NR571 Midterm Exam - Complex Diagnosis &
Management in Acute Care - Adult-Gerontology
Acute Care NP - 2026/2027
40 multiple-choice items | Graduate ACNP level | 100 % clinical-decision focus
SECTION 1 ‑ SHOCK & SEPSIS
Q1
Vignette: 68-year-old man, DM-2, 24 h fever & confusion. T 102.5 °F, HR 128, BP 78/42,
RR 28, SpO₂ 92 % RA. Dry mucous membranes, RLL crackles. WBC 22 k, lactate 5.0
mmol/L, Cr 1.8 mg/dL (baseline 1.0), CXR RLL consolidation.
Question: MOST urgent bundled next step?
A. Blood cultures then vancomycin/piperacillin-tazobactam
B. 30 mL/kg crystalloid bolus AND cultures AND broad-spectrum antibiotics within 1 h
C. Start norepinephrine for MAP > 65
D. CT abdomen to rule out intra-abdominal source
Correct: B
Rationale: Septic-shock Hour-1 bundle mandates simultaneous fluid, cultures, and
antibiotics; vasopressors follow if hypotension persists after fluids.
,Q2
Same patient; 2 L NS given in 30 min, BP 74/38, HR 130, urine output 5 mL/h. Central
venous O₂ sat 68 %.
Question: NEXT most appropriate intervention?
A. Add 2 L more NS
B. Start norepinephrine 0.05 μg/kg/min
C. Start dopamine 10 μg/kg/min
D. Give 1 unit PRBC
Correct: B
Rationale: Fluid-refractory septic shock → norepinephrine first-line per Surviving Sepsis;
continued blind fluid risks overload.
Q3
Vignette: 54-year-old woman, HTN, HFpEF, presents 1 h severe chest pain. HR 118, BP
72/48, RR 26, SpO₂ 88 % RA. JVP 14 cm, bilateral crackles, new holosystolic murmur at
apex. CXR pulmonary edema, trop I 8.2 ng/mL, lactate 3.4. Bedside echo: severe MR, EF
35 %.
Question: Which pathophysiologic process BEST explains shock?
A. Hypovolemia from diuresis
B. Cardiogenic shock due to acute severe mitral regurgitation
C. Septic shock from unknown source
, D. Massive PE with RV failure
Correct: B
Rationale: Acute MR (papillary-muscle rupture post-MI) causes abrupt LV volume
overload ↓ forward flow → cardiogenic shock.
Q4
Question: MOST appropriate immediate therapy?
A. 1 L NS bolus
B. Start norepinephrine
C. Emerent echocardiography & cardiac surgery consult for possible valve repair
D. Start broad-spectrum antibiotics
Correct: C
Rationale: Acute severe MR is a surgical emergency; temporizing measures (IABP) may
bridge, but definitive repair required.
Q5
Vignette: 29-year-old man, asthma, intubated 2 days ago for severe exacerbation. Now
temp 38.8 °C, BP 86/50, HR 135, SpO₂ 92 % (FiO₂ 0.6, PEEP 10). Peak airway pressure
55 cmH₂O (baseline 35), plateau 38 cmH₂O, new R-sided crackles. WBC 18 k,
procalcitonin 0.9 ng/mL.
Question: NEXT best diagnostic test?
A. Chest CT angiogram
Management in Acute Care - Adult-Gerontology
Acute Care NP - 2026/2027
40 multiple-choice items | Graduate ACNP level | 100 % clinical-decision focus
SECTION 1 ‑ SHOCK & SEPSIS
Q1
Vignette: 68-year-old man, DM-2, 24 h fever & confusion. T 102.5 °F, HR 128, BP 78/42,
RR 28, SpO₂ 92 % RA. Dry mucous membranes, RLL crackles. WBC 22 k, lactate 5.0
mmol/L, Cr 1.8 mg/dL (baseline 1.0), CXR RLL consolidation.
Question: MOST urgent bundled next step?
A. Blood cultures then vancomycin/piperacillin-tazobactam
B. 30 mL/kg crystalloid bolus AND cultures AND broad-spectrum antibiotics within 1 h
C. Start norepinephrine for MAP > 65
D. CT abdomen to rule out intra-abdominal source
Correct: B
Rationale: Septic-shock Hour-1 bundle mandates simultaneous fluid, cultures, and
antibiotics; vasopressors follow if hypotension persists after fluids.
,Q2
Same patient; 2 L NS given in 30 min, BP 74/38, HR 130, urine output 5 mL/h. Central
venous O₂ sat 68 %.
Question: NEXT most appropriate intervention?
A. Add 2 L more NS
B. Start norepinephrine 0.05 μg/kg/min
C. Start dopamine 10 μg/kg/min
D. Give 1 unit PRBC
Correct: B
Rationale: Fluid-refractory septic shock → norepinephrine first-line per Surviving Sepsis;
continued blind fluid risks overload.
Q3
Vignette: 54-year-old woman, HTN, HFpEF, presents 1 h severe chest pain. HR 118, BP
72/48, RR 26, SpO₂ 88 % RA. JVP 14 cm, bilateral crackles, new holosystolic murmur at
apex. CXR pulmonary edema, trop I 8.2 ng/mL, lactate 3.4. Bedside echo: severe MR, EF
35 %.
Question: Which pathophysiologic process BEST explains shock?
A. Hypovolemia from diuresis
B. Cardiogenic shock due to acute severe mitral regurgitation
C. Septic shock from unknown source
, D. Massive PE with RV failure
Correct: B
Rationale: Acute MR (papillary-muscle rupture post-MI) causes abrupt LV volume
overload ↓ forward flow → cardiogenic shock.
Q4
Question: MOST appropriate immediate therapy?
A. 1 L NS bolus
B. Start norepinephrine
C. Emerent echocardiography & cardiac surgery consult for possible valve repair
D. Start broad-spectrum antibiotics
Correct: C
Rationale: Acute severe MR is a surgical emergency; temporizing measures (IABP) may
bridge, but definitive repair required.
Q5
Vignette: 29-year-old man, asthma, intubated 2 days ago for severe exacerbation. Now
temp 38.8 °C, BP 86/50, HR 135, SpO₂ 92 % (FiO₂ 0.6, PEEP 10). Peak airway pressure
55 cmH₂O (baseline 35), plateau 38 cmH₂O, new R-sided crackles. WBC 18 k,
procalcitonin 0.9 ng/mL.
Question: NEXT best diagnostic test?
A. Chest CT angiogram
