1
Advanced Cardiovascular Life Support (ACLS):
Comprehensive Examination V2 – 150
Multiple-Choice Questions a well detailed one
written and graded A+
upgraded Advanced Clinical Decision-Making
in Cardiovascular Emergencies:
Pathophysiology, Hemodynamic Monitoring,
Pharmacological Nuance, and Evidence-Based
Resuscitation Strategies According to the 2025
AHA Guidelines for Healthcare Professionals
SECTION 1: CARDIAC ARREST ALGORITHM – SHOCKABLE RHYTHMS (Questions 1–20)
1. A 62-year-old male with a history of ischemic cardiomyopathy collapses in the cardiac
catheterization laboratory. The monitor reveals coarse ventricular fibrillation. The team
defibrillates at 200 J biphasic with immediate resumption of CPR. After 2 minutes of high-
quality CPR, the rhythm check reveals organized electrical activity with a palpable femoral
, 2
pulse. The patient remains unresponsive with a blood pressure of 78/42 mmHg. Which of the
following is the MOST appropriate immediate intervention?
A) Administer amiodarone 300 mg IV push to prevent recurrence of VF
B) Administer 500 mL of normal saline bolus while initiating a norepinephrine infusion
C) Administer lidocaine 1.5 mg/kg IV push for prophylaxis
D) Obtain a 12-lead ECG and prepare for immediate coronary angiography
- detailed answer 100% correct :- D
Rationale: Following ROSC after VF arrest, the priority is identifying and treating the underlying
etiology. Given the history of ischemic cardiomyopathy and arrest in the cath lab, immediate
coronary angiography is indicated regardless of ECG findings. Antiarrhythmics are not routinely
indicated post-ROSC. Volume resuscitation should be guided by hemodynamics and etiology. A
12-lead ECG should be obtained, but coronary angiography remains the definitive diagnostic
and therapeutic intervention.
2. A 55-year-old patient in the emergency department develops witnessed ventricular
fibrillation. Defibrillation at the manufacturer-recommended energy setting is immediately
performed with termination of VF. The patient converts to sinus rhythm with a palpable
pulse. Two minutes later, the patient develops pulseless ventricular tachycardia. What is the
MOST appropriate next step?
A) Administer amiodarone 300 mg IV push
B) Administer epinephrine 1 mg IV push
C) Defibrillate at the same energy setting
D) Perform synchronized cardioversion at 100 J
- detailed answer 100% correct :- C
Rationale: Recurrent VT/VF after initial successful defibrillation is treated with defibrillation at
the same energy setting. Antiarrhythmics should not delay defibrillation. Synchronized
cardioversion is not appropriate for pulseless rhythms. Epinephrine may be given, but
defibrillation takes precedence.
3. A 68-year-old patient with end-stage renal disease and hyperkalemia (K⁺ 7.2 mEq/L)
develops pulseless ventricular tachycardia. The team administers defibrillation three times
with epinephrine and amiodarone, but the rhythm remains refractory. What additional
intervention should be prioritized?
, 3
A) Repeat amiodarone 150 mg
B) Administer sodium bicarbonate 1 mEq/kg
C) Administer lidocaine 1.5 mg/kg
D) Perform double sequential defibrillation
- detailed answer 100% correct :- B
Rationale: Hyperkalemia is a reversible cause of cardiac arrest. While all options may be
considered, sodium bicarbonate (1 mEq/kg) is specifically indicated for hyperkalemia and
metabolic acidosis. It should be administered in addition to calcium gluconate, insulin, and
glucose. Double sequential defibrillation is not established therapy.
4. A patient in VF cardiac arrest receives 4 defibrillation attempts, epinephrine 1 mg, and
amiodarone 300 mg. Despite these interventions, VF persists. The team leader considers a
"shock-first" approach with a different defibrillator pad placement. Which of the following
pad placements is MOST appropriate for anterior-posterior positioning?
A) Right upper chest and left lower chest
B) Right upper chest and left upper chest
C) Left lower chest and right lower chest
D) Sternal pad and posterior pad over the left shoulder blade
- detailed answer 100% correct :- D
Rationale: Anterior-posterior pad placement involves placing one pad on the right or left
anterior chest and the other pad on the back, over the left shoulder blade region. This vector
change may be beneficial in refractory VF. Anterolateral placement (right upper and left lower
chest) is the standard position.
5. A 70-year-old patient with an implantable cardioverter-defibrillator (ICD) presents with
cardiac arrest. The monitor shows VF, and the ICD has delivered three shocks without
conversion. What is the appropriate management?
A) Place a magnet over the ICD to deactivate it
B) Apply external defibrillation pads and deliver a shock
C) Wait for the ICD to deliver additional shocks
D) Administer amiodarone before external defibrillation
- detailed answer 100% correct :- B
, 4
Rationale: External defibrillation pads should be applied and a shock delivered from an external
defibrillator, even if the patient has an ICD. Magnet application deactivates the ICD and is not
appropriate in an emergency. Defibrillation should not be delayed.
6. A patient with cardiac arrest is in VF. The first defibrillation attempt is successful, and the
rhythm converts to sinus bradycardia at 40 bpm with a palpable pulse. The patient's blood
pressure is 70/40 mmHg. The patient is now complaining of chest pain. What is the MOST
appropriate intervention?
A) Administer atropine 0.5 mg IV
B) Initiate transcutaneous pacing
C) Administer dopamine 5 mcg/kg/min
D) Perform immediate coronary angiography
- detailed answer 100% correct :- D
Rationale: Post-cardiac arrest with presumed cardiac etiology and ongoing symptoms (chest
pain) is an indication for immediate coronary angiography. Bradycardia and hypotension are
likely due to myocardial stunning or ischemia. Pacing and vasopressors may be needed, but
addressing the underlying coronary occlusion is the priority.
7. Which of the following ECG findings is MOST suggestive of acute myocardial infarction in a
patient who achieves ROSC?
A) ST-segment depression in leads V1-V4
B) ST-segment elevation in leads II, III, and aVF
C) T-wave inversion in the lateral leads
D) New left bundle branch block with concordant ST-segment elevation
- detailed answer 100% correct :- D
Rationale: In patients with LBBB, ST-segment elevation that is concordant with the QRS complex
(≥1 mm) is highly specific for acute MI (Sgarbossa criteria). ST-segment elevation in the inferior
leads (II, III, aVF) is classic for inferior MI, but concordant ST elevation in LBBB is more specific.
8. A patient in cardiac arrest with VF receives CPR and defibrillation. The team leader notes
that the ETCO₂ waveform shows a sudden increase from 18 mmHg to 45 mmHg during CPR.
What does this finding MOST likely indicate?
Advanced Cardiovascular Life Support (ACLS):
Comprehensive Examination V2 – 150
Multiple-Choice Questions a well detailed one
written and graded A+
upgraded Advanced Clinical Decision-Making
in Cardiovascular Emergencies:
Pathophysiology, Hemodynamic Monitoring,
Pharmacological Nuance, and Evidence-Based
Resuscitation Strategies According to the 2025
AHA Guidelines for Healthcare Professionals
SECTION 1: CARDIAC ARREST ALGORITHM – SHOCKABLE RHYTHMS (Questions 1–20)
1. A 62-year-old male with a history of ischemic cardiomyopathy collapses in the cardiac
catheterization laboratory. The monitor reveals coarse ventricular fibrillation. The team
defibrillates at 200 J biphasic with immediate resumption of CPR. After 2 minutes of high-
quality CPR, the rhythm check reveals organized electrical activity with a palpable femoral
, 2
pulse. The patient remains unresponsive with a blood pressure of 78/42 mmHg. Which of the
following is the MOST appropriate immediate intervention?
A) Administer amiodarone 300 mg IV push to prevent recurrence of VF
B) Administer 500 mL of normal saline bolus while initiating a norepinephrine infusion
C) Administer lidocaine 1.5 mg/kg IV push for prophylaxis
D) Obtain a 12-lead ECG and prepare for immediate coronary angiography
- detailed answer 100% correct :- D
Rationale: Following ROSC after VF arrest, the priority is identifying and treating the underlying
etiology. Given the history of ischemic cardiomyopathy and arrest in the cath lab, immediate
coronary angiography is indicated regardless of ECG findings. Antiarrhythmics are not routinely
indicated post-ROSC. Volume resuscitation should be guided by hemodynamics and etiology. A
12-lead ECG should be obtained, but coronary angiography remains the definitive diagnostic
and therapeutic intervention.
2. A 55-year-old patient in the emergency department develops witnessed ventricular
fibrillation. Defibrillation at the manufacturer-recommended energy setting is immediately
performed with termination of VF. The patient converts to sinus rhythm with a palpable
pulse. Two minutes later, the patient develops pulseless ventricular tachycardia. What is the
MOST appropriate next step?
A) Administer amiodarone 300 mg IV push
B) Administer epinephrine 1 mg IV push
C) Defibrillate at the same energy setting
D) Perform synchronized cardioversion at 100 J
- detailed answer 100% correct :- C
Rationale: Recurrent VT/VF after initial successful defibrillation is treated with defibrillation at
the same energy setting. Antiarrhythmics should not delay defibrillation. Synchronized
cardioversion is not appropriate for pulseless rhythms. Epinephrine may be given, but
defibrillation takes precedence.
3. A 68-year-old patient with end-stage renal disease and hyperkalemia (K⁺ 7.2 mEq/L)
develops pulseless ventricular tachycardia. The team administers defibrillation three times
with epinephrine and amiodarone, but the rhythm remains refractory. What additional
intervention should be prioritized?
, 3
A) Repeat amiodarone 150 mg
B) Administer sodium bicarbonate 1 mEq/kg
C) Administer lidocaine 1.5 mg/kg
D) Perform double sequential defibrillation
- detailed answer 100% correct :- B
Rationale: Hyperkalemia is a reversible cause of cardiac arrest. While all options may be
considered, sodium bicarbonate (1 mEq/kg) is specifically indicated for hyperkalemia and
metabolic acidosis. It should be administered in addition to calcium gluconate, insulin, and
glucose. Double sequential defibrillation is not established therapy.
4. A patient in VF cardiac arrest receives 4 defibrillation attempts, epinephrine 1 mg, and
amiodarone 300 mg. Despite these interventions, VF persists. The team leader considers a
"shock-first" approach with a different defibrillator pad placement. Which of the following
pad placements is MOST appropriate for anterior-posterior positioning?
A) Right upper chest and left lower chest
B) Right upper chest and left upper chest
C) Left lower chest and right lower chest
D) Sternal pad and posterior pad over the left shoulder blade
- detailed answer 100% correct :- D
Rationale: Anterior-posterior pad placement involves placing one pad on the right or left
anterior chest and the other pad on the back, over the left shoulder blade region. This vector
change may be beneficial in refractory VF. Anterolateral placement (right upper and left lower
chest) is the standard position.
5. A 70-year-old patient with an implantable cardioverter-defibrillator (ICD) presents with
cardiac arrest. The monitor shows VF, and the ICD has delivered three shocks without
conversion. What is the appropriate management?
A) Place a magnet over the ICD to deactivate it
B) Apply external defibrillation pads and deliver a shock
C) Wait for the ICD to deliver additional shocks
D) Administer amiodarone before external defibrillation
- detailed answer 100% correct :- B
, 4
Rationale: External defibrillation pads should be applied and a shock delivered from an external
defibrillator, even if the patient has an ICD. Magnet application deactivates the ICD and is not
appropriate in an emergency. Defibrillation should not be delayed.
6. A patient with cardiac arrest is in VF. The first defibrillation attempt is successful, and the
rhythm converts to sinus bradycardia at 40 bpm with a palpable pulse. The patient's blood
pressure is 70/40 mmHg. The patient is now complaining of chest pain. What is the MOST
appropriate intervention?
A) Administer atropine 0.5 mg IV
B) Initiate transcutaneous pacing
C) Administer dopamine 5 mcg/kg/min
D) Perform immediate coronary angiography
- detailed answer 100% correct :- D
Rationale: Post-cardiac arrest with presumed cardiac etiology and ongoing symptoms (chest
pain) is an indication for immediate coronary angiography. Bradycardia and hypotension are
likely due to myocardial stunning or ischemia. Pacing and vasopressors may be needed, but
addressing the underlying coronary occlusion is the priority.
7. Which of the following ECG findings is MOST suggestive of acute myocardial infarction in a
patient who achieves ROSC?
A) ST-segment depression in leads V1-V4
B) ST-segment elevation in leads II, III, and aVF
C) T-wave inversion in the lateral leads
D) New left bundle branch block with concordant ST-segment elevation
- detailed answer 100% correct :- D
Rationale: In patients with LBBB, ST-segment elevation that is concordant with the QRS complex
(≥1 mm) is highly specific for acute MI (Sgarbossa criteria). ST-segment elevation in the inferior
leads (II, III, aVF) is classic for inferior MI, but concordant ST elevation in LBBB is more specific.
8. A patient in cardiac arrest with VF receives CPR and defibrillation. The team leader notes
that the ETCO₂ waveform shows a sudden increase from 18 mmHg to 45 mmHg during CPR.
What does this finding MOST likely indicate?
