NGN ATI RN VATI COMPREHENSIVE PREDICTOR 2024
FORM C VATI RN COMPREHENSIVE, (LATEST
UPDATE), ACTUAL EXAM/TEST QUESTIONS AND 100%
VERIFIED ANSWERS| A+ GRADE.
Item 1
Item Type: Bowtie
Client Scenario (Form C Exclusive): Mr. Álvarez, 68, is admitted with acute
decompensated heart failure (ADHF), stage-4 CKD (eGFR 19 mL/min), and advancing
vascular dementia. He lives alone, refuses dialysis, and his daughter (HCP) demands
“everything” while the nephrology fellow documents “futility.” Home meds: metformin 1
g BID, digoxin 0.25 mg daily, aspirin 81 mg, and OTC naproxen PRN. Today: BP 88/54,
HR 52 irregular, K+ 5.9 mEq/L, SCr 3.4 mg/dL, BNP 2 840 pg/mL, digoxin level 3.2
ng/mL (2025 AHA alert: >2 ng/mL = toxicity), CXR bilateral “bat-wing” infiltrates.
Bowtie Stem: Identify the two highest-priority nursing actions to prevent immediate
harm AND the two labs that must be trended every 4 h for the next 24 h.
Options/Response Fields:
A. Administer digoxin immune Fab 38 mg IV push
B. Hold metformin and start dapagliflozin 10 mg daily
C. Initiate continuous furosemide infusion 5 mg/h after 200 mL fluid bolus
D. Obtain 12-lead ECG and place on continuous telemetry
E. Trend serum digoxin level
,F. Trend serum potassium
G. Trend serum creatinine & urine output
H. Trend serum magnesium
Correct answers: A, D, F, G
Rationale:
Digoxin toxicity (level 3.2 ng/mL) plus bradycardia and hyperkalemia creates a lethal
synergistic membrane-stabilizing effect; Fab fragments bind digoxin within 20 min and
are indicated when level >2 ng/mL with brady-arrhythmia or K+ >5 mEq/L per 2025
AHA/ACC focused update. Holding dapagliflozin is correct (SGLT2i not approved for
eGFR <20 and may worsen hypotension), but starting it is wrong—hence B is a critical
distractor. Continuous furosemide without perfusion correction risks cardiogenic shock.
Telemetry and ECG are essential to capture ventricular ectopy. Potassium and
creatinine/UOP are the two labs that must be trended q4h to detect rebound
hypokalemia post-Fab and continuing AKI. Magnesium is important but not q4h; dig
level post-Fab is unreliable (bound to Fab).
Item 2
Item Type: Matrix/Grid
Client Scenario (Form C Exclusive): Ms. Chen, 34 weeks pregnant with twin-to-twin
transfusion syndrome (TTTS) post-laser ablation, is now on continuous terbutaline 0.25
mg SQ q20 min × 4 doses. She develops 10/10 midepigastric pain radiating to scapula,
platelets 78 K, AST 1 420 U/L, LDH 2 100 U/L, normal amylase.
Matrix Stem: For each potential diagnosis, indicate whether it is MOST likely,
SUPPORTIVE finding present, or CONTRAINDICTED by data.
,Rows:
1. Acute fatty liver of pregnancy (AFLP)
2. HELLP syndrome
3. Acute pancreatitis
4. Hepatic sub-capsular hematoma
Columns:
● MOST likely
● SUPPORTIVE finding
● CONTRAINDICTED
Correct grid key: HELLP = MOST likely; AFLP & hematoma = SUPPORTIVE;
pancreatitis = CONTRAINDICTED.
Rationale:
HELLP is MOST likely—platelets <100 K, AST >2× ULN, epigastric pain. AFLP
shares lab pattern but typically AST <1 000 and markedly prolonged INR; data do
not show INR 6. Pancreatitis lacks elevated amylase/lipase. Sub-capsular
hematoma is SUPPORTIVE (pain radiating to scapula, thrombocytopenia) but not
MOST likely without imaging evidence.
Item 3
Item Type: Extended Drag-and-Drop (Cloze)
Client Scenario (Form C Exclusive): 16-year-old, 48 kg, cystinosis, G-tube, admitted for
Burkholderia cepacia pneumonia. Ordered: meropenem 2 g IV q8h infused over 3 h
(2025 CF Foundation guideline: prolonged infusion ↑T>MIC). Pharmacy prepares 2 g in
100 mL NS.
Drag-and-Drop Stem: Place the steps in correct order to reconstitute, dilute, and
program the pump to deliver the 2025 guideline-recommended dose.
, Drag items:
1. Add 20 mL SWI to vial; shake to yield 50 mg/mL
2. Withdraw 40 mL (2 g) and inject into 100 mL NS bag
3. Set pump: VTBI 102 mL, rate 34 mL/h, 3 h duration
4. Set pump: VTBI 100 mL, rate 33 mL/h, 3 h duration
5. Label “3-h extended infusion”
6. Administer via central line only
Correct sequence: 1 → 2 → 3 → 5
Rationale:
Correct sequence: 1 → 2 → 3 → 5. Pump must account for 2 mL overfill; 102 mL
at 34 mL/h = 3 h. Central line not required—meropenem can be given peripherally
if limited to 3 h.
Item 4
Item Type: Cloze/Bowtie Hybrid
Client Scenario (Form C Exclusive): Post-op day-1 transcatheter aortic valve
replacement (TAVR) on 2025 CMS mandated Q6-h 12-lead ECG surveillance. At 0400
nurse notes new LBBB, QTc 520 ms, K+ 3.1 mEq/L, Mg 1.3 mg/dL, and patient asleep.
Stem: Identify the immediate action AND the electrolyte replacement protocol.
Options:
A. Page on-call EP fellow STAT
B. Administer 20 mEq KCl IV over 2 h via central line
C. Give 2 g MgSO4 IV over 5 min
FORM C VATI RN COMPREHENSIVE, (LATEST
UPDATE), ACTUAL EXAM/TEST QUESTIONS AND 100%
VERIFIED ANSWERS| A+ GRADE.
Item 1
Item Type: Bowtie
Client Scenario (Form C Exclusive): Mr. Álvarez, 68, is admitted with acute
decompensated heart failure (ADHF), stage-4 CKD (eGFR 19 mL/min), and advancing
vascular dementia. He lives alone, refuses dialysis, and his daughter (HCP) demands
“everything” while the nephrology fellow documents “futility.” Home meds: metformin 1
g BID, digoxin 0.25 mg daily, aspirin 81 mg, and OTC naproxen PRN. Today: BP 88/54,
HR 52 irregular, K+ 5.9 mEq/L, SCr 3.4 mg/dL, BNP 2 840 pg/mL, digoxin level 3.2
ng/mL (2025 AHA alert: >2 ng/mL = toxicity), CXR bilateral “bat-wing” infiltrates.
Bowtie Stem: Identify the two highest-priority nursing actions to prevent immediate
harm AND the two labs that must be trended every 4 h for the next 24 h.
Options/Response Fields:
A. Administer digoxin immune Fab 38 mg IV push
B. Hold metformin and start dapagliflozin 10 mg daily
C. Initiate continuous furosemide infusion 5 mg/h after 200 mL fluid bolus
D. Obtain 12-lead ECG and place on continuous telemetry
E. Trend serum digoxin level
,F. Trend serum potassium
G. Trend serum creatinine & urine output
H. Trend serum magnesium
Correct answers: A, D, F, G
Rationale:
Digoxin toxicity (level 3.2 ng/mL) plus bradycardia and hyperkalemia creates a lethal
synergistic membrane-stabilizing effect; Fab fragments bind digoxin within 20 min and
are indicated when level >2 ng/mL with brady-arrhythmia or K+ >5 mEq/L per 2025
AHA/ACC focused update. Holding dapagliflozin is correct (SGLT2i not approved for
eGFR <20 and may worsen hypotension), but starting it is wrong—hence B is a critical
distractor. Continuous furosemide without perfusion correction risks cardiogenic shock.
Telemetry and ECG are essential to capture ventricular ectopy. Potassium and
creatinine/UOP are the two labs that must be trended q4h to detect rebound
hypokalemia post-Fab and continuing AKI. Magnesium is important but not q4h; dig
level post-Fab is unreliable (bound to Fab).
Item 2
Item Type: Matrix/Grid
Client Scenario (Form C Exclusive): Ms. Chen, 34 weeks pregnant with twin-to-twin
transfusion syndrome (TTTS) post-laser ablation, is now on continuous terbutaline 0.25
mg SQ q20 min × 4 doses. She develops 10/10 midepigastric pain radiating to scapula,
platelets 78 K, AST 1 420 U/L, LDH 2 100 U/L, normal amylase.
Matrix Stem: For each potential diagnosis, indicate whether it is MOST likely,
SUPPORTIVE finding present, or CONTRAINDICTED by data.
,Rows:
1. Acute fatty liver of pregnancy (AFLP)
2. HELLP syndrome
3. Acute pancreatitis
4. Hepatic sub-capsular hematoma
Columns:
● MOST likely
● SUPPORTIVE finding
● CONTRAINDICTED
Correct grid key: HELLP = MOST likely; AFLP & hematoma = SUPPORTIVE;
pancreatitis = CONTRAINDICTED.
Rationale:
HELLP is MOST likely—platelets <100 K, AST >2× ULN, epigastric pain. AFLP
shares lab pattern but typically AST <1 000 and markedly prolonged INR; data do
not show INR 6. Pancreatitis lacks elevated amylase/lipase. Sub-capsular
hematoma is SUPPORTIVE (pain radiating to scapula, thrombocytopenia) but not
MOST likely without imaging evidence.
Item 3
Item Type: Extended Drag-and-Drop (Cloze)
Client Scenario (Form C Exclusive): 16-year-old, 48 kg, cystinosis, G-tube, admitted for
Burkholderia cepacia pneumonia. Ordered: meropenem 2 g IV q8h infused over 3 h
(2025 CF Foundation guideline: prolonged infusion ↑T>MIC). Pharmacy prepares 2 g in
100 mL NS.
Drag-and-Drop Stem: Place the steps in correct order to reconstitute, dilute, and
program the pump to deliver the 2025 guideline-recommended dose.
, Drag items:
1. Add 20 mL SWI to vial; shake to yield 50 mg/mL
2. Withdraw 40 mL (2 g) and inject into 100 mL NS bag
3. Set pump: VTBI 102 mL, rate 34 mL/h, 3 h duration
4. Set pump: VTBI 100 mL, rate 33 mL/h, 3 h duration
5. Label “3-h extended infusion”
6. Administer via central line only
Correct sequence: 1 → 2 → 3 → 5
Rationale:
Correct sequence: 1 → 2 → 3 → 5. Pump must account for 2 mL overfill; 102 mL
at 34 mL/h = 3 h. Central line not required—meropenem can be given peripherally
if limited to 3 h.
Item 4
Item Type: Cloze/Bowtie Hybrid
Client Scenario (Form C Exclusive): Post-op day-1 transcatheter aortic valve
replacement (TAVR) on 2025 CMS mandated Q6-h 12-lead ECG surveillance. At 0400
nurse notes new LBBB, QTc 520 ms, K+ 3.1 mEq/L, Mg 1.3 mg/dL, and patient asleep.
Stem: Identify the immediate action AND the electrolyte replacement protocol.
Options:
A. Page on-call EP fellow STAT
B. Administer 20 mEq KCl IV over 2 h via central line
C. Give 2 g MgSO4 IV over 5 min
