AGACNP Spring 2025 Exam 2.Final Test 2024\2025.
A 23-year-old man is brought to the emergency department after being found
obtunded on the street. The history suggests that he may have ingested 180 mg of his
friend's methadone during a suicide attempt. On arrival he has a Glasgow Coma Scale
(GCS) score of 6, with hypoactive bowel sounds and pinpoint pupils. His initial vital
signs are temperature 36C, heart rate 56/min, blood pressure 103/70 mm Hg,
respiratory rate 6, and oxygen saturation 84% on room air. Blood glucose is 4.6
mmol/L. Initially, his ventilation was supported through bag-valve-mask (BVM)
apparatus but after three doses of 0.4 mg IV naloxone there is improvement in his
respiratory effort. He is transferred to the ICU. What is the most appropriate
management?
A. Intubation for airway protection
B. Naloxone boluses as needed plus activated charcoal
C. Naloxone infusion at 0.4 mg/h
D. Naloxone infusion at 0.8 mg/h
The correct answer is D.
Rationale: This patient's presentation is consistent with opioid toxicity.
Immediate resuscitation and administration of antidotal therapy are the most important
initial steps in management. Given the hypoxia and bradypnea, supplemental oxygen without
assisted ventilation is of minimal benefit. As a disease of hypoventilation, opioid toxicity
requires ventilation. This is achieved through BVM and administration of opioid antagonists.
Methadone is a long- acting opioid, with expected clinical toxicity to last beyond 24 hours.
The proper dosing of a naloxone infusion per hour is 2/3 the dose required to adequately
reverse the patient. This patient responded to 1.2 mg IV naloxone, so the infusion dose should
start at 0.8 mg/h (choice D is correct). If naloxone was not available, intubation would be an
option, but there is no need to do so at this time (choice A is incorrect). Methadone is a
liquid product with rapid absorption, so activated charcoal would be of no benefit and
,AGACNP Spring 2025 Exam 2.Final Test 2024\2025.
potentially harmful as the fluctuating level of consciousness may result in aspiration, and
lower doses of naloxone would be insufficient (choices B and C are incorrect).
A 48-year-old woman is brought in after being found unconscious in a house fire. She
was intubated in the emergency department and transferred to the ICU for further
management. She received 2L IV Ringer lactate and is now on a norepinephrine
infusion. Her Glasgow Coma Scale (GCS) score has remained at 3 since arrival. Her
vitals are temperature 37.2 C, HR 120/min, BP 70/50 mm Hg, respiratory rate 18 set
by ventilator, and oxygen saturation 95% on 100% FiO2. Blood glucose is 8.5 mmol/L.
Initial laboratory testing reveals pH 6.98,
pCO2 34 mm Hg, bicarbonate 6 mmol/L, and lactate 17 mmol/L. What is the most
appropriate next step in management?
A. Dantrolene
B. Hydroxocobalamin
C. Hyperbaric oxygenation
D. Methylene Blue
The correct answer is B.
Rationale: This clinical presentation is highly suggestive of cyanide toxicity.
Patients with hyperlactatemia after a fire should be assumed to have inhaled cyanide.
Obtundation, hypotension, and tachycardia all support the diagnosis. Treatment of cyanide
toxicity is prompt administration of hydroxocobalamin (choice B is correct). Dantrolene
would be used in patients with significant hyperthermia and muscle rigidity secondary to
malignant hyperthermia (choice A is incorrect). Carbon monoxide toxicity is also a concern
after a fire, and a carboxyhemoglobin level should certainly be obtained. However, given the
elevated lactate and hemodynamic instability, management of suspected cyanide
takes precedence over transfer to a hyperbaric chamber for carbon monoxide toxicity
(choice C is incorrect). Methylene blue is therapy for methemoglobinemia (choice D is
incorrect).
,AGACNP Spring 2025 Exam 2.Final Test 2024\2025.
A 38-year-old man is admitted to the ICU after being intubated for severe agitation.
He was brought to the emergency department after being detained at an international
airport for aggressive behavior. He required prehospital sedation with intramuscular
midazolam to facilitate transport. On arrival, his vital signs were temperature 40.2 C,
HR 165/min, BP 180/100 mm Hg, respiratory rate 24, and oxygen saturation 96% on
room air. Blood glucose 10.5 mmol/L
(189 mg/dL). He was intubated using rocuronium and was started on a propofol
infusion at 4 mg/kg/hr. Vitals signs have not significantly changed. What is the most
appropriate management?
A. Active cooling
B. Active cooling, increased sedation
C. Active cooling, increased sedation, and β-blockade
D. Active cooling, increased sedation, and paralysis
The correct answer is D.
Rationale: This patient's presentation is consistent with significant toxicity
from sympathomimetic agents (such as cocaine or amphetamines). His most immediate life-
threatening problem is his hyperthermia, and goal is to cool the patient, which will be
facilitated by a neuromuscular blocker (choice D is correct). Cooling with sedation alone are
insufficient (choices A and B are incorrect) and β-Blockade is not indicated (choice C is
incorrect). Sympathomimetic toxicity is a centrally driven disease (symptoms are due to an
increase in excitation in the central nervous system). β-Blockade does not address this, as
it only targets the peripheral symptoms of that centrally mediated process. Furthermore, β-
blockers pharmacologically result in unopposed alpha stimulation, though the clinical
significance of this has been recently debated.
A 24-year-old woman presents 45 minutes after an intentional ingestion of
approximately 25 g of acetaminophen (APAP). She denies any other ingestions. Her
vital signs are heart rate 80 beats/min, blood pressure 128/62 mm Hg, respiratory
, AGACNP Spring 2025 Exam 2.Final Test 2024\2025.
rate of 18/min, temperature of 37 °C, and oxygen saturation 99% on room air. Her
physical examination is normal except for tearfulness. What is the most appropriate
next step in management?
A. Give activated charcoal
B. Give intravenous N-acetylcysteine (NAC) therapy
C Measure serum APAP level
D. Obtain ECG
The correct answer is A.
Rationale: This is a significant ingestion, and activated charcoal is indicated
as it has been less than 2 hours since ingestion (choice A is correct). There is no
indication or benefit to immediate treatment with oral or intravenous NAC at less than 1 hour
post ingestion (choice B is incorrect). While an APAP blood concentration is needed,
obtaining one within an hour is neither necessary nor helpful (choice C is incorrect). An ECG
is indicated after all intentional ingestions, but at the time of presentation oral activated
charcoal is of greater benefit than an ECG (choice D is not the best answer). Not listed here
as a choice, but in the absence of severe liver injury or other prognostic factors that predict
need for liver transplantation, there is also no indication to transfer to a transplantation
center.
A 35-year-old man presents 5 hours after an overdose. He admits to ingesting only
atenolol and diphenhydramine (doses unknown). His vital signs are heart rate 88
beats/min, blood pressure 134/72 mm Hg, respiratory rate of 20/min, temperature
of 36.8 °C, and oxygen saturation 99% on room air. Other than a depressed
sensorium, his physical examination is unremarkable. What is the most appropriate
next step in management?
A. Check serum acetaminophen (APAP) level
B. Give 2 mg physostigmine
A 23-year-old man is brought to the emergency department after being found
obtunded on the street. The history suggests that he may have ingested 180 mg of his
friend's methadone during a suicide attempt. On arrival he has a Glasgow Coma Scale
(GCS) score of 6, with hypoactive bowel sounds and pinpoint pupils. His initial vital
signs are temperature 36C, heart rate 56/min, blood pressure 103/70 mm Hg,
respiratory rate 6, and oxygen saturation 84% on room air. Blood glucose is 4.6
mmol/L. Initially, his ventilation was supported through bag-valve-mask (BVM)
apparatus but after three doses of 0.4 mg IV naloxone there is improvement in his
respiratory effort. He is transferred to the ICU. What is the most appropriate
management?
A. Intubation for airway protection
B. Naloxone boluses as needed plus activated charcoal
C. Naloxone infusion at 0.4 mg/h
D. Naloxone infusion at 0.8 mg/h
The correct answer is D.
Rationale: This patient's presentation is consistent with opioid toxicity.
Immediate resuscitation and administration of antidotal therapy are the most important
initial steps in management. Given the hypoxia and bradypnea, supplemental oxygen without
assisted ventilation is of minimal benefit. As a disease of hypoventilation, opioid toxicity
requires ventilation. This is achieved through BVM and administration of opioid antagonists.
Methadone is a long- acting opioid, with expected clinical toxicity to last beyond 24 hours.
The proper dosing of a naloxone infusion per hour is 2/3 the dose required to adequately
reverse the patient. This patient responded to 1.2 mg IV naloxone, so the infusion dose should
start at 0.8 mg/h (choice D is correct). If naloxone was not available, intubation would be an
option, but there is no need to do so at this time (choice A is incorrect). Methadone is a
liquid product with rapid absorption, so activated charcoal would be of no benefit and
,AGACNP Spring 2025 Exam 2.Final Test 2024\2025.
potentially harmful as the fluctuating level of consciousness may result in aspiration, and
lower doses of naloxone would be insufficient (choices B and C are incorrect).
A 48-year-old woman is brought in after being found unconscious in a house fire. She
was intubated in the emergency department and transferred to the ICU for further
management. She received 2L IV Ringer lactate and is now on a norepinephrine
infusion. Her Glasgow Coma Scale (GCS) score has remained at 3 since arrival. Her
vitals are temperature 37.2 C, HR 120/min, BP 70/50 mm Hg, respiratory rate 18 set
by ventilator, and oxygen saturation 95% on 100% FiO2. Blood glucose is 8.5 mmol/L.
Initial laboratory testing reveals pH 6.98,
pCO2 34 mm Hg, bicarbonate 6 mmol/L, and lactate 17 mmol/L. What is the most
appropriate next step in management?
A. Dantrolene
B. Hydroxocobalamin
C. Hyperbaric oxygenation
D. Methylene Blue
The correct answer is B.
Rationale: This clinical presentation is highly suggestive of cyanide toxicity.
Patients with hyperlactatemia after a fire should be assumed to have inhaled cyanide.
Obtundation, hypotension, and tachycardia all support the diagnosis. Treatment of cyanide
toxicity is prompt administration of hydroxocobalamin (choice B is correct). Dantrolene
would be used in patients with significant hyperthermia and muscle rigidity secondary to
malignant hyperthermia (choice A is incorrect). Carbon monoxide toxicity is also a concern
after a fire, and a carboxyhemoglobin level should certainly be obtained. However, given the
elevated lactate and hemodynamic instability, management of suspected cyanide
takes precedence over transfer to a hyperbaric chamber for carbon monoxide toxicity
(choice C is incorrect). Methylene blue is therapy for methemoglobinemia (choice D is
incorrect).
,AGACNP Spring 2025 Exam 2.Final Test 2024\2025.
A 38-year-old man is admitted to the ICU after being intubated for severe agitation.
He was brought to the emergency department after being detained at an international
airport for aggressive behavior. He required prehospital sedation with intramuscular
midazolam to facilitate transport. On arrival, his vital signs were temperature 40.2 C,
HR 165/min, BP 180/100 mm Hg, respiratory rate 24, and oxygen saturation 96% on
room air. Blood glucose 10.5 mmol/L
(189 mg/dL). He was intubated using rocuronium and was started on a propofol
infusion at 4 mg/kg/hr. Vitals signs have not significantly changed. What is the most
appropriate management?
A. Active cooling
B. Active cooling, increased sedation
C. Active cooling, increased sedation, and β-blockade
D. Active cooling, increased sedation, and paralysis
The correct answer is D.
Rationale: This patient's presentation is consistent with significant toxicity
from sympathomimetic agents (such as cocaine or amphetamines). His most immediate life-
threatening problem is his hyperthermia, and goal is to cool the patient, which will be
facilitated by a neuromuscular blocker (choice D is correct). Cooling with sedation alone are
insufficient (choices A and B are incorrect) and β-Blockade is not indicated (choice C is
incorrect). Sympathomimetic toxicity is a centrally driven disease (symptoms are due to an
increase in excitation in the central nervous system). β-Blockade does not address this, as
it only targets the peripheral symptoms of that centrally mediated process. Furthermore, β-
blockers pharmacologically result in unopposed alpha stimulation, though the clinical
significance of this has been recently debated.
A 24-year-old woman presents 45 minutes after an intentional ingestion of
approximately 25 g of acetaminophen (APAP). She denies any other ingestions. Her
vital signs are heart rate 80 beats/min, blood pressure 128/62 mm Hg, respiratory
, AGACNP Spring 2025 Exam 2.Final Test 2024\2025.
rate of 18/min, temperature of 37 °C, and oxygen saturation 99% on room air. Her
physical examination is normal except for tearfulness. What is the most appropriate
next step in management?
A. Give activated charcoal
B. Give intravenous N-acetylcysteine (NAC) therapy
C Measure serum APAP level
D. Obtain ECG
The correct answer is A.
Rationale: This is a significant ingestion, and activated charcoal is indicated
as it has been less than 2 hours since ingestion (choice A is correct). There is no
indication or benefit to immediate treatment with oral or intravenous NAC at less than 1 hour
post ingestion (choice B is incorrect). While an APAP blood concentration is needed,
obtaining one within an hour is neither necessary nor helpful (choice C is incorrect). An ECG
is indicated after all intentional ingestions, but at the time of presentation oral activated
charcoal is of greater benefit than an ECG (choice D is not the best answer). Not listed here
as a choice, but in the absence of severe liver injury or other prognostic factors that predict
need for liver transplantation, there is also no indication to transfer to a transplantation
center.
A 35-year-old man presents 5 hours after an overdose. He admits to ingesting only
atenolol and diphenhydramine (doses unknown). His vital signs are heart rate 88
beats/min, blood pressure 134/72 mm Hg, respiratory rate of 20/min, temperature
of 36.8 °C, and oxygen saturation 99% on room air. Other than a depressed
sensorium, his physical examination is unremarkable. What is the most appropriate
next step in management?
A. Check serum acetaminophen (APAP) level
B. Give 2 mg physostigmine
