NR 571 Complex Diagnosis & Management in Acute
Care Practicum | Chamberlain University NR571 Study
Guide, AGACNP Acute Care Exam Prep, Advanced
Clinical Assessment, Complex Patient Diagnosis,
Differential Diagnosis, Diagnostic Testing &
Interpretation, Evidence-Based Treatment Planning,
Clinical Decision-Making, Practice Questions with
Answers & Detailed Rationales
Question 1: A 72-year-old male with a history of heart failure with reduced
ejection fraction (HFrEF) is admitted with acute decompensated heart failure.
He is started on an intravenous infusion of milrinone. Which of the following
hemodynamic parameters would most appropriately indicate a positive
therapeutic response to this therapy?
A. A decrease in systemic vascular resistance (SVR) and an increase in cardiac index
(CI)
B. An increase in pulmonary capillary wedge pressure (PCWP) and a decrease in heart
rate (HR)
C. A decrease in cardiac output (CO) and an increase in mean arterial pressure (MAP)
D. An increase in SVR and a decrease in central venous pressure (CVP)
CORRECT ANSWER: A. A decrease in systemic vascular resistance (SVR) and
an increase in cardiac index (CI)
Rationale: Milrinone is a phosphodiesterase-3 inhibitor that causes vasodilation and
increased inotropy. The therapeutic effect is reflected by a decrease in SVR (afterload
reduction) and an increase in CI (improved cardiac output). An increase in PCWP would
indicate worsening failure, and an increase in SVR would be counterproductive. A
decrease in CO is a sign of drug failure or toxicity.
Question 2: A 65-year-old female is admitted with septic shock secondary to a
urinary tract infection. She requires norepinephrine to maintain a MAP >65
mmHg. Despite adequate fluid resuscitation, her ScvO2 is 62%. Which of the
following is the most appropriate next step in her management?
A. Increase the rate of norepinephrine infusion
B. Administer a fluid bolus of 500 mL of normal saline
C. Initiate an infusion of dobutamine
D. Start an infusion of vasopressin
CORRECT ANSWER: C. Initiate an infusion of dobutamine
Rationale: In septic shock, a low ScvO2 (<70%) after fluid resuscitation and
vasopressor support suggests inadequate oxygen delivery due to low cardiac output or
increased extraction. Dobutamine is an inotrope that increases cardiac contractility and
oxygen delivery. Increasing norepinephrine would worsen vasoconstriction without
,addressing cardiac output, and vasopressin is typically added for refractory vasodilatory
shock, not primarily for low ScvO2.
Question 3: A 58-year-old male with a history of cirrhosis presents with
massive upper GI bleeding. He is intubated for airway protection. Which of the
following is the most appropriate initial pharmacologic therapy to manage his
portal hypertension and control bleeding?
A. Intravenous propranolol
B. Intravenous octreotide
C. Intravenous pantoprazole
D. Oral nadolol
CORRECT ANSWER: B. Intravenous octreotide
Rationale: Octreotide is a somatostatin analogue that reduces splanchnic blood flow
and portal pressure by inhibiting vasodilatory hormones. It is the first-line
pharmacologic therapy for acute variceal bleeding. Propranolol and nadolol are non-
selective beta-blockers used for primary or secondary prophylaxis, not for acute
management. Pantoprazole is for stress ulcer prophylaxis, not for variceal bleeding.
Question 4: A 45-year-old female with no significant past medical history is
admitted with acute pancreatitis. Her lipase is 1,200 U/L, and she has a SIRS
score of 3. Which of the following is the most important immediate goal in her
management?
A. Initiate broad-spectrum antibiotics
B. Administer oral pancreatic enzyme supplements
C. Aggressive intravenous fluid resuscitation
D. Place a nasogastric tube for early enteral feeding
CORRECT ANSWER: C. Aggressive intravenous fluid resuscitation
Rationale: The cornerstone of early management of acute pancreatitis is aggressive
fluid resuscitation to maintain intravascular volume and prevent pancreatic necrosis.
Antibiotics are not indicated prophylactically unless infection is confirmed. Oral
pancreatic enzymes are for chronic insufficiency. Enteral feeding is important but not the
most immediate priority compared to fluid resuscitation in the early phase.
Question 5: A 78-year-old male with end-stage renal disease on hemodialysis
presents with a 2-day history of fever and chills. His blood cultures are
positive for Gram-positive cocci in clusters. A transesophageal echocardiogram
reveals a 1.5 cm vegetation on the mitral valve. Which of the following empiric
antibiotic regimens is most appropriate while awaiting susceptibility results?
,A. Vancomycin and gentamicin
B. Ceftriaxone and azithromycin
C. Piperacillin-tazobactam
D. Linezolid monotherapy
CORRECT ANSWER: A. Vancomycin and gentamicin
Rationale: For suspected infective endocarditis in a patient on hemodialysis (high risk
for MRSA), empiric therapy should cover MRSA and other Gram-positive organisms.
Vancomycin provides MRSA coverage, and gentamicin provides synergy against
streptococci and enterococci. Ceftriaxone does not cover MRSA, and piperacillin-
tazobactam is not first-line for endocarditis. Linezolid monotherapy is not standard
empiric therapy for endocarditis.
Question 6: A 52-year-old male with a history of severe COPD is admitted with
an acute exacerbation. He is on 2 L/min nasal cannula at home. On admission,
his ABG shows pH 7.28, PaCO2 68 mmHg, PaO2 55 mmHg, and HCO3 28
mEq/L. Which of the following is the most appropriate initial ventilator
strategy if he requires intubation?
A. Assist-control ventilation with a tidal volume of 8 mL/kg and respiratory rate of 16
B. Pressure support ventilation with a tidal volume of 6 mL/kg
C. Low tidal volume (6 mL/kg) with permissive hypercapnia and adequate PEEP
D. High-frequency oscillatory ventilation
CORRECT ANSWER: C. Low tidal volume (6 mL/kg) with permissive
hypercapnia and adequate PEEP
Rationale: In COPD patients with acute respiratory failure, the goal is to minimize
dynamic hyperinflation and auto-PEEP. Low tidal volume (6-8 mL/kg) with permissive
hypercapnia and appropriate PEEP reduces the risk of barotrauma and improves
ventilation-perfusion matching. High tidal volumes (8 mL/kg) are not recommended.
High-frequency ventilation is rarely used in COPD.
Question 7: A 60-year-old female presents with acute abdominal pain,
vomiting, and a history of multiple prior abdominal surgeries. A CT scan
shows dilated loops of small bowel with a transition point. Which of the
following is the most significant finding that would indicate the need for
immediate surgical intervention?
A. Presence of air-fluid levels on CT
B. CT evidence of pneumatosis intestinalis
C. Mild leukocytosis of 14,000/mm³
D. Nausea and vomiting
CORRECT ANSWER: B. CT evidence of pneumatosis intestinalis
, Rationale: Pneumatosis intestinalis (air in the bowel wall) indicates ischemia or
necrosis of the bowel, which is a surgical emergency. Air-fluid levels are consistent with
obstruction but not necessarily emergent. Leukocytosis and nausea are common but
non-specific. Immediate surgery is required for bowel ischemia.
Question 8: A 55-year-old male with a history of diabetes and hypertension is
admitted with a massive pulmonary embolism. He is hypotensive with a BP of
85/50 mmHg and tachycardic. Which of the following is the most appropriate
immediate treatment?
A. Subcutaneous enoxaparin
B. Systemic thrombolytic therapy
C. Inferior vena cava filter placement
D. Unfractionated heparin drip
CORRECT ANSWER: B. Systemic thrombolytic therapy
Rationale: This patient has a massive PE with hemodynamic instability (hypotension),
which is an indication for systemic thrombolysis. Anticoagulation alone is insufficient.
An IVC filter is for patients with contraindications to anticoagulation. Unfractionated
heparin is appropriate for submassive PE without instability.
Question 9: A 70-year-old female with chronic kidney disease stage 4 presents
with worsening shortness of breath and a dry cough. She is found to have
pulmonary edema and a pericardial friction rub. Which of the following is the
most likely diagnosis?
A. Uremic pericarditis
B. Bacterial pericarditis
C. Viral pericarditis
D. Post-MI pericarditis
CORRECT ANSWER: A. Uremic pericarditis
Rationale: Uremic pericarditis is a common complication in patients with advanced
renal failure (CKD stage 4-5). It presents with dyspnea, pulmonary edema, and a
pericardial friction rub. The absence of a recent MI or signs of infection makes viral or
bacterial less likely. Uremic pericarditis is an indication for urgent dialysis.
Question 10: A 45-year-old male is admitted with diabetic ketoacidosis (DKA).
His labs show glucose 620 mg/dL, pH 7.15, bicarbonate 12 mEq/L, and anion
gap 25. Which of the following is the most appropriate insulin regimen?
A. Intravenous insulin bolus followed by continuous infusion
B. Subcutaneous regular insulin every 4 hours
Care Practicum | Chamberlain University NR571 Study
Guide, AGACNP Acute Care Exam Prep, Advanced
Clinical Assessment, Complex Patient Diagnosis,
Differential Diagnosis, Diagnostic Testing &
Interpretation, Evidence-Based Treatment Planning,
Clinical Decision-Making, Practice Questions with
Answers & Detailed Rationales
Question 1: A 72-year-old male with a history of heart failure with reduced
ejection fraction (HFrEF) is admitted with acute decompensated heart failure.
He is started on an intravenous infusion of milrinone. Which of the following
hemodynamic parameters would most appropriately indicate a positive
therapeutic response to this therapy?
A. A decrease in systemic vascular resistance (SVR) and an increase in cardiac index
(CI)
B. An increase in pulmonary capillary wedge pressure (PCWP) and a decrease in heart
rate (HR)
C. A decrease in cardiac output (CO) and an increase in mean arterial pressure (MAP)
D. An increase in SVR and a decrease in central venous pressure (CVP)
CORRECT ANSWER: A. A decrease in systemic vascular resistance (SVR) and
an increase in cardiac index (CI)
Rationale: Milrinone is a phosphodiesterase-3 inhibitor that causes vasodilation and
increased inotropy. The therapeutic effect is reflected by a decrease in SVR (afterload
reduction) and an increase in CI (improved cardiac output). An increase in PCWP would
indicate worsening failure, and an increase in SVR would be counterproductive. A
decrease in CO is a sign of drug failure or toxicity.
Question 2: A 65-year-old female is admitted with septic shock secondary to a
urinary tract infection. She requires norepinephrine to maintain a MAP >65
mmHg. Despite adequate fluid resuscitation, her ScvO2 is 62%. Which of the
following is the most appropriate next step in her management?
A. Increase the rate of norepinephrine infusion
B. Administer a fluid bolus of 500 mL of normal saline
C. Initiate an infusion of dobutamine
D. Start an infusion of vasopressin
CORRECT ANSWER: C. Initiate an infusion of dobutamine
Rationale: In septic shock, a low ScvO2 (<70%) after fluid resuscitation and
vasopressor support suggests inadequate oxygen delivery due to low cardiac output or
increased extraction. Dobutamine is an inotrope that increases cardiac contractility and
oxygen delivery. Increasing norepinephrine would worsen vasoconstriction without
,addressing cardiac output, and vasopressin is typically added for refractory vasodilatory
shock, not primarily for low ScvO2.
Question 3: A 58-year-old male with a history of cirrhosis presents with
massive upper GI bleeding. He is intubated for airway protection. Which of the
following is the most appropriate initial pharmacologic therapy to manage his
portal hypertension and control bleeding?
A. Intravenous propranolol
B. Intravenous octreotide
C. Intravenous pantoprazole
D. Oral nadolol
CORRECT ANSWER: B. Intravenous octreotide
Rationale: Octreotide is a somatostatin analogue that reduces splanchnic blood flow
and portal pressure by inhibiting vasodilatory hormones. It is the first-line
pharmacologic therapy for acute variceal bleeding. Propranolol and nadolol are non-
selective beta-blockers used for primary or secondary prophylaxis, not for acute
management. Pantoprazole is for stress ulcer prophylaxis, not for variceal bleeding.
Question 4: A 45-year-old female with no significant past medical history is
admitted with acute pancreatitis. Her lipase is 1,200 U/L, and she has a SIRS
score of 3. Which of the following is the most important immediate goal in her
management?
A. Initiate broad-spectrum antibiotics
B. Administer oral pancreatic enzyme supplements
C. Aggressive intravenous fluid resuscitation
D. Place a nasogastric tube for early enteral feeding
CORRECT ANSWER: C. Aggressive intravenous fluid resuscitation
Rationale: The cornerstone of early management of acute pancreatitis is aggressive
fluid resuscitation to maintain intravascular volume and prevent pancreatic necrosis.
Antibiotics are not indicated prophylactically unless infection is confirmed. Oral
pancreatic enzymes are for chronic insufficiency. Enteral feeding is important but not the
most immediate priority compared to fluid resuscitation in the early phase.
Question 5: A 78-year-old male with end-stage renal disease on hemodialysis
presents with a 2-day history of fever and chills. His blood cultures are
positive for Gram-positive cocci in clusters. A transesophageal echocardiogram
reveals a 1.5 cm vegetation on the mitral valve. Which of the following empiric
antibiotic regimens is most appropriate while awaiting susceptibility results?
,A. Vancomycin and gentamicin
B. Ceftriaxone and azithromycin
C. Piperacillin-tazobactam
D. Linezolid monotherapy
CORRECT ANSWER: A. Vancomycin and gentamicin
Rationale: For suspected infective endocarditis in a patient on hemodialysis (high risk
for MRSA), empiric therapy should cover MRSA and other Gram-positive organisms.
Vancomycin provides MRSA coverage, and gentamicin provides synergy against
streptococci and enterococci. Ceftriaxone does not cover MRSA, and piperacillin-
tazobactam is not first-line for endocarditis. Linezolid monotherapy is not standard
empiric therapy for endocarditis.
Question 6: A 52-year-old male with a history of severe COPD is admitted with
an acute exacerbation. He is on 2 L/min nasal cannula at home. On admission,
his ABG shows pH 7.28, PaCO2 68 mmHg, PaO2 55 mmHg, and HCO3 28
mEq/L. Which of the following is the most appropriate initial ventilator
strategy if he requires intubation?
A. Assist-control ventilation with a tidal volume of 8 mL/kg and respiratory rate of 16
B. Pressure support ventilation with a tidal volume of 6 mL/kg
C. Low tidal volume (6 mL/kg) with permissive hypercapnia and adequate PEEP
D. High-frequency oscillatory ventilation
CORRECT ANSWER: C. Low tidal volume (6 mL/kg) with permissive
hypercapnia and adequate PEEP
Rationale: In COPD patients with acute respiratory failure, the goal is to minimize
dynamic hyperinflation and auto-PEEP. Low tidal volume (6-8 mL/kg) with permissive
hypercapnia and appropriate PEEP reduces the risk of barotrauma and improves
ventilation-perfusion matching. High tidal volumes (8 mL/kg) are not recommended.
High-frequency ventilation is rarely used in COPD.
Question 7: A 60-year-old female presents with acute abdominal pain,
vomiting, and a history of multiple prior abdominal surgeries. A CT scan
shows dilated loops of small bowel with a transition point. Which of the
following is the most significant finding that would indicate the need for
immediate surgical intervention?
A. Presence of air-fluid levels on CT
B. CT evidence of pneumatosis intestinalis
C. Mild leukocytosis of 14,000/mm³
D. Nausea and vomiting
CORRECT ANSWER: B. CT evidence of pneumatosis intestinalis
, Rationale: Pneumatosis intestinalis (air in the bowel wall) indicates ischemia or
necrosis of the bowel, which is a surgical emergency. Air-fluid levels are consistent with
obstruction but not necessarily emergent. Leukocytosis and nausea are common but
non-specific. Immediate surgery is required for bowel ischemia.
Question 8: A 55-year-old male with a history of diabetes and hypertension is
admitted with a massive pulmonary embolism. He is hypotensive with a BP of
85/50 mmHg and tachycardic. Which of the following is the most appropriate
immediate treatment?
A. Subcutaneous enoxaparin
B. Systemic thrombolytic therapy
C. Inferior vena cava filter placement
D. Unfractionated heparin drip
CORRECT ANSWER: B. Systemic thrombolytic therapy
Rationale: This patient has a massive PE with hemodynamic instability (hypotension),
which is an indication for systemic thrombolysis. Anticoagulation alone is insufficient.
An IVC filter is for patients with contraindications to anticoagulation. Unfractionated
heparin is appropriate for submassive PE without instability.
Question 9: A 70-year-old female with chronic kidney disease stage 4 presents
with worsening shortness of breath and a dry cough. She is found to have
pulmonary edema and a pericardial friction rub. Which of the following is the
most likely diagnosis?
A. Uremic pericarditis
B. Bacterial pericarditis
C. Viral pericarditis
D. Post-MI pericarditis
CORRECT ANSWER: A. Uremic pericarditis
Rationale: Uremic pericarditis is a common complication in patients with advanced
renal failure (CKD stage 4-5). It presents with dyspnea, pulmonary edema, and a
pericardial friction rub. The absence of a recent MI or signs of infection makes viral or
bacterial less likely. Uremic pericarditis is an indication for urgent dialysis.
Question 10: A 45-year-old male is admitted with diabetic ketoacidosis (DKA).
His labs show glucose 620 mg/dL, pH 7.15, bicarbonate 12 mEq/L, and anion
gap 25. Which of the following is the most appropriate insulin regimen?
A. Intravenous insulin bolus followed by continuous infusion
B. Subcutaneous regular insulin every 4 hours
