NR 571 Complex Diagnosis & Management in Acute Care
Practicum | NR571 Chamberlain University AGACNP Exam
Prep, Final Exam Study Guide, Acute Care Clinical Reasoning,
Differential Diagnosis, Complex Patient Management,
Practice Questions & Answers, Detailed Rationales
Question 1: A 68-year-old male with a history of hypertension and type 2
diabetes presents with acute onset of severe, tearing chest pain radiating to his
back. His blood pressure is 180/100 mmHg in the right arm and 140/80 mmHg
in the left arm. Which of the following is the most appropriate initial imaging
modality to confirm the suspected diagnosis?
A. Computed Tomography Angiography (CTA) of the chest and abdomen
B. Transesophageal Echocardiography (TEE)
C. Magnetic Resonance Angiography (MRA)
D. Chest X-ray
CORRECT ANSWER: A. Computed Tomography Angiography (CTA) of the
chest and abdomen
Rationale: The patient's presentation of acute aortic dissection is highly suspected due
to the classic tearing pain and blood pressure differential. CTA of the chest and
abdomen is the initial imaging modality of choice in most emergency settings due to its
high sensitivity and specificity, rapid acquisition, and ability to assess the entire aorta
and branch involvement. TEE is highly sensitive but is invasive and operator-dependent.
MRA takes too long and is not readily available in acute emergencies. Chest X-ray is
non-specific and often normal.
Question 2: A 45-year-old female with a history of systemic lupus
erythematosus presents with acute shortness of breath and pleuritic chest
pain. Her ECG shows sinus tachycardia and diffuse ST elevations. A bedside
echocardiogram reveals a large pericardial effusion with signs of right
ventricular diastolic collapse. What is the definitive management for this
patient's condition?
A. High-dose corticosteroids
B. Pericardiocentesis
C. Colchicine
D. NSAIDs
CORRECT ANSWER: B. Pericardiocentesis
Rationale: The patient is exhibiting signs of cardiac tamponade (large effusion, right
ventricular diastolic collapse, tachycardia, and shortness of breath). Pericardiocentesis is
the definitive, life-saving procedure to remove the fluid and relieve the pressure on the
heart. Medical management with NSAIDs, colchicine, or corticosteroids may be used for
pericarditis, but they are not definitive for tamponade physiology and will not provide
immediate hemodynamic relief.
,Question 3: A 72-year-old male with a history of COPD and coronary artery
disease is intubated for respiratory failure. He becomes acutely hypotensive
and hypoxic. On examination, breath sounds are absent on the left side, and
the trachea is deviated to the right. What is the most immediate next step?
A. Needle decompression of the left chest
B. Stat chest X-ray
C. Increase PEEP settings on the ventilator
D. Administer a fluid bolus
CORRECT ANSWER: A. Needle decompression of the left chest
Rationale: The patient is presenting with a tension pneumothorax, evidenced by
absent breath sounds on the left, tracheal deviation to the right, hypotension, and
hypoxia. This is a life-threatening emergency requiring immediate needle
decompression (or finger thoracostomy) to convert the tension pneumothorax to a
simple pneumothorax. Waiting for a chest X-ray would delay critical care. Increasing
PEEP would worsen the condition, and a fluid bolus is not the primary treatment for the
underlying mechanical problem.
Question 4: A 60-year-old male with a history of alcohol use disorder presents
with hematemesis and melena. He is hypotensive and tachycardic. After
securing the airway and initiating two large-bore IVs, which medication is
most appropriate to initiate while awaiting endoscopy?
A. Octreotide
B. Pantoprazole
C. Vasopressin
D. N-acetylcysteine
CORRECT ANSWER: A. Octreotide
Rationale: The patient's presentation is consistent with variceal bleeding due to portal
hypertension from alcoholic liver disease. Octreotide is a somatostatin analog that
reduces splanchnic blood flow and portal pressure, making it the first-line
pharmacologic therapy for acute variceal hemorrhage. Pantoprazole is used for peptic
ulcer disease, not varices. Vasopressin can be used but has more systemic side effects
and is generally second-line. N-acetylcysteine is for acetaminophen toxicity.
Question 5: A 55-year-old female with a history of breast cancer on tamoxifen
presents with acute onset of right leg swelling, pain, and erythema. She is
afebrile and hemodynamically stable. A Duplex ultrasound confirms a
proximal deep vein thrombosis (DVT). Which of the following is the most
appropriate anticoagulation strategy?
,A. Unfractionated heparin (UFH) IV bolus followed by continuous infusion
B. Enoxaparin 1 mg/kg subcutaneously twice daily
C. Warfarin 5 mg orally with a heparin bridge
D. Direct oral anticoagulant (DOAC) monotherapy
CORRECT ANSWER: D. Direct oral anticoagulant (DOAC) monotherapy
Rationale: For a patient with a proximal DVT who is hemodynamically stable and has
no contraindications, DOACs (e.g., rivaroxaban, apixaban) are preferred over warfarin
due to their fixed dosing, lack of need for routine monitoring, and faster onset of action.
UFH is typically reserved for patients with severe renal impairment, hemodynamic
instability, or those at high risk for bleeding. Warfarin requires bridging, which is no
longer preferred in stable patients when DOACs are available.
Question 6: A 38-year-old male with a history of asthma presents with
increasing dyspnea, cough, and wheezing that is not responding to his
albuterol inhaler. On exam, he is tachypneic, using accessory muscles, and has
a peak expiratory flow rate of 35% of predicted. Which of the following
findings would indicate the need for immediate non-invasive positive pressure
ventilation (NIPPV) or intubation?
A. Pulsus paradoxus
B. Silent chest on auscultation
C. Heart rate of 110 bpm
D. Respiratory rate of 28/min
CORRECT ANSWER: B. Silent chest on auscultation
Rationale: A "silent chest" in an asthmatic patient indicates severe airflow obstruction
to the point where air movement is minimal, representing an impending respiratory
failure. This is a critical sign that necessitates immediate intervention such as NIPPV or
intubation. Pulsus paradoxus, tachycardia, and tachypnea are concerning signs but are
not as indicative of impending respiratory arrest as the absence of breath sounds, which
suggests a near-complete airway obstruction.
Question 7: A 72-year-old male with a past medical history of heart failure
with reduced ejection fraction presents with severe shortness of breath and
hypoxia. He is tachypneic, with jugular venous distension and bilateral
crackles up to the mid-lungs. Which of the following is the most appropriate
initial pharmacological therapy to reduce preload?
A. Intravenous furosemide
B. Intravenous nitroglycerin
C. Dobutamine
D. Morphine
, CORRECT ANSWER: A. Intravenous furosemide
Rationale: The patient is experiencing acute decompensated heart failure with
pulmonary edema. The immediate goal is to reduce fluid overload (preload).
Intravenous loop diuretics like furosemide are the mainstay of initial therapy to promote
rapid diuresis and venodilation. Nitroglycerin also reduces preload but is used as an
adjunct or in specific scenarios like hypertensive crisis. Dobutamine is an inotrope for
cardiogenic shock. Morphine is no longer recommended as first-line therapy due to
limited evidence and potential side effects.
Question 8: A 65-year-old male with a history of end-stage renal disease on
hemodialysis presents to the emergency department with weakness, nausea,
and a heart rate of 30 bpm. His electrocardiogram shows a sine wave pattern.
What is the immediate treatment of choice?
A. Atropine 1 mg IV
B. Transcutaneous pacing
C. Calcium gluconate IV
D. Sodium bicarbonate IV
CORRECT ANSWER: C. Calcium gluconate IV
Rationale: The patient has a sine wave ECG pattern, which is diagnostic of severe
hyperkalemia. The immediate treatment is to stabilize the cardiac membrane by
administering intravenous calcium (either gluconate or chloride) to antagonize the
effects of potassium on the myocardium. Atropine is for bradycardia not caused by
hyperkalemia. Pacing is a temporizing measure but does not treat the underlying cause.
Sodium bicarbonate shifts potassium intracellularly but takes longer and is not the first
line in an emergency.
Question 9: A 48-year-old male with a history of hypertension is admitted with
acute pancreatitis. He develops a sudden onset of dyspnea and hypoxia. A
chest X-ray reveals bilateral infiltrates. His urine output has decreased to 20
mL/hr. Which of the following is the most likely diagnosis?
A. Acute Respiratory Distress Syndrome (ARDS)
B. Pulmonary embolism
C. Atelectasis
D. Aspiration pneumonia
CORRECT ANSWER: A. Acute Respiratory Distress Syndrome (ARDS)
Rationale: The patient has an acute onset of respiratory failure (dyspnea, hypoxia)
within one week of a known clinical insult (acute pancreatitis), with bilateral infiltrates
on chest X-ray, consistent with ARDS. The decreased urine output suggests multi-organ
dysfunction. Pulmonary embolism is possible but less likely without other risk factors.
Practicum | NR571 Chamberlain University AGACNP Exam
Prep, Final Exam Study Guide, Acute Care Clinical Reasoning,
Differential Diagnosis, Complex Patient Management,
Practice Questions & Answers, Detailed Rationales
Question 1: A 68-year-old male with a history of hypertension and type 2
diabetes presents with acute onset of severe, tearing chest pain radiating to his
back. His blood pressure is 180/100 mmHg in the right arm and 140/80 mmHg
in the left arm. Which of the following is the most appropriate initial imaging
modality to confirm the suspected diagnosis?
A. Computed Tomography Angiography (CTA) of the chest and abdomen
B. Transesophageal Echocardiography (TEE)
C. Magnetic Resonance Angiography (MRA)
D. Chest X-ray
CORRECT ANSWER: A. Computed Tomography Angiography (CTA) of the
chest and abdomen
Rationale: The patient's presentation of acute aortic dissection is highly suspected due
to the classic tearing pain and blood pressure differential. CTA of the chest and
abdomen is the initial imaging modality of choice in most emergency settings due to its
high sensitivity and specificity, rapid acquisition, and ability to assess the entire aorta
and branch involvement. TEE is highly sensitive but is invasive and operator-dependent.
MRA takes too long and is not readily available in acute emergencies. Chest X-ray is
non-specific and often normal.
Question 2: A 45-year-old female with a history of systemic lupus
erythematosus presents with acute shortness of breath and pleuritic chest
pain. Her ECG shows sinus tachycardia and diffuse ST elevations. A bedside
echocardiogram reveals a large pericardial effusion with signs of right
ventricular diastolic collapse. What is the definitive management for this
patient's condition?
A. High-dose corticosteroids
B. Pericardiocentesis
C. Colchicine
D. NSAIDs
CORRECT ANSWER: B. Pericardiocentesis
Rationale: The patient is exhibiting signs of cardiac tamponade (large effusion, right
ventricular diastolic collapse, tachycardia, and shortness of breath). Pericardiocentesis is
the definitive, life-saving procedure to remove the fluid and relieve the pressure on the
heart. Medical management with NSAIDs, colchicine, or corticosteroids may be used for
pericarditis, but they are not definitive for tamponade physiology and will not provide
immediate hemodynamic relief.
,Question 3: A 72-year-old male with a history of COPD and coronary artery
disease is intubated for respiratory failure. He becomes acutely hypotensive
and hypoxic. On examination, breath sounds are absent on the left side, and
the trachea is deviated to the right. What is the most immediate next step?
A. Needle decompression of the left chest
B. Stat chest X-ray
C. Increase PEEP settings on the ventilator
D. Administer a fluid bolus
CORRECT ANSWER: A. Needle decompression of the left chest
Rationale: The patient is presenting with a tension pneumothorax, evidenced by
absent breath sounds on the left, tracheal deviation to the right, hypotension, and
hypoxia. This is a life-threatening emergency requiring immediate needle
decompression (or finger thoracostomy) to convert the tension pneumothorax to a
simple pneumothorax. Waiting for a chest X-ray would delay critical care. Increasing
PEEP would worsen the condition, and a fluid bolus is not the primary treatment for the
underlying mechanical problem.
Question 4: A 60-year-old male with a history of alcohol use disorder presents
with hematemesis and melena. He is hypotensive and tachycardic. After
securing the airway and initiating two large-bore IVs, which medication is
most appropriate to initiate while awaiting endoscopy?
A. Octreotide
B. Pantoprazole
C. Vasopressin
D. N-acetylcysteine
CORRECT ANSWER: A. Octreotide
Rationale: The patient's presentation is consistent with variceal bleeding due to portal
hypertension from alcoholic liver disease. Octreotide is a somatostatin analog that
reduces splanchnic blood flow and portal pressure, making it the first-line
pharmacologic therapy for acute variceal hemorrhage. Pantoprazole is used for peptic
ulcer disease, not varices. Vasopressin can be used but has more systemic side effects
and is generally second-line. N-acetylcysteine is for acetaminophen toxicity.
Question 5: A 55-year-old female with a history of breast cancer on tamoxifen
presents with acute onset of right leg swelling, pain, and erythema. She is
afebrile and hemodynamically stable. A Duplex ultrasound confirms a
proximal deep vein thrombosis (DVT). Which of the following is the most
appropriate anticoagulation strategy?
,A. Unfractionated heparin (UFH) IV bolus followed by continuous infusion
B. Enoxaparin 1 mg/kg subcutaneously twice daily
C. Warfarin 5 mg orally with a heparin bridge
D. Direct oral anticoagulant (DOAC) monotherapy
CORRECT ANSWER: D. Direct oral anticoagulant (DOAC) monotherapy
Rationale: For a patient with a proximal DVT who is hemodynamically stable and has
no contraindications, DOACs (e.g., rivaroxaban, apixaban) are preferred over warfarin
due to their fixed dosing, lack of need for routine monitoring, and faster onset of action.
UFH is typically reserved for patients with severe renal impairment, hemodynamic
instability, or those at high risk for bleeding. Warfarin requires bridging, which is no
longer preferred in stable patients when DOACs are available.
Question 6: A 38-year-old male with a history of asthma presents with
increasing dyspnea, cough, and wheezing that is not responding to his
albuterol inhaler. On exam, he is tachypneic, using accessory muscles, and has
a peak expiratory flow rate of 35% of predicted. Which of the following
findings would indicate the need for immediate non-invasive positive pressure
ventilation (NIPPV) or intubation?
A. Pulsus paradoxus
B. Silent chest on auscultation
C. Heart rate of 110 bpm
D. Respiratory rate of 28/min
CORRECT ANSWER: B. Silent chest on auscultation
Rationale: A "silent chest" in an asthmatic patient indicates severe airflow obstruction
to the point where air movement is minimal, representing an impending respiratory
failure. This is a critical sign that necessitates immediate intervention such as NIPPV or
intubation. Pulsus paradoxus, tachycardia, and tachypnea are concerning signs but are
not as indicative of impending respiratory arrest as the absence of breath sounds, which
suggests a near-complete airway obstruction.
Question 7: A 72-year-old male with a past medical history of heart failure
with reduced ejection fraction presents with severe shortness of breath and
hypoxia. He is tachypneic, with jugular venous distension and bilateral
crackles up to the mid-lungs. Which of the following is the most appropriate
initial pharmacological therapy to reduce preload?
A. Intravenous furosemide
B. Intravenous nitroglycerin
C. Dobutamine
D. Morphine
, CORRECT ANSWER: A. Intravenous furosemide
Rationale: The patient is experiencing acute decompensated heart failure with
pulmonary edema. The immediate goal is to reduce fluid overload (preload).
Intravenous loop diuretics like furosemide are the mainstay of initial therapy to promote
rapid diuresis and venodilation. Nitroglycerin also reduces preload but is used as an
adjunct or in specific scenarios like hypertensive crisis. Dobutamine is an inotrope for
cardiogenic shock. Morphine is no longer recommended as first-line therapy due to
limited evidence and potential side effects.
Question 8: A 65-year-old male with a history of end-stage renal disease on
hemodialysis presents to the emergency department with weakness, nausea,
and a heart rate of 30 bpm. His electrocardiogram shows a sine wave pattern.
What is the immediate treatment of choice?
A. Atropine 1 mg IV
B. Transcutaneous pacing
C. Calcium gluconate IV
D. Sodium bicarbonate IV
CORRECT ANSWER: C. Calcium gluconate IV
Rationale: The patient has a sine wave ECG pattern, which is diagnostic of severe
hyperkalemia. The immediate treatment is to stabilize the cardiac membrane by
administering intravenous calcium (either gluconate or chloride) to antagonize the
effects of potassium on the myocardium. Atropine is for bradycardia not caused by
hyperkalemia. Pacing is a temporizing measure but does not treat the underlying cause.
Sodium bicarbonate shifts potassium intracellularly but takes longer and is not the first
line in an emergency.
Question 9: A 48-year-old male with a history of hypertension is admitted with
acute pancreatitis. He develops a sudden onset of dyspnea and hypoxia. A
chest X-ray reveals bilateral infiltrates. His urine output has decreased to 20
mL/hr. Which of the following is the most likely diagnosis?
A. Acute Respiratory Distress Syndrome (ARDS)
B. Pulmonary embolism
C. Atelectasis
D. Aspiration pneumonia
CORRECT ANSWER: A. Acute Respiratory Distress Syndrome (ARDS)
Rationale: The patient has an acute onset of respiratory failure (dyspnea, hypoxia)
within one week of a known clinical insult (acute pancreatitis), with bilateral infiltrates
on chest X-ray, consistent with ARDS. The decreased urine output suggests multi-organ
dysfunction. Pulmonary embolism is possible but less likely without other risk factors.
