NR574 / NR 574 Acute Care Practicum I Final Exam
(Latest 2026/2027) – Complete Review & Study
Guide | AGACNP Focus | Clinical Competency
Assessment
Section 1: Complex Resuscitation & Critical Illness Management
Q1. You are called to a rapid response for a 68-year-old patient on the medical floor. The
patient is lethargic, tachypneic (28/min), with BP 78/40, HR 128 (sinus tach), SpO₂ 88 %
on 4 L NC. Crackles are heard bilaterally. A stat portable CXR shows bilateral pulmonary
edema. An ECG shows no ST changes. The nurse reports a urine output of 10 mL over
the last 2 hours. After applying high-flow oxygen, your NEXT priority intervention is:
A. Administer IV furosemide 40 mg push.
B. Start a norepinephrine infusion to target MAP >65 mmHg.
C. Obtain a stat echocardiogram.
D. Initiate a nitroglycerin infusion starting at 10 mcg/min.
Correct Answer: B
Rationale: Cardiogenic shock with systolic BP <90 mmHg mandates immediate
vasopressor support (norepinephrine) to restore coronary perfusion before any diuresis
or vasodilation. Diuretics or vasodilators would further compromise afterload and
precipitate collapse. Echo is diagnostic, not life-saving in the first 5 minutes.
,Q2. A 54-year-old intubated ICU patient with severe ARDS (P/F 78) on VC-AC 6 mL/kg,
PEEP 14, FiO₂ 1.0, has plateau pressure 34 cmH₂O and declining SpO₂ to 82 %. A stat
ABG shows pH 7.19, PaCO₂ 58, PaO₂ 56. Which SINGLE ventilator change do you make
FIRST?
A. Increase RR to 35/min.
B. Increase PEEP to 18 cmH₂O.
C. Switch to pressure-controlled ventilation with P-high 30, PEEP 15.
D. Initiate inhaled nitric oxide 20 ppm.
Correct Answer: C
Rationale: Plateau >30 cmH₂O risks ventilator-induced lung injury; pressure-control
limits distending pressure while maintaining acceptable driving pressure (∆P = P-high –
PEEP = 15). Increasing RR (A) worsens auto-PEEP, higher PEEP (B) may over-distend,
and nitric oxide (D) is adjunctive, not first-line.
Q3. A 19-year-old restrained driver arrives 45 min after high-speed MVA with GCS 12 (E3
V4 M5), BP 90/60, HR 120, RR 28. FAST is positive in Morrison’s pouch. Pelvic X-ray
shows open-book pelvis. While the blood bank types and crosses, the best INITIAL fluid
strategy is:
A. 2 L warmed LR bolus.
B. 1 unit PRBC : 1 unit FFP : 1 unit platelets (1:1:1) immediately.
C. Permissive hypotension with 250 mL aliquots of LR to maintain SBP 80–90 mmHg.
D. Start norepinephrine to MAP 65 mmHg.
,Correct Answer: C
Rationale: In uncontrolled hemorrhagic shock without brain injury, permissive
hypotension (SBP 80–90) limits clot disruption and hemodilution until definitive control.
Large crystalloid (A) increases bleeding and coagulopathy; blood products (B) are ideal
but not yet available; pressors (D) worsen tissue ischemia.
Q4. A 72-year-old woman receiving ceftriaxone for urosepsis develops diffuse
abdominal pain, profuse watery diarrhea, and fever 38.9 °C. WBC 28 000 with 45 %
bands. Stool C. difficile PCR is positive. BP 82/48, HR 124, lactate 4.2 mmol/L. Which
intervention is MOST appropriate NEXT?
A. Start oral metronidazole 500 mg TID.
B. Start oral vancomycin 125 mg QID + IV metronidazole 500 mg TID.
C. Obtain urgent surgical consult for colectomy.
D. Begin vancomycin enemas Q6h.
Correct Answer: B
Rationale: Fulminant C. difficile with shock requires dual therapy: high-dose oral
vancomycin to achieve intraluminal kill plus IV metronidazole for systemic tissue levels.
Monotherapy (A) is insufficient for severe disease; surgery (C) is reserved for peritonitis
or toxic megacolon; enemas (D) are not superior to oral route.
Q5. A 60 kg patient with septic shock is on norepinephrine 24 mcg/min (0.4
mcg/kg/min) and vasopressin 0.04 units/min. MAP remains 58 mmHg, HR 105, urine
output 0.3 mL/kg/h. Bedside echo shows hyper-dynamic LV, SV 45 mL. ScvO₂ is 78 %.
The best NEXT addition is:
, A. Add epinephrine 0.1 mcg/kg/min.
B. Administer 500 mL balanced crystalloid.
C. Start hydrocortisone 200 mg/day.
D. Add phenylephrine 100 mcg/min.
Correct Answer: C
Rationale: Refractory shock with adequate fluid resuscitation (normal SV, high ScvO₂)
suggests vasoplegia; corticosteroids improve catecholamine responsiveness within
6–8 h. Adding another inotrope/pressor (A, D) without steroid coverage increases
arrhythmia risk; further fluid (B) is unlikely to help when SV is already optimized.
Q6. A 3-year-post-orthotopic-heart-transplant patient presents to ED with fatigue; ECG
shows wide-complex tachycardia at 180 bpm, HR > RR, no discernible P waves. BP
70/40. Which agent do you AVOID?
A. Adenosine 6 mg rapid push.
B. Amiodarone 150 mg over 10 min.
C. Synchronized cardioversion 100 J.
D. Procainamide 20 mg/min load.
Correct Answer: A
Rationale: Denervated transplanted hearts lack vagal innervation; adenosine is
ineffective and may precipitate prolonged asystole. Electrical cardioversion (C) is drug
of choice when unstable; amiodarone or procainamide are safe.
(Latest 2026/2027) – Complete Review & Study
Guide | AGACNP Focus | Clinical Competency
Assessment
Section 1: Complex Resuscitation & Critical Illness Management
Q1. You are called to a rapid response for a 68-year-old patient on the medical floor. The
patient is lethargic, tachypneic (28/min), with BP 78/40, HR 128 (sinus tach), SpO₂ 88 %
on 4 L NC. Crackles are heard bilaterally. A stat portable CXR shows bilateral pulmonary
edema. An ECG shows no ST changes. The nurse reports a urine output of 10 mL over
the last 2 hours. After applying high-flow oxygen, your NEXT priority intervention is:
A. Administer IV furosemide 40 mg push.
B. Start a norepinephrine infusion to target MAP >65 mmHg.
C. Obtain a stat echocardiogram.
D. Initiate a nitroglycerin infusion starting at 10 mcg/min.
Correct Answer: B
Rationale: Cardiogenic shock with systolic BP <90 mmHg mandates immediate
vasopressor support (norepinephrine) to restore coronary perfusion before any diuresis
or vasodilation. Diuretics or vasodilators would further compromise afterload and
precipitate collapse. Echo is diagnostic, not life-saving in the first 5 minutes.
,Q2. A 54-year-old intubated ICU patient with severe ARDS (P/F 78) on VC-AC 6 mL/kg,
PEEP 14, FiO₂ 1.0, has plateau pressure 34 cmH₂O and declining SpO₂ to 82 %. A stat
ABG shows pH 7.19, PaCO₂ 58, PaO₂ 56. Which SINGLE ventilator change do you make
FIRST?
A. Increase RR to 35/min.
B. Increase PEEP to 18 cmH₂O.
C. Switch to pressure-controlled ventilation with P-high 30, PEEP 15.
D. Initiate inhaled nitric oxide 20 ppm.
Correct Answer: C
Rationale: Plateau >30 cmH₂O risks ventilator-induced lung injury; pressure-control
limits distending pressure while maintaining acceptable driving pressure (∆P = P-high –
PEEP = 15). Increasing RR (A) worsens auto-PEEP, higher PEEP (B) may over-distend,
and nitric oxide (D) is adjunctive, not first-line.
Q3. A 19-year-old restrained driver arrives 45 min after high-speed MVA with GCS 12 (E3
V4 M5), BP 90/60, HR 120, RR 28. FAST is positive in Morrison’s pouch. Pelvic X-ray
shows open-book pelvis. While the blood bank types and crosses, the best INITIAL fluid
strategy is:
A. 2 L warmed LR bolus.
B. 1 unit PRBC : 1 unit FFP : 1 unit platelets (1:1:1) immediately.
C. Permissive hypotension with 250 mL aliquots of LR to maintain SBP 80–90 mmHg.
D. Start norepinephrine to MAP 65 mmHg.
,Correct Answer: C
Rationale: In uncontrolled hemorrhagic shock without brain injury, permissive
hypotension (SBP 80–90) limits clot disruption and hemodilution until definitive control.
Large crystalloid (A) increases bleeding and coagulopathy; blood products (B) are ideal
but not yet available; pressors (D) worsen tissue ischemia.
Q4. A 72-year-old woman receiving ceftriaxone for urosepsis develops diffuse
abdominal pain, profuse watery diarrhea, and fever 38.9 °C. WBC 28 000 with 45 %
bands. Stool C. difficile PCR is positive. BP 82/48, HR 124, lactate 4.2 mmol/L. Which
intervention is MOST appropriate NEXT?
A. Start oral metronidazole 500 mg TID.
B. Start oral vancomycin 125 mg QID + IV metronidazole 500 mg TID.
C. Obtain urgent surgical consult for colectomy.
D. Begin vancomycin enemas Q6h.
Correct Answer: B
Rationale: Fulminant C. difficile with shock requires dual therapy: high-dose oral
vancomycin to achieve intraluminal kill plus IV metronidazole for systemic tissue levels.
Monotherapy (A) is insufficient for severe disease; surgery (C) is reserved for peritonitis
or toxic megacolon; enemas (D) are not superior to oral route.
Q5. A 60 kg patient with septic shock is on norepinephrine 24 mcg/min (0.4
mcg/kg/min) and vasopressin 0.04 units/min. MAP remains 58 mmHg, HR 105, urine
output 0.3 mL/kg/h. Bedside echo shows hyper-dynamic LV, SV 45 mL. ScvO₂ is 78 %.
The best NEXT addition is:
, A. Add epinephrine 0.1 mcg/kg/min.
B. Administer 500 mL balanced crystalloid.
C. Start hydrocortisone 200 mg/day.
D. Add phenylephrine 100 mcg/min.
Correct Answer: C
Rationale: Refractory shock with adequate fluid resuscitation (normal SV, high ScvO₂)
suggests vasoplegia; corticosteroids improve catecholamine responsiveness within
6–8 h. Adding another inotrope/pressor (A, D) without steroid coverage increases
arrhythmia risk; further fluid (B) is unlikely to help when SV is already optimized.
Q6. A 3-year-post-orthotopic-heart-transplant patient presents to ED with fatigue; ECG
shows wide-complex tachycardia at 180 bpm, HR > RR, no discernible P waves. BP
70/40. Which agent do you AVOID?
A. Adenosine 6 mg rapid push.
B. Amiodarone 150 mg over 10 min.
C. Synchronized cardioversion 100 J.
D. Procainamide 20 mg/min load.
Correct Answer: A
Rationale: Denervated transplanted hearts lack vagal innervation; adenosine is
ineffective and may precipitate prolonged asystole. Electrical cardioversion (C) is drug
of choice when unstable; amiodarone or procainamide are safe.
