110 mg/dL).Serum calcium
(total): 9.1 mg/dL (8.2-10.2 mg/dL). Serum AST (SGOT) 60 IU/L (8-48 IU/L).Serum ALT
(SGPT) 49 IU/L (7-55 IU/L).
Treatment with 4 mg intravenous lorazepam three times over 30 minutes is ineffective for
stopping her seizures. An overdose of which of the following patient's medicati - ANS-The
correct answer is C.
Rationale: Of the drugs listed, this clinical picture of seizures refractory to
GABAA receptor agonist lorazepam, coma, and metabolic acidosis would be due
to isoniazid overdose (choice C is correct). None of the other medication choices cause
seizures (choices A, B, and D are incorrect). Overdoses of dolutegravir and lamivudine result
in lactic acidosis, hypokalemia, and altered mental status. Somnolence, nausea, vomiting,
tachycardia, QT prolongation, and tremor occur with escitalopram. Nausea, vomiting,
lethargy, and hepatoxicity may occur after rifapentine overdose.
A 23-year-old man is brought to the emergency department after being found obtunded on
the street. The history suggests that he may have ingested 180 mg of his friend's methadone
during a suicide attempt. On arrival he has a Glasgow Coma Scale (GCS) score of 6, with
hypoactive bowel sounds and pinpoint pupils. His initial vital signs are temperature 36C,
heart rate 56/min, blood pressure 103/70 mm Hg, respiratory rate 6, and oxygen saturation
84% on room air. Blood glucose is 4.6 mmol/L. Initially, his ventilation was supported through
bag-valve-mask (BVM) apparatus but after three doses of 0.4 mg IV naloxone there is
(POCUS) and deep venous thrombosis (DVT) and pulmonary embolism (PE)?
Which of the following is true regarding ICU point-of-care ultrasound
A. Evaluation for DVT is best done with a phased array probe without compression
B. The combination of DVT and findings consistent with acute right- sided heart strain has
high diagnostic accuracy for PE
C. The lower extremity source of an embolism as well as the embolism in the pulmonary
vasculature are commonly visualized together
D. Ultrasonographic images of right-sided heart findings definitively diagnosis PE - ANS-The
correct answer is B.
Rationale: The combination of a lower extremity source of an embolism
(DVT) and findings consistent with acute right-sided heart strain in an at-risk patient has
sufficient diagnostic accuracy for VTE to justify emergent treatment (choice B is correct).
While lower extremity source of an embolism is often imaged, only the relatively uncommon
thrombus in transit can be visualized through the heart or in the main pulmonary artery by
POCUS (choice C is incorrect). Acute right-sided heart strain is suggestive of pulmonary
embolism but by itself should not be taken as definitive proof (choice D is incorrect).
Compression studies for a lower extremity source of VTE are best done with a linear
vascular probe (7.5 MHz) used for vascular access studies (choice A is incorrect).
A 19-year-old woman with history of depression is found unresponsive on the floor of her
grandparent's bathroom with an empty bottle of pills. She is
breathing spontaneously and is transported to the nearest hospital. After the patient is put on
cardiac telemetry she suddenly goes into pulseless bidirectional ventricular tachycardia.
Cardiopulmonary resuscitation is initiated. Emergency medical personnel do not know what
the empty pill bottle contained but you suspect digoxin. What is the digoxin-specific antibody
fragments dose to administer to the patient?
A, 1 to 2 vials
B. 5 to 10 vials
C. 20 to 30 vials
D. Calculate once serum digoxin level is known - ANS-The correct answer is B.
Rationale: The empiric dose of digoxin-specific antibody fragments to
administer to a hemodynamically unstable patient following an acute overdose is 5 to 10
vials (choice B is correct). This dose should be given as a bolus in the setting of imminent or
active cardiac arrest. One or two vials may be appropriate in the setting of chronic digoxin
poisoning without impending cardiac arrest, but not in this emergent acute case (choice A is
incorrect). Twenty to 30 vials is more than required as initial dose for most acute overdoses,
though a patient may end up needing 20 or more vials throughout their hospitalization
(choice C is incorrect). During cardiac arrest or imminent arrest, patients should receive
empirical treatment. Physicians should not wait to calculate total body burden of digoxin
(choice D is incorrect).
,A 2-year old healthy child on no medications presents to Arizona emergency department. He
has been inconsolable, agitated, and hysterical for the last hour. Initial vital signs are positive
for tachycardia and tachypnea, but no fever. Exam demonstrates clear lungs, normal eye
exam, and all four extremities are normal with no skin lesions. The tap test is impossible to
conduct due to the child's nature. What is the most appropriate next step in management?
A. Benzodiazepine
B. Centruroides immune F(ab')2 antivenom
C. Crotalid Antivenom FabAV—10 vials
D. Cr otalid Antivenom F(ab')2AV—10 vials - ANS-The correct answer is A.
Rationale: While some of the symptoms this child is having are consistent with Centruroides
(bark scorpion) envenomation, with no increase in secretions and no ocular findings (no
opsoclonus) that diagnosis should be questioned. The tap test or tapping in the area of a
suspected scorpion sting to see if pain gets worse, will be impossible to conduct with this
child. Initial treatment for a Centruroides sting would be benzodiazepines (choice A is
correct) with antivenom reserved for systemic symptoms. Acute amphetamine toxicity can
appear similar and would initially be treated with benzodiazepines and potentially
antipsychotics depending on the response.
A 2-year-old child presents to the emergency department at 6pm after being bitten by a
copperhead. The bite is to the calf, and there are two oozing puncture wounds about 1.5 cm
apart with some mild local erythema. The calf is soft, and there is no swelling. Vitals are
normal, and physical exam is otherwise unremarkable. Over the first few hours of
observation the patient has minimal pain. What is the most appropriate management?
A. Administer IV Crotalid Antivenom
B. Admit for observation overnight
C. Discharge now with follow-up in 3 days
D. Observe for a total of 6 hours, if no progression, then follow up in
3 days - ANS-The correct answer is B.
Rationale: Lower extremity bites from copperheads especially to ankle or calf
can have significant delay in progression of swelling, so admission is warranted (choice B is
correct). Children may also have greater extremity injury from a copperhead bite relative to
adults as their limbs are smaller and the venom load is larger per unit weight. With a full 8
hours observation this patient could be discharged if he has an excellent support network,
negative/normal laboratories at 6 hours, and a follow-up 8 hours after discharge (usually by
phone) but waiting 3 days is too long (choices C and D are incorrect). For this patient who
has what looks to be a "dry" bite (a bite without venom administration), antivenom should not
be used at this point (choice A is incorrect).
A 20-year-old woman has taken an unknown medication during a suicide attempt. She
presents complaining of chest pain with her heart racing and pounding. Her vital signs are
blood pressure 150/90, heart rate 130 bpm, respiratory rate 18 breaths/min, and temperature
100.4 °F. Her physical examination is notable for anxious appearance with tremulousness,
but her mental status is oriented to person, place, and time. Her pupils are dilated
symmetrically. Mucous membranes are moist. Cardiac examination is notable for a rapid rate
without murmurs, lungs are clear, abdomen is nondistended with active bowel sounds, and
neurological exam shows a slight tremor and hyperreflexia but no ankle clonus. Which of the
following medications did this patient most likely overdose?
A. Dextromethorphan
,B. Diphenhydramine
C. Donepezil
D. Pseudoephedrine - ANS-The correct answer is D.
Rationale: This presentation is consistent with a sympathomimetic toxidrome
(tachycardia, hypertension, anxiety, mydriasis, and tremor), making pseudoephedrine the
right answer (choice D is correct). Dextromethorphan enhances central serotonergic tone by
blocking its reuptake as well as increasing its release and is an N-methyl-D-aspartate
receptor antagonist that is associated with postsynaptic 5-HT stimulation. Dextromethorphan
administrated at supratherapeutic doses or in combination with serotonergic agents could
induce a serotonin syndrome that also has overlapping signs and symptoms of
anticholinergic toxicity including hypertension, tachycardia, fever, and agitated delirium. The
major distinguishing feature is often muscle rigidity and sustained clonus (choice A is
incorrect). Diphenhydramine would produce an anticholinergic syndrome (choice B is
incorrect). There are many overlapping features with the sympathomimetic and
anticholinergic syndromes. They both may cause tachycardia, hypertension, temperature
elevation, mydriasis, and seizures and motor signs with tremor common in the
sympathomimetic syndrome and myoclonus in the anticholinergic syndrome. The major
distinguishing features for anticholinergic toxicity are altered mental status changes, that
may include agitated delirium and garbled speech, and dry mucous membranes with
diminished bowel sounds. Donepezil would produce a cholinergic syndrome with
bradycardia and hypotension (choice C is incorrect).
A 21-year-old man presents with a chief complaint of a spider bite 1 day ago that he says
was a brown recluse. On examination, there is an erythematous, raised, warm lesion on the
left forearm. His vitals are normal, he has no systemic symptoms, his urine is pale in color,
and his pain is controlled with minimal analgesia. What is the most appropriate
management?
A. Administer recluse antivenom, half around the site, half intravenously
B. Administer black widow antivenom, 1 vial
C. Check CBC with diff, Type and cross, LDH, U/A and admit for
observation
D. Evaluate for methicillin-resistant Staphylococcus aureus (MRSA) - ANS-The correct
answer is D.
Rationale: While brown recluses can cause necrotic lesions in adults, their
evolution is over several days and often the spider bite is unrecognized. Most often with this
initial presentation the lesion turns out to be a skin MRSA infection (choice D is correct).
There is no antivenom for brown recluse bites. The laboratories suggested might be
appropriate for a child where the history was concerning for a recluse bite with systemic
effects such as fever, weakness, and malaise.
A 21-year-old previously healthy man is being admitted with fatigue and abdominal pain
without diarrhea for the past week. Vital signs are normal except for a heart rate of 102
beats/min. There is no bleeding, and his mental status is normal. Laboratory studies are
significant for the following:
Leukocyte count 6600/μL
Hemoglobin 7.9 g/dL
Platelet count 34,000/μL
Creatinine 6.3 mg/dL
, Serum lactate dehydrogenase 1600 U/L
Coagulation studies and fibrinogen Normal
ADAMTS-13 49% activity
The peripheral blood smear shows many schistocytes, decreased platelets, and normal
white blood cells without blast forms.What is the most appropriate therapy?
A. Cryoprecipitate
B. Eculizumab
C. Platelet transfusion
D. Therapeutic plasma exchange - ANS-The correct answer is B.
Rationale: This patient presents with severe acute renal failure,
thrombocytopenia, and hemolytic anemia. Schistocytes are seen on the peripheral blood
smear consistent with a thrombotic microangiopathy. The clinical presentation and laboratory
data are consistent with atypical HUS (aHUS) and the terminal complement inhibitor
eculizumab is the recommended first-line treatment (choice B is correct). In thrombotic
thrombocytopenia purpura (TTP), the ADAMTS-13 level is typically below 5% to 10% and
the degree of renal dysfunction is mild, thus therapeutic plasma exchange is not indicated
(choice D is incorrect). Coagulation studies and fibrinogen are normal, so there is no
indication for cryoprecipitate replacement (choice A is incorrect). At the current platelet count
and without bleeding, platelet transfusion is also not indicated (choice C is incorrect).
A 22-year-old woman with HIV, tuberculosis, and depression who recently immigrated from
Bangladesh is brought to the hospital in status epilepticus. On arrival her vital signs are heart
rate 120 beats per minute, blood pressure150/90 mmHg, respirations 20 per minute, and
temperature 38 °C. Initial laboratory studies with normal values in parentheses are shown:
Serum sodium: 138 mEq/L (136-144 mEq/L). Serum potassium: 5.8 mEq/L (3.7-5.2 mEq/L).
Serum chloride: 99 mEq/L (96-106 mEq/L). CO2 (carbon dioxide): 13 mEq/L (22-28 mEq/L).
BUN: 11 mg/dL (8-23 mg/L).
Creatinine: 0.9 mg/dL (0.3-0.9 mg/L).Glucose: 220 mg/dL (70-110 mg/dL).Serum calcium
(total): 9.1 mg/dL (8.2-10.2 mg/dL). Serum AST (SGOT) 60 IU/L (8-48 IU/L).Serum ALT
(SGPT) 49 IU/L (7-55 IU/L).
Treatment with 4 mg intravenous lorazepam three times over 30 minutes is ineffective for
stopping her seizures. An overdose of which of the following patient's medicati - ANS-The
correct answer is C.
Rationale: Of the drugs listed, this clinical picture of seizures refractory to
GABAA receptor agonist lorazepam, coma, and metabolic acidosis would be due
to isoniazid overdose (choice C is correct). None of the other medication choices cause
seizures (choices A, B, and D are incorrect). Overdoses of dolutegravir and lamivudine result
in lactic acidosis, hypokalemia, and altered mental status. Somnolence, nausea, vomiting,
tachycardia, QT prolongation, and tremor occur with escitalopram. Nausea, vomiting,
lethargy, and hepatoxicity may occur after rifapentine overdose.
A 23-year-old man is brought to the emergency department after being found obtunded on
the street. The history suggests that he may have ingested 180 mg of his friend's methadone
during a suicide attempt. On arrival he has a Glasgow Coma Scale (GCS) score of 6, with
hypoactive bowel sounds and pinpoint pupils. His initial vital signs are temperature 36C,
heart rate 56/min, blood pressure 103/70 mm Hg, respiratory rate 6, and oxygen saturation
84% on room air. Blood glucose is 4.6 mmol/L. Initially, his ventilation was supported through
bag-valve-mask (BVM) apparatus but after three doses of 0.4 mg IV naloxone there is
