NR 574 Acute Care Practicum MIDTERM EXAM:
Weeks 1-4 Clinical Integration & Management
Mastery | 2026/2027 Edition | 450+ High-Acuity
Scenarios & Management Algorithms
This midterm exam consists of 45 questions assessing your clinical judgment and
management skills for acute care scenarios covered in Weeks 1-4 of the 2026/2027 NR
574 curriculum. Select the single best, most appropriate acute care nurse practitioner
action.
1. A 68 kg, 52-year-old post-esophagectomy patient in the SICU has the following
06:00 hemodynamic data: HR 118 bpm, MAP 54 mmHg, CVP 14 mmHg (on PEEP
8 cmH₂O), PAOP 18 mmHg, CI 1.8 L/min/m² (thermodilution), SVV 16 %, lactate
4.2 mmol/L, Hgb 7.9 g/dL, ScvO₂ 58 %. A chest X-ray shows bilateral pulmonary
edema and a 3-cm left pleural effusion.
A. Order a stat CT pulmonary angiography to rule out PE.
*B. Administer norepinephrine 0.1 µg/kg/min IV, transfuse 1 unit PRBC, initiate
furosemide 20 mg IV push after BP stabilizes, obtain a bedside cardiac echo, and
plan diagnostic thoracentesis if effusion enlarges.
C. Reposition the patient to high-Fowler’s and titrate FiO₂ per RT protocol.
D. Draw repeat lactate in 2 hours and consult nephrology for possible CRRT.
Rationale: 1) B is correct because cardiogenic-hypovolemic mixed shock requires
afterload increase, oxygen-carrying capacity improvement, and decongestion
once perfusion is restored. 2) A delays treating hypoperfusion and contrast load
may worsen renal function. 3) C is supportive nursing care, not definitive ACNP
management. 4) D is important follow-up but only after initial resuscitation.
2. A 72-year-old trauma patient arrives intubated from the scene. Arterial blood gas
on arrival: pH 7.18, PaCO₂ 65 mmHg, PaO₂ 58 mmHg, HCO₃ 24 mEq/L, SpO₂ 86 %
on 100 % FiO₂. Ventilator settings are AC/VC 500 mL, RR 14, PEEP 5 cmH₂O, PIP
34 cmH₂O, plateau 30 cmH₂O. Breath sounds are diminished on the right with
, tracheal deviation to the left.
A. Increase PEEP to 10 cmH₂O and increase RR to 20.
*B. Suspect right tension pneumothorax; stat needle decompression at 2nd ICS
MCL followed by chest tube insertion, increase FiO₂ to 100 %, obtain portable
CXR, and prepare for possible vasopressor support.
C. Suction the ETT and send sputum for culture.
D. Order a bedside cardiac echo to assess right-heart strain.
Rationale: 1) B is correct because tension physiology mandates immediate
decompression. 2) A worsens intrathoracic pressure and hypotension. 3) C is an
RN task and delays source control. 4) D is useful confirmation but only after
life-saving decompression.
3. A 58-year-old with decompensated cirrhosis is admitted with massive
hematemesis. BP 78/46 mmHg, HR 138 bpm, RR 28, SpO₂ 92 % on 15 L
non-rebreather. Nasogastric lavage returns coffee-ground blood. Hgb 6.1 g/dL,
INR 3.4, platelets 46 k/µL, lactate 6.1 mmol/L. Two 18-gauge IVs are in place.
A. Order an emergent EGD for banding and begin pantoprazole 8 mg/hr infusion.
*B. Rapidly infuse 2 L balanced crystalloid, transfuse 2 units PRBC, 1 unit
platelets, give 10 mg IV vitamin K and 1500 units IV prothrombin complex
concentrate, insert a Blakemore tube if variceal bleeding persists, and arrange
emergent EGD.
C. Place the patient in Trendelenburg and initiate high-dose PPI.
D. Type and cross for 6 units and draw a stat CBC in 30 minutes.
Rationale: 1) B addresses hemorrhagic shock, coagulopathy, and airway
protection first. 2) A proceeds without hemodynamic stabilization. 3) C is an
outdated nursing maneuver with no evidence. 4) D is supportive lab follow-up
after resuscitation is initiated.
4. A 5-day post-pancreatoduodenectomy patient has sudden onset SOB and
pleuritic chest pain. HR 112 bpm, BP 94/58 mmHg, RR 26, SpO₂ 88 % on 4 L NC.
ABG: pH 7.48, PaCO₂ 28 mmHg, PaO₂ 62 mmHg, HCO₃ 20 mEq/L. D-dimer 4,800
ng/mL, chest X-ray shows oligemia in the left lower zone.
A. Start heparin 80 units/kg bolus then 18 units/kg/hr and order a V/Q scan.
*B. Obtain stat CTPA, start empiric heparin 80 units/kg bolus followed by 18
units/kg/hr if PE confirmed, increase FiO₂ to maintain SpO₂ >94 %, place 5-lead
telemetry, and consider alteplase 100 mg over 2 h if massive PE.
C. Increase oxygen to high-flow nasal cannula and reassess in 1 hour.
D. Draw a statBNP and troponin and page cardiology.
Rationale: 1) B provides rapid diagnosis and guideline-directed therapy for
possible sub-massive/massive PE. 2) A delays imaging and may treat blindly. 3)
Weeks 1-4 Clinical Integration & Management
Mastery | 2026/2027 Edition | 450+ High-Acuity
Scenarios & Management Algorithms
This midterm exam consists of 45 questions assessing your clinical judgment and
management skills for acute care scenarios covered in Weeks 1-4 of the 2026/2027 NR
574 curriculum. Select the single best, most appropriate acute care nurse practitioner
action.
1. A 68 kg, 52-year-old post-esophagectomy patient in the SICU has the following
06:00 hemodynamic data: HR 118 bpm, MAP 54 mmHg, CVP 14 mmHg (on PEEP
8 cmH₂O), PAOP 18 mmHg, CI 1.8 L/min/m² (thermodilution), SVV 16 %, lactate
4.2 mmol/L, Hgb 7.9 g/dL, ScvO₂ 58 %. A chest X-ray shows bilateral pulmonary
edema and a 3-cm left pleural effusion.
A. Order a stat CT pulmonary angiography to rule out PE.
*B. Administer norepinephrine 0.1 µg/kg/min IV, transfuse 1 unit PRBC, initiate
furosemide 20 mg IV push after BP stabilizes, obtain a bedside cardiac echo, and
plan diagnostic thoracentesis if effusion enlarges.
C. Reposition the patient to high-Fowler’s and titrate FiO₂ per RT protocol.
D. Draw repeat lactate in 2 hours and consult nephrology for possible CRRT.
Rationale: 1) B is correct because cardiogenic-hypovolemic mixed shock requires
afterload increase, oxygen-carrying capacity improvement, and decongestion
once perfusion is restored. 2) A delays treating hypoperfusion and contrast load
may worsen renal function. 3) C is supportive nursing care, not definitive ACNP
management. 4) D is important follow-up but only after initial resuscitation.
2. A 72-year-old trauma patient arrives intubated from the scene. Arterial blood gas
on arrival: pH 7.18, PaCO₂ 65 mmHg, PaO₂ 58 mmHg, HCO₃ 24 mEq/L, SpO₂ 86 %
on 100 % FiO₂. Ventilator settings are AC/VC 500 mL, RR 14, PEEP 5 cmH₂O, PIP
34 cmH₂O, plateau 30 cmH₂O. Breath sounds are diminished on the right with
, tracheal deviation to the left.
A. Increase PEEP to 10 cmH₂O and increase RR to 20.
*B. Suspect right tension pneumothorax; stat needle decompression at 2nd ICS
MCL followed by chest tube insertion, increase FiO₂ to 100 %, obtain portable
CXR, and prepare for possible vasopressor support.
C. Suction the ETT and send sputum for culture.
D. Order a bedside cardiac echo to assess right-heart strain.
Rationale: 1) B is correct because tension physiology mandates immediate
decompression. 2) A worsens intrathoracic pressure and hypotension. 3) C is an
RN task and delays source control. 4) D is useful confirmation but only after
life-saving decompression.
3. A 58-year-old with decompensated cirrhosis is admitted with massive
hematemesis. BP 78/46 mmHg, HR 138 bpm, RR 28, SpO₂ 92 % on 15 L
non-rebreather. Nasogastric lavage returns coffee-ground blood. Hgb 6.1 g/dL,
INR 3.4, platelets 46 k/µL, lactate 6.1 mmol/L. Two 18-gauge IVs are in place.
A. Order an emergent EGD for banding and begin pantoprazole 8 mg/hr infusion.
*B. Rapidly infuse 2 L balanced crystalloid, transfuse 2 units PRBC, 1 unit
platelets, give 10 mg IV vitamin K and 1500 units IV prothrombin complex
concentrate, insert a Blakemore tube if variceal bleeding persists, and arrange
emergent EGD.
C. Place the patient in Trendelenburg and initiate high-dose PPI.
D. Type and cross for 6 units and draw a stat CBC in 30 minutes.
Rationale: 1) B addresses hemorrhagic shock, coagulopathy, and airway
protection first. 2) A proceeds without hemodynamic stabilization. 3) C is an
outdated nursing maneuver with no evidence. 4) D is supportive lab follow-up
after resuscitation is initiated.
4. A 5-day post-pancreatoduodenectomy patient has sudden onset SOB and
pleuritic chest pain. HR 112 bpm, BP 94/58 mmHg, RR 26, SpO₂ 88 % on 4 L NC.
ABG: pH 7.48, PaCO₂ 28 mmHg, PaO₂ 62 mmHg, HCO₃ 20 mEq/L. D-dimer 4,800
ng/mL, chest X-ray shows oligemia in the left lower zone.
A. Start heparin 80 units/kg bolus then 18 units/kg/hr and order a V/Q scan.
*B. Obtain stat CTPA, start empiric heparin 80 units/kg bolus followed by 18
units/kg/hr if PE confirmed, increase FiO₂ to maintain SpO₂ >94 %, place 5-lead
telemetry, and consider alteplase 100 mg over 2 h if massive PE.
C. Increase oxygen to high-flow nasal cannula and reassess in 1 hour.
D. Draw a statBNP and troponin and page cardiology.
Rationale: 1) B provides rapid diagnosis and guideline-directed therapy for
possible sub-massive/massive PE. 2) A delays imaging and may treat blindly. 3)
