Section 1: Acute Cardiovascular Disorders
Midterm Exam: NR 570
Q1: A 62-year-old male presents
Common to the emergency
Diagnosis department with substernal
& Management in Acute chestCare
pain that began 45
minutes ago. The pain is described as a heavy pressure radiating to the left arm and jaw. He is
Questions
diaphoretic. A 12-lead ECG reveals and Verified
ST-segment Answers
elevation | 100%
in leads II, Correct
III, and aVF. Which of the following
is the most appropriate initial pharmacologic
Latestintervention for this patient?
2026/2027 Update
A. Administer sublingual nitroglycerin and repeat ECG in 30 minutes
B. Administer aspirin 325 mg chewed, initiate dual antiplatelet therapy with ticagrelor, and prepare for
Aligned with AHA, ACC, CDC, IDSA, Surviving Sepsis Campaign Guidelines
immediate PCI [CORRECT]
Expert-Developed
C. Administer heparin and for Acute
schedule a stress Care
test for theNP Midtermmorning
following Exam Preparation
D. Administer morphine 2 mg IV and observe for 2 hours before deciding on intervention
Section 1: Acute Cardiovascular Disorders (Q1-Q20)
Correct Answer: B
Section 2: Acute Respiratory Disorders (Q21-Q35)
Rationale: This patient presents with an acute inferior STEMI based on ST elevation in leads II, III, and aVF with classic chest
Section 3: Acute Neurological Disorders (Q36-Q45)
pain presentation. The 2026 AHA/ACC guidelines for STEMI management recommend immediate administration of aspirin 325
Section 4: Acute Gastrointestinal Disorders (Q46-Q55)
mg chewed and dual antiplatelet therapy (DAPT) with a P2Y12 inhibitor such as ticagrelor, along with preparation for primary
Section 5: Acute Renal and Genitourinary Disorders (Q56-Q65)
percutaneous coronary intervention (PCI) as the preferred reperfusion strategy. Time is critical in STEMI, with a
Section 6: Acute Endocrine Disorders (Q66-Q75)
door-to-balloon target of less than 90 minutes. Sublingual nitroglycerin is contraindicated in right ventricular involvement
(common in inferior MI) due to risk of profound7:hypotension,
Section Infectious Disease and Sepsisintervention
and delaying (Q76-Q85) for stress testing or observation is
inappropriate for STEMI. Section 8: Pain, Toxicology, and Multisystem Disorders (Q86-Q100)
Q2: A 58-year-old female presents with acute onset chest pain and shortness of breath. Her initial
troponin I is elevated at 0.8 ng/mL (reference less than 0.04 ng/mL). The ECG shows T-wave inversions in
leads V1 through V4 and diffuse ST-segment depression. Her blood pressure is 140/88 mmHg and heart
rate is 92 bpm. Which diagnosis is most consistent with these findings?
A. Prinzmetal (variant) angina
B. Non-ST-elevation myocardial infarction (NSTEMI) [CORRECT]
C. Pericarditis
D. Stable angina pectoris
Correct Answer: B
Rationale: This patient presents with NSTEMI, characterized by elevated cardiac biomarkers (troponin) in the absence of
ST-segment elevation, with ECG changes including T-wave inversions and ST-segment depression. Unlike STEMI, NSTEMI does
not show persistent ST elevation, but the troponin elevation confirms myocardial necrosis. Prinzmetal angina typically presents
with transient ST elevation during coronary vasospasm and troponin is usually normal. Pericarditis presents with diffuse ST
elevation and PR depression, not focal T-wave inversions. Stable angina does not result in troponin elevation, as it represents
demand ischemia without myocardial necrosis.
Q3: A 55-year-old male with a history of hypertension and type 2 diabetes presents with progressive
dyspnea on exertion, orthopnea, and bilateral lower extremity edema over the past 3 days. Examination
reveals jugular venous distension, bilateral crackles at the lung bases, and a third heart sound (S3 gallop).
BNP is 1,200 pg/mL. Echocardiography shows LVEF of 30%. Which of the following is the most
appropriate initial pharmacologic management?
A. Metoprolol tartrate 25 mg PO twice daily and lisinopril 10 mg PO daily
B. Intravenous furosemide 40 mg and supplemental oxygen to maintain SpO2 above 94% [CORRECT]
C. Intravenous milrinone 0.25 mcg/kg/min without diuretic therapy
, NR 570 Midterm Exam: Common Diagnosis & Management in Acute Care | Questions and Verified Answers
D. Oral spironolactone 25 mg daily as monotherapy
Correct Answer: B
Rationale: This patient presents with acute decompensated heart failure (ADHF) with volume overload, evidenced by orthopnea,
JVD, crackles, S3 gallop, and elevated BNP. The initial priority in ADHF with volume overload is diuresis with IV furosemide to
reduce pulmonary congestion and edema. While beta-blockers and ACE inhibitors are essential for chronic HF management,
they are typically initiated after acute decompensation has stabilized. Milrinone is reserved for cardiogenic shock. Spironolactone
alone is insufficient for acute volume management.
Q4: A 70-year-old female with known HFrEF (LVEF 25%) presents with worsening dyspnea, 15-pound
weight gain over 2 weeks, and increasing lower extremity edema despite furosemide 80 mg twice daily at
home. She is dyspneic with respiratory rate of 28 breaths/min and SpO2 of 88% on room air. Which
intervention is most appropriate?
A. Increase oral furosemide to 120 mg twice daily and discharge with follow-up in 1 week
B. Initiate CPAP at 10 cm H2O and administer IV bumetanide [CORRECT]
C. Administer IV dobutamine 5 mcg/kg/min as first-line therapy
D. Perform emergent intubation and mechanical ventilation immediately
Correct Answer: B
Rationale: This patient has acute decompensated heart failure with refractory volume overload despite high-dose oral
furosemide, presenting with acute pulmonary edema. CPAP/BiPAP is indicated for acute cardiogenic pulmonary edema to
reduce preload and afterload, improve oxygenation, and decrease work of breathing. IV bumetanide (a more potent loop
diuretic) provides aggressive diuresis. Dobutamine is not first-line for volume-overloaded HF; it is reserved for low-output states.
Intubation may be needed if CPAP fails but is not the first step.
Q5: A 48-year-old male presents with sudden onset palpitations and lightheadedness that began 20
minutes ago. His blood pressure is 88/60 mmHg and heart rate is 180 bpm. The ECG reveals a regular,
narrow-complex tachycardia without discernible P waves. The patient is diaphoretic and reporting
near-syncope. Which of the following is the most appropriate initial intervention?
A. Administer adenosine 6 mg rapid IV push followed by 12 mg if needed
B. Administer amiodarone 150 mg IV over 10 minutes
C. Perform immediate synchronized cardioversion at 50 joules [CORRECT]
D. Administer diltiazem 0.25 mg/kg IV over 2 minutes
Correct Answer: C
Rationale: This patient has unstable supraventricular tachycardia (SVT) with hypotension and near-syncope, indicating
hemodynamic instability. Per ACLS guidelines, unstable tachycardia with signs of poor perfusion requires immediate
synchronized cardioversion. While adenosine is first-line for stable SVT, it is contraindicated in hemodynamically unstable
patients because the transient asystole it causes may worsen instability. Amiodarone and diltiazem are not appropriate first-line
therapy for unstable SVT.
Q6: A 65-year-old male with heart failure and atrial fibrillation reports fatigue and decreased exercise
tolerance. His ECG reveals AF with a ventricular rate of 110 bpm. Echocardiography shows LVEF of
35%. Which of the following is the most appropriate rate control strategy?
A. Diltiazem 120 mg PO daily for rate control
B. Metoprolol succinate 50 mg PO daily titrated to resting heart rate less than 80 bpm [CORRECT]
C. Amiodarone 200 mg PO daily for rhythm control
D. Digoxin 0.25 mg PO daily as monotherapy for rate control
Correct Answer: B
Page 2
, NR 570 Midterm Exam: Common Diagnosis & Management in Acute Care | Questions and Verified Answers
Rationale: In patients with HFrEF and atrial fibrillation, beta-blockers such as metoprolol succinate are the preferred first-line
agents for rate control because they improve mortality in HFrEF. The target resting heart rate for AF rate control is less than 80
bpm per current guidelines. Diltiazem is contraindicated in HFrEF due to its negative inotropic effects. While amiodarone can be
used for rhythm control, rate control with beta-blockers is the preferred initial strategy. Digoxin alone is insufficient for
adequate rate control during exertion.
Q7: A 72-year-old female is admitted to the ICU with ventricular fibrillation. She is pulseless and
unresponsive. After initiating high-quality CPR, which of the following is the definitive treatment for this
rhythm per current ACLS guidelines?
A. Synchronized cardioversion at 200 joules
B. Defibrillation at 200 joules biphasic followed by immediate resumption of CPR [CORRECT]
C. IV amiodarone 300 mg bolus followed by defibrillation
D. IV epinephrine 1 mg every 3 minutes until rhythm converts
Correct Answer: B
Rationale: Ventricular fibrillation (VF) is a shockable rhythm, and the definitive treatment is unsynchronized defibrillation, not
synchronized cardioversion. The AHA ACLS guidelines recommend immediate defibrillation at 200 joules biphasic, followed by
immediate resumption of chest compressions for 2 minutes before reassessing. While epinephrine and amiodarone are
administered in subsequent cycles, defibrillation itself is the definitive treatment. The key distinction is that defibrillation
(unsynchronized) is used for pulseless rhythms, while cardioversion (synchronized) is for perfusing rhythms.
Q8: A 58-year-old male presents with BP 210/130 mmHg, severe headache, blurred vision, and confusion.
Fundoscopic examination reveals papilledema. Serum creatinine is 2.5 mg/dL (baseline 1.0 mg/dL).
Which of the following best describes this clinical presentation?
A. Hypertensive urgency requiring outpatient BP management within 24 hours
B. Hypertensive emergency requiring immediate IV antihypertensive therapy with target MAP reduction
of 20-25% in the first hour [CORRECT]
C. Malignant hypertension treated with oral clonidine 0.1 mg
D. Preeclampsia requiring magnesium sulfate and delivery planning
Correct Answer: B
Rationale: This patient presents with a hypertensive emergency, defined as severe hypertension (SBP greater than 180 or DBP
greater than 120 mmHg) with evidence of acute target organ damage, including encephalopathy (confusion), visual changes,
papilledema, and acute kidney injury. The treatment requires immediate IV antihypertensive therapy with a target MAP
reduction of no more than 20-25% in the first hour to avoid precipitating cerebral or myocardial ischemia. Hypertensive urgency
involves severe hypertension without acute target organ damage.
Q9: A 45-year-old male presents with sudden onset severe tearing chest pain radiating to the back
between the shoulder blades. BP is 170/100 mmHg in the right arm and 140/80 mmHg in the left arm. CT
angiogram reveals a dissecting flap in the ascending aorta. Which is the most appropriate management?
A. Administer IV labetalol and nitroprusside to reduce SBP less than 120 mmHg and HR less than 60
bpm, then consult cardiovascular surgery [CORRECT]
B. Administer IV nicardipine to reduce SBP less than 140 mmHg and observe for 24 hours
C. Administer thrombolytic therapy and heparin for suspected acute MI
D. Administer oral beta-blocker and schedule outpatient follow-up with cardiology in 1 week
Correct Answer: A
Rationale: This patient has an acute Type A aortic dissection (ascending aorta), which is a surgical emergency. Immediate
management includes IV beta-blocker (labetalol or esmolol) to reduce shear force by decreasing HR below 60 bpm and reducing
SBP, followed by vasodilators (nitroprusside) for further BP control. Type A dissections require emergent surgical intervention,
Page 3
, NR 570 Midterm Exam: Common Diagnosis & Management in Acute Care | Questions and Verified Answers
as medical management alone carries mortality over 50% within 48 hours. Thrombolytics are absolutely contraindicated.
Q10: A 60-year-old male presents with acute onset severe sharp left leg pain. The left lower extremity is
pale, cool, and pulseless. He reports a history of atrial fibrillation but has not been taking his prescribed
anticoagulation. Which is the most appropriate immediate diagnostic study?
A. CT angiography of the affected extremity [CORRECT]
B. Ankle-brachial index (ABI) measurement
C. Doppler ultrasound of the lower extremity
D. Contrast venography of the lower extremity
Correct Answer: A
Rationale: This patient has acute limb ischemia (ALI), evidenced by the classic signs of pain, pallor, pulselessness,
poikilothermia, paresthesias, and paralysis. Given his history of AF and non-adherence to anticoagulation, the likely etiology is
arterial embolism. CT angiography (CTA) is the most appropriate immediate diagnostic study as it rapidly identifies the location
and extent of arterial occlusion and helps guide intervention. While Doppler ultrasound can detect occlusion, CTA provides
faster and more comprehensive detail for surgical planning.
Q11: A 50-year-old female presents with crushing substernal chest pain that began 30 minutes prior. Her
ECG shows ST-segment elevation in leads V1 through V6. She has no contraindications to fibrinolytic
therapy. The nearest PCI-capable hospital is 120 minutes away. Which is the most appropriate
reperfusion strategy?
A. Transfer to the PCI-capable hospital for primary PCI regardless of transport time
B. Administer fibrinolytic therapy (tenecteplase) within 30 minutes of arrival [CORRECT]
C. Administer heparin and wait for cardiac catheterization lab availability
D. Administer aspirin only and observe for ECG changes over the next 6 hours
Correct Answer: B
Rationale: This patient has an anterior STEMI and the nearest PCI-capable hospital is 120 minutes away, exceeding the
recommended first medical contact-to-device time of 120 minutes. When primary PCI cannot be performed within the
guideline-recommended time window, fibrinolytic therapy should be administered within 30 minutes of hospital arrival
(door-to-needle time of 30 minutes or less). Tenecteplase is a preferred fibrinolytic agent due to its single-bolus administration.
Q12: A 68-year-old male with acute decompensated heart failure has persistent hypotension (MAP 58
mmHg) and decreased urine output (0.3 mL/kg/hr) despite adequate diuretic therapy. Cardiac index is 1.8
L/min/m2 and PCWP is elevated at 28 mmHg. Which is the most appropriate pharmacologic
intervention?
A. Increase furosemide drip to 20 mg/hr
B. Initiate dobutamine 2.5 mcg/kg/min IV infusion [CORRECT]
C. Administer IV enalaprilat 1.25 mg
D. Administer carvedilol 3.125 mg PO twice daily
Correct Answer: B
Rationale: This patient presents with cardiogenic shock, characterized by hypotension, oliguria, low cardiac index (normal
2.5-4.0 L/min/m2), and elevated PCWP. Dobutamine, a beta-1 agonist inotropic agent, is the most appropriate choice for
cardiogenic shock with low cardiac output. Increasing diuretics would further reduce preload and worsen hypotension. ACE
inhibitors and beta-blockers are contraindicated in acute cardiogenic shock due to their vasodilatory and negative inotropic
effects.
Page 4
Midterm Exam: NR 570
Q1: A 62-year-old male presents
Common to the emergency
Diagnosis department with substernal
& Management in Acute chestCare
pain that began 45
minutes ago. The pain is described as a heavy pressure radiating to the left arm and jaw. He is
Questions
diaphoretic. A 12-lead ECG reveals and Verified
ST-segment Answers
elevation | 100%
in leads II, Correct
III, and aVF. Which of the following
is the most appropriate initial pharmacologic
Latestintervention for this patient?
2026/2027 Update
A. Administer sublingual nitroglycerin and repeat ECG in 30 minutes
B. Administer aspirin 325 mg chewed, initiate dual antiplatelet therapy with ticagrelor, and prepare for
Aligned with AHA, ACC, CDC, IDSA, Surviving Sepsis Campaign Guidelines
immediate PCI [CORRECT]
Expert-Developed
C. Administer heparin and for Acute
schedule a stress Care
test for theNP Midtermmorning
following Exam Preparation
D. Administer morphine 2 mg IV and observe for 2 hours before deciding on intervention
Section 1: Acute Cardiovascular Disorders (Q1-Q20)
Correct Answer: B
Section 2: Acute Respiratory Disorders (Q21-Q35)
Rationale: This patient presents with an acute inferior STEMI based on ST elevation in leads II, III, and aVF with classic chest
Section 3: Acute Neurological Disorders (Q36-Q45)
pain presentation. The 2026 AHA/ACC guidelines for STEMI management recommend immediate administration of aspirin 325
Section 4: Acute Gastrointestinal Disorders (Q46-Q55)
mg chewed and dual antiplatelet therapy (DAPT) with a P2Y12 inhibitor such as ticagrelor, along with preparation for primary
Section 5: Acute Renal and Genitourinary Disorders (Q56-Q65)
percutaneous coronary intervention (PCI) as the preferred reperfusion strategy. Time is critical in STEMI, with a
Section 6: Acute Endocrine Disorders (Q66-Q75)
door-to-balloon target of less than 90 minutes. Sublingual nitroglycerin is contraindicated in right ventricular involvement
(common in inferior MI) due to risk of profound7:hypotension,
Section Infectious Disease and Sepsisintervention
and delaying (Q76-Q85) for stress testing or observation is
inappropriate for STEMI. Section 8: Pain, Toxicology, and Multisystem Disorders (Q86-Q100)
Q2: A 58-year-old female presents with acute onset chest pain and shortness of breath. Her initial
troponin I is elevated at 0.8 ng/mL (reference less than 0.04 ng/mL). The ECG shows T-wave inversions in
leads V1 through V4 and diffuse ST-segment depression. Her blood pressure is 140/88 mmHg and heart
rate is 92 bpm. Which diagnosis is most consistent with these findings?
A. Prinzmetal (variant) angina
B. Non-ST-elevation myocardial infarction (NSTEMI) [CORRECT]
C. Pericarditis
D. Stable angina pectoris
Correct Answer: B
Rationale: This patient presents with NSTEMI, characterized by elevated cardiac biomarkers (troponin) in the absence of
ST-segment elevation, with ECG changes including T-wave inversions and ST-segment depression. Unlike STEMI, NSTEMI does
not show persistent ST elevation, but the troponin elevation confirms myocardial necrosis. Prinzmetal angina typically presents
with transient ST elevation during coronary vasospasm and troponin is usually normal. Pericarditis presents with diffuse ST
elevation and PR depression, not focal T-wave inversions. Stable angina does not result in troponin elevation, as it represents
demand ischemia without myocardial necrosis.
Q3: A 55-year-old male with a history of hypertension and type 2 diabetes presents with progressive
dyspnea on exertion, orthopnea, and bilateral lower extremity edema over the past 3 days. Examination
reveals jugular venous distension, bilateral crackles at the lung bases, and a third heart sound (S3 gallop).
BNP is 1,200 pg/mL. Echocardiography shows LVEF of 30%. Which of the following is the most
appropriate initial pharmacologic management?
A. Metoprolol tartrate 25 mg PO twice daily and lisinopril 10 mg PO daily
B. Intravenous furosemide 40 mg and supplemental oxygen to maintain SpO2 above 94% [CORRECT]
C. Intravenous milrinone 0.25 mcg/kg/min without diuretic therapy
, NR 570 Midterm Exam: Common Diagnosis & Management in Acute Care | Questions and Verified Answers
D. Oral spironolactone 25 mg daily as monotherapy
Correct Answer: B
Rationale: This patient presents with acute decompensated heart failure (ADHF) with volume overload, evidenced by orthopnea,
JVD, crackles, S3 gallop, and elevated BNP. The initial priority in ADHF with volume overload is diuresis with IV furosemide to
reduce pulmonary congestion and edema. While beta-blockers and ACE inhibitors are essential for chronic HF management,
they are typically initiated after acute decompensation has stabilized. Milrinone is reserved for cardiogenic shock. Spironolactone
alone is insufficient for acute volume management.
Q4: A 70-year-old female with known HFrEF (LVEF 25%) presents with worsening dyspnea, 15-pound
weight gain over 2 weeks, and increasing lower extremity edema despite furosemide 80 mg twice daily at
home. She is dyspneic with respiratory rate of 28 breaths/min and SpO2 of 88% on room air. Which
intervention is most appropriate?
A. Increase oral furosemide to 120 mg twice daily and discharge with follow-up in 1 week
B. Initiate CPAP at 10 cm H2O and administer IV bumetanide [CORRECT]
C. Administer IV dobutamine 5 mcg/kg/min as first-line therapy
D. Perform emergent intubation and mechanical ventilation immediately
Correct Answer: B
Rationale: This patient has acute decompensated heart failure with refractory volume overload despite high-dose oral
furosemide, presenting with acute pulmonary edema. CPAP/BiPAP is indicated for acute cardiogenic pulmonary edema to
reduce preload and afterload, improve oxygenation, and decrease work of breathing. IV bumetanide (a more potent loop
diuretic) provides aggressive diuresis. Dobutamine is not first-line for volume-overloaded HF; it is reserved for low-output states.
Intubation may be needed if CPAP fails but is not the first step.
Q5: A 48-year-old male presents with sudden onset palpitations and lightheadedness that began 20
minutes ago. His blood pressure is 88/60 mmHg and heart rate is 180 bpm. The ECG reveals a regular,
narrow-complex tachycardia without discernible P waves. The patient is diaphoretic and reporting
near-syncope. Which of the following is the most appropriate initial intervention?
A. Administer adenosine 6 mg rapid IV push followed by 12 mg if needed
B. Administer amiodarone 150 mg IV over 10 minutes
C. Perform immediate synchronized cardioversion at 50 joules [CORRECT]
D. Administer diltiazem 0.25 mg/kg IV over 2 minutes
Correct Answer: C
Rationale: This patient has unstable supraventricular tachycardia (SVT) with hypotension and near-syncope, indicating
hemodynamic instability. Per ACLS guidelines, unstable tachycardia with signs of poor perfusion requires immediate
synchronized cardioversion. While adenosine is first-line for stable SVT, it is contraindicated in hemodynamically unstable
patients because the transient asystole it causes may worsen instability. Amiodarone and diltiazem are not appropriate first-line
therapy for unstable SVT.
Q6: A 65-year-old male with heart failure and atrial fibrillation reports fatigue and decreased exercise
tolerance. His ECG reveals AF with a ventricular rate of 110 bpm. Echocardiography shows LVEF of
35%. Which of the following is the most appropriate rate control strategy?
A. Diltiazem 120 mg PO daily for rate control
B. Metoprolol succinate 50 mg PO daily titrated to resting heart rate less than 80 bpm [CORRECT]
C. Amiodarone 200 mg PO daily for rhythm control
D. Digoxin 0.25 mg PO daily as monotherapy for rate control
Correct Answer: B
Page 2
, NR 570 Midterm Exam: Common Diagnosis & Management in Acute Care | Questions and Verified Answers
Rationale: In patients with HFrEF and atrial fibrillation, beta-blockers such as metoprolol succinate are the preferred first-line
agents for rate control because they improve mortality in HFrEF. The target resting heart rate for AF rate control is less than 80
bpm per current guidelines. Diltiazem is contraindicated in HFrEF due to its negative inotropic effects. While amiodarone can be
used for rhythm control, rate control with beta-blockers is the preferred initial strategy. Digoxin alone is insufficient for
adequate rate control during exertion.
Q7: A 72-year-old female is admitted to the ICU with ventricular fibrillation. She is pulseless and
unresponsive. After initiating high-quality CPR, which of the following is the definitive treatment for this
rhythm per current ACLS guidelines?
A. Synchronized cardioversion at 200 joules
B. Defibrillation at 200 joules biphasic followed by immediate resumption of CPR [CORRECT]
C. IV amiodarone 300 mg bolus followed by defibrillation
D. IV epinephrine 1 mg every 3 minutes until rhythm converts
Correct Answer: B
Rationale: Ventricular fibrillation (VF) is a shockable rhythm, and the definitive treatment is unsynchronized defibrillation, not
synchronized cardioversion. The AHA ACLS guidelines recommend immediate defibrillation at 200 joules biphasic, followed by
immediate resumption of chest compressions for 2 minutes before reassessing. While epinephrine and amiodarone are
administered in subsequent cycles, defibrillation itself is the definitive treatment. The key distinction is that defibrillation
(unsynchronized) is used for pulseless rhythms, while cardioversion (synchronized) is for perfusing rhythms.
Q8: A 58-year-old male presents with BP 210/130 mmHg, severe headache, blurred vision, and confusion.
Fundoscopic examination reveals papilledema. Serum creatinine is 2.5 mg/dL (baseline 1.0 mg/dL).
Which of the following best describes this clinical presentation?
A. Hypertensive urgency requiring outpatient BP management within 24 hours
B. Hypertensive emergency requiring immediate IV antihypertensive therapy with target MAP reduction
of 20-25% in the first hour [CORRECT]
C. Malignant hypertension treated with oral clonidine 0.1 mg
D. Preeclampsia requiring magnesium sulfate and delivery planning
Correct Answer: B
Rationale: This patient presents with a hypertensive emergency, defined as severe hypertension (SBP greater than 180 or DBP
greater than 120 mmHg) with evidence of acute target organ damage, including encephalopathy (confusion), visual changes,
papilledema, and acute kidney injury. The treatment requires immediate IV antihypertensive therapy with a target MAP
reduction of no more than 20-25% in the first hour to avoid precipitating cerebral or myocardial ischemia. Hypertensive urgency
involves severe hypertension without acute target organ damage.
Q9: A 45-year-old male presents with sudden onset severe tearing chest pain radiating to the back
between the shoulder blades. BP is 170/100 mmHg in the right arm and 140/80 mmHg in the left arm. CT
angiogram reveals a dissecting flap in the ascending aorta. Which is the most appropriate management?
A. Administer IV labetalol and nitroprusside to reduce SBP less than 120 mmHg and HR less than 60
bpm, then consult cardiovascular surgery [CORRECT]
B. Administer IV nicardipine to reduce SBP less than 140 mmHg and observe for 24 hours
C. Administer thrombolytic therapy and heparin for suspected acute MI
D. Administer oral beta-blocker and schedule outpatient follow-up with cardiology in 1 week
Correct Answer: A
Rationale: This patient has an acute Type A aortic dissection (ascending aorta), which is a surgical emergency. Immediate
management includes IV beta-blocker (labetalol or esmolol) to reduce shear force by decreasing HR below 60 bpm and reducing
SBP, followed by vasodilators (nitroprusside) for further BP control. Type A dissections require emergent surgical intervention,
Page 3
, NR 570 Midterm Exam: Common Diagnosis & Management in Acute Care | Questions and Verified Answers
as medical management alone carries mortality over 50% within 48 hours. Thrombolytics are absolutely contraindicated.
Q10: A 60-year-old male presents with acute onset severe sharp left leg pain. The left lower extremity is
pale, cool, and pulseless. He reports a history of atrial fibrillation but has not been taking his prescribed
anticoagulation. Which is the most appropriate immediate diagnostic study?
A. CT angiography of the affected extremity [CORRECT]
B. Ankle-brachial index (ABI) measurement
C. Doppler ultrasound of the lower extremity
D. Contrast venography of the lower extremity
Correct Answer: A
Rationale: This patient has acute limb ischemia (ALI), evidenced by the classic signs of pain, pallor, pulselessness,
poikilothermia, paresthesias, and paralysis. Given his history of AF and non-adherence to anticoagulation, the likely etiology is
arterial embolism. CT angiography (CTA) is the most appropriate immediate diagnostic study as it rapidly identifies the location
and extent of arterial occlusion and helps guide intervention. While Doppler ultrasound can detect occlusion, CTA provides
faster and more comprehensive detail for surgical planning.
Q11: A 50-year-old female presents with crushing substernal chest pain that began 30 minutes prior. Her
ECG shows ST-segment elevation in leads V1 through V6. She has no contraindications to fibrinolytic
therapy. The nearest PCI-capable hospital is 120 minutes away. Which is the most appropriate
reperfusion strategy?
A. Transfer to the PCI-capable hospital for primary PCI regardless of transport time
B. Administer fibrinolytic therapy (tenecteplase) within 30 minutes of arrival [CORRECT]
C. Administer heparin and wait for cardiac catheterization lab availability
D. Administer aspirin only and observe for ECG changes over the next 6 hours
Correct Answer: B
Rationale: This patient has an anterior STEMI and the nearest PCI-capable hospital is 120 minutes away, exceeding the
recommended first medical contact-to-device time of 120 minutes. When primary PCI cannot be performed within the
guideline-recommended time window, fibrinolytic therapy should be administered within 30 minutes of hospital arrival
(door-to-needle time of 30 minutes or less). Tenecteplase is a preferred fibrinolytic agent due to its single-bolus administration.
Q12: A 68-year-old male with acute decompensated heart failure has persistent hypotension (MAP 58
mmHg) and decreased urine output (0.3 mL/kg/hr) despite adequate diuretic therapy. Cardiac index is 1.8
L/min/m2 and PCWP is elevated at 28 mmHg. Which is the most appropriate pharmacologic
intervention?
A. Increase furosemide drip to 20 mg/hr
B. Initiate dobutamine 2.5 mcg/kg/min IV infusion [CORRECT]
C. Administer IV enalaprilat 1.25 mg
D. Administer carvedilol 3.125 mg PO twice daily
Correct Answer: B
Rationale: This patient presents with cardiogenic shock, characterized by hypotension, oliguria, low cardiac index (normal
2.5-4.0 L/min/m2), and elevated PCWP. Dobutamine, a beta-1 agonist inotropic agent, is the most appropriate choice for
cardiogenic shock with low cardiac output. Increasing diuretics would further reduce preload and worsen hypotension. ACE
inhibitors and beta-blockers are contraindicated in acute cardiogenic shock due to their vasodilatory and negative inotropic
effects.
Page 4
