1. A 68-year-old with septic shock on norepinephrine 0.4 mcg/kg/min has a MAP of 58 mm
Hg. What is the next best action?
A) Increase norepinephrine to 0.6 mcg/kg/min
B) Add vasopressin at 0.04 units/min
C) Give a 2L normal saline bolus
D) Start phenylephrine 100 mcg/min
.Correct answer: Add vasopressin at 0.04 units/min.
.Rationale: Vasopressin is additive to norepinephrine in vasodilatory shock; guidelines
recommend adding it when norepinephrine dose exceeds 0.25 mcg/kg/min..
2. A post-cardiac arrest patient has a Glasgow Coma Scale score of 7 and is shivering
despite normothermia. Which intervention is most appropriate?
A) Propofol infusion titrated to sedation goal
B) Neuromuscular blocker with continuous EEG monitoring
C) Increase ambient room temperature
D) Administer acetaminophen 1g IV
Correct answer: Neuromuscular blocker with continuous EEG monitoring
Rationale: Shivering after cardiac arrest increases oxygen demand; NMBs suppress
shivering, but require EEG to detect seizures.
3. Which finding in a patient with severe metabolic acidosis (pH 7.1, HCO3 8) indicates the
need for immediate renal replacement therapy?
A) Serum potassium 5.2 mEq/L
B) Anion gap 24 mEq/L
C) Oliguric AKI with pulmonary edema
D) Serum lactate 6 mmol/L
Correct answer: Oliguric AKI with pulmonary edema
Rationale: RRT is indicated for severe acidosis with volume overload not responsive to
diuretics, not merely for elevated lactate or mild hyperkalemia.
,4. A 72-year-old with acute hypoxemic respiratory failure on FiO2 0.8 and PEEP 12 has a
PaO2 of 55 mm Hg. What is the priority?
A) Increase FiO2 to 1.0
B) Perform a recruitment maneuver
C) Prone positioning
D) Switch to pressure control ventilation
Correct answer: Prone positioning
.Rationale: Severe ARDS (PaO2/FiO2 <100) benefits from prone positioning to improve
V/Q matching and reduce mortality..
5. A patient with acute anterior STEMI develops new hypotension and a harsh holosystolic
murmur at the apex. What is the most likely diagnosis?
A) Papillary muscle rupture
B) Ventricular septal rupture
C) Mitral regurgitation from papillary muscle dysfunction
D) Free wall rupture
Correct answer: Mitral regurgitation from papillary muscle dysfunction
Rationale: Apical murmur after anterior MI suggests ischemia of posteromedial papillary
muscle causing acute MR, not VSD (which is harsher and mid-systolic).
6. A patient in DKA has a glucose of 380 mg/dL after initial insulin bolus. Which lab value
should be monitored to prevent iatrogenic complication?
A) Serum calcium
B) Phosphorus level
C) Magnesium
D) BUN/creatinine
Correct answer: Phosphorus level
Rationale: Insulin drives phosphate into cells; severe hypophosphatemia can cause
respiratory muscle weakness and hemolysis.
7. Which ventilator setting adjustment is most appropriate for a patient with status
asthmaticus and auto-PEEP of 12 cm H2O?
A) Increase respiratory rate to 18
, B) .Decrease tidal volume to 6 mL/kg.
C) Increase inspiratory time to 1.5 seconds
D) Add 10 cm H2O of extrinsic PEEP
.Correct answer: Decrease tidal volume to 6 mL/kg.
Rationale: Lowering Vt reduces minute ventilation, allowing more expiratory time to
unload auto-PEEP; increasing rate worsens air trapping.
8. A 58-year-old with cirrhosis and hematemesis has a heart rate of 130 and BP 85/50. After
securing airway, what is the next priority?
A) Octreotide infusion
B) .Transfuse to hemoglobin >7 g/dL and initiate vasopressin.
C) Urgent endoscopy
D) Intravenous pantoprazole
.Correct answer: Transfuse to hemoglobin >7 g/dL and initiate vasopressin.
.Rationale: In variceal bleed with hemorrhagic shock, restrictive transfusion (Hgb 7-8)
plus vasopressin/terlipressin precedes endoscopy..
9. A patient on norepinephrine and dobutamine for cardiogenic shock has a cardiac index of
1.6 L/min/m2 and ScvO2 of 48%. Which therapy should be added?
A) Milrinone
B) Intra-aortic balloon pump
C) Increase norepinephrine to 1 mcg/kg/min
D) Levosimendan
Correct answer: Intra-aortic balloon pump
Rationale: IABP improves coronary perfusion and reduces afterload in refractory
cardiogenic shock with low CI and ScvO2 <50%.
10. Which cerebrospinal fluid finding is most consistent with bacterial meningitis in a 45-
year-old with fever, neck stiffness, and altered mental status?
A) Glucose 55 mg/dL, protein 60 mg/dL, WBC 200 lymphs
B) .Glucose 25 mg/dL, protein 250 mg/dL, WBC 3000 PMNs.
C) Glucose 70 mg/dL, protein 40 mg/dL, WBC 5 lymphs
D) Glucose 40 mg/dL, protein 100 mg/dL, RBC 10,000
, .Correct answer: Glucose 25 mg/dL, protein 250 mg/dL, WBC 3000 PMNs.
Rationale: Bacterial meningitis causes low CSF glucose (<40), high protein (>150), and
marked neutrophilic pleocytosis.
11. A mechanically ventilated patient with severe TBI and ICP 22 mm Hg has a PaCO2 of 38
mm Hg. What is the most appropriate next step?
A) Hyperventilate to PaCO2 30 mm Hg
B) .Mannitol 1 g/kg IV.
C) Elevate head of bed to 15 degrees
D) Start hypertonic saline 3% at 30 mL/hr
.Correct answer: Mannitol 1 g/kg IV.
.Rationale: First-tier therapy for elevated ICP (20-25) is mannitol or hypertonic saline;
hyperventilation is reserved for herniation..
12. Which lab abnormality in a patient with acute pancreatitis suggests necrotizing infection?
A) Lipase >3 times normal
B) .CRP >150 mg/L on day 3.
C) Amylase 1500 U/L
D) Hypocalcemia 7.5 mg/dL
.Correct answer: CRP >150 mg/L on day 3.
Rationale: Persistent high CRP (>150) at day 3 predicts infected necrosis, not severity of
lipase or hypocalcemia alone.
13. A 62-year-old with acute ischemic stroke received tPA 90 minutes ago and now has
severe headache and worsening NIHSS from 8 to 22. What is the immediate action?
A) Repeat head CT without contrast
B) Hold antiplatelet and obtain STAT CT angiogram
C) Administer cryoprecipitate
D) Start nicardipine for BP 160/90
Correct answer: Hold antiplatelet and obtain STAT CT angiogram
Rationale: Sudden worsening post-tPA suggests symptomatic intracranial hemorrhage;
emergent imaging is priority before reversal.
Hg. What is the next best action?
A) Increase norepinephrine to 0.6 mcg/kg/min
B) Add vasopressin at 0.04 units/min
C) Give a 2L normal saline bolus
D) Start phenylephrine 100 mcg/min
.Correct answer: Add vasopressin at 0.04 units/min.
.Rationale: Vasopressin is additive to norepinephrine in vasodilatory shock; guidelines
recommend adding it when norepinephrine dose exceeds 0.25 mcg/kg/min..
2. A post-cardiac arrest patient has a Glasgow Coma Scale score of 7 and is shivering
despite normothermia. Which intervention is most appropriate?
A) Propofol infusion titrated to sedation goal
B) Neuromuscular blocker with continuous EEG monitoring
C) Increase ambient room temperature
D) Administer acetaminophen 1g IV
Correct answer: Neuromuscular blocker with continuous EEG monitoring
Rationale: Shivering after cardiac arrest increases oxygen demand; NMBs suppress
shivering, but require EEG to detect seizures.
3. Which finding in a patient with severe metabolic acidosis (pH 7.1, HCO3 8) indicates the
need for immediate renal replacement therapy?
A) Serum potassium 5.2 mEq/L
B) Anion gap 24 mEq/L
C) Oliguric AKI with pulmonary edema
D) Serum lactate 6 mmol/L
Correct answer: Oliguric AKI with pulmonary edema
Rationale: RRT is indicated for severe acidosis with volume overload not responsive to
diuretics, not merely for elevated lactate or mild hyperkalemia.
,4. A 72-year-old with acute hypoxemic respiratory failure on FiO2 0.8 and PEEP 12 has a
PaO2 of 55 mm Hg. What is the priority?
A) Increase FiO2 to 1.0
B) Perform a recruitment maneuver
C) Prone positioning
D) Switch to pressure control ventilation
Correct answer: Prone positioning
.Rationale: Severe ARDS (PaO2/FiO2 <100) benefits from prone positioning to improve
V/Q matching and reduce mortality..
5. A patient with acute anterior STEMI develops new hypotension and a harsh holosystolic
murmur at the apex. What is the most likely diagnosis?
A) Papillary muscle rupture
B) Ventricular septal rupture
C) Mitral regurgitation from papillary muscle dysfunction
D) Free wall rupture
Correct answer: Mitral regurgitation from papillary muscle dysfunction
Rationale: Apical murmur after anterior MI suggests ischemia of posteromedial papillary
muscle causing acute MR, not VSD (which is harsher and mid-systolic).
6. A patient in DKA has a glucose of 380 mg/dL after initial insulin bolus. Which lab value
should be monitored to prevent iatrogenic complication?
A) Serum calcium
B) Phosphorus level
C) Magnesium
D) BUN/creatinine
Correct answer: Phosphorus level
Rationale: Insulin drives phosphate into cells; severe hypophosphatemia can cause
respiratory muscle weakness and hemolysis.
7. Which ventilator setting adjustment is most appropriate for a patient with status
asthmaticus and auto-PEEP of 12 cm H2O?
A) Increase respiratory rate to 18
, B) .Decrease tidal volume to 6 mL/kg.
C) Increase inspiratory time to 1.5 seconds
D) Add 10 cm H2O of extrinsic PEEP
.Correct answer: Decrease tidal volume to 6 mL/kg.
Rationale: Lowering Vt reduces minute ventilation, allowing more expiratory time to
unload auto-PEEP; increasing rate worsens air trapping.
8. A 58-year-old with cirrhosis and hematemesis has a heart rate of 130 and BP 85/50. After
securing airway, what is the next priority?
A) Octreotide infusion
B) .Transfuse to hemoglobin >7 g/dL and initiate vasopressin.
C) Urgent endoscopy
D) Intravenous pantoprazole
.Correct answer: Transfuse to hemoglobin >7 g/dL and initiate vasopressin.
.Rationale: In variceal bleed with hemorrhagic shock, restrictive transfusion (Hgb 7-8)
plus vasopressin/terlipressin precedes endoscopy..
9. A patient on norepinephrine and dobutamine for cardiogenic shock has a cardiac index of
1.6 L/min/m2 and ScvO2 of 48%. Which therapy should be added?
A) Milrinone
B) Intra-aortic balloon pump
C) Increase norepinephrine to 1 mcg/kg/min
D) Levosimendan
Correct answer: Intra-aortic balloon pump
Rationale: IABP improves coronary perfusion and reduces afterload in refractory
cardiogenic shock with low CI and ScvO2 <50%.
10. Which cerebrospinal fluid finding is most consistent with bacterial meningitis in a 45-
year-old with fever, neck stiffness, and altered mental status?
A) Glucose 55 mg/dL, protein 60 mg/dL, WBC 200 lymphs
B) .Glucose 25 mg/dL, protein 250 mg/dL, WBC 3000 PMNs.
C) Glucose 70 mg/dL, protein 40 mg/dL, WBC 5 lymphs
D) Glucose 40 mg/dL, protein 100 mg/dL, RBC 10,000
, .Correct answer: Glucose 25 mg/dL, protein 250 mg/dL, WBC 3000 PMNs.
Rationale: Bacterial meningitis causes low CSF glucose (<40), high protein (>150), and
marked neutrophilic pleocytosis.
11. A mechanically ventilated patient with severe TBI and ICP 22 mm Hg has a PaCO2 of 38
mm Hg. What is the most appropriate next step?
A) Hyperventilate to PaCO2 30 mm Hg
B) .Mannitol 1 g/kg IV.
C) Elevate head of bed to 15 degrees
D) Start hypertonic saline 3% at 30 mL/hr
.Correct answer: Mannitol 1 g/kg IV.
.Rationale: First-tier therapy for elevated ICP (20-25) is mannitol or hypertonic saline;
hyperventilation is reserved for herniation..
12. Which lab abnormality in a patient with acute pancreatitis suggests necrotizing infection?
A) Lipase >3 times normal
B) .CRP >150 mg/L on day 3.
C) Amylase 1500 U/L
D) Hypocalcemia 7.5 mg/dL
.Correct answer: CRP >150 mg/L on day 3.
Rationale: Persistent high CRP (>150) at day 3 predicts infected necrosis, not severity of
lipase or hypocalcemia alone.
13. A 62-year-old with acute ischemic stroke received tPA 90 minutes ago and now has
severe headache and worsening NIHSS from 8 to 22. What is the immediate action?
A) Repeat head CT without contrast
B) Hold antiplatelet and obtain STAT CT angiogram
C) Administer cryoprecipitate
D) Start nicardipine for BP 160/90
Correct answer: Hold antiplatelet and obtain STAT CT angiogram
Rationale: Sudden worsening post-tPA suggests symptomatic intracranial hemorrhage;
emergent imaging is priority before reversal.
