Final Exam: NRNP 6566 / NRNP6566 Advanced Care
of Adults in Acute Settings I | ACTUAL EXAM | ACTUAL
Questions and Verified Answers | Latest
Update – Walden University
1
A 68-year-old man is rushed to the resuscitation bay with crushing chest pain,
diaphoresis, and ST-segment elevation in leads V1–V4. Blood pressure 80/50
mm Hg, heart rate 110 beats/min. He is receiving high-flow oxygen and has two
large-bore IVs. Which action is the IMMEDIATE next priority?
A. Administer tissue plasminogen activator (tPA)
B. Obtain a stat echocardiogram
C. Start a norepinephrine infusion
D. Activate the cardiac catheterization laboratory
Correct Answer: D
Rationale: The patient is in cardiogenic shock secondary to an acute anterior
ST-segment elevation myocardial infarction (STEMI). Current AHA/ACC
guidelines prioritize rapid reperfusion; therefore activating the cath lab for
emergent percutaneous coronary intervention (PCI) is the single most important
determinant of survival. Administering fibrinolytics (A) is reasonable only if PCI
cannot be performed within 120 minutes, but this patient is already in the ED with
,access to PCI. A stat echo (B) would delay definitive care. Starting
norepinephrine (C) may be necessary if hypotension persists after PCI, but
revascularization is the definitive treatment for shock.
2
A 54-year-old woman with COPD is intubated for acute hypercapnic respiratory
failure. After 30 min her ABG shows pH 7.18, PaCO2 85 mm Hg, PaO2 68 mm Hg
on assist-control 14/min, VT 450 mL, PEEP 5 cm H2O, FiO2 0.5. Which ventilator
change is MOST appropriate?
A. Increase respiratory rate to 18/min
B. Increase PEEP to 8 cm H2O
C. Switch to pressure-support ventilation
D. Administer IV sodium bicarbonate
Correct Answer: A
Rationale: The primary abnormality is severe acute hypercapnia with acidemia.
Minute ventilation equals respiratory rate × tidal volume; increasing the rate will
increase alveolar ventilation and lower PaCO2. Raising PEEP (B) improves
oxygenation but has minimal effect on CO2 removal. Pressure support (C) is
used for spontaneous breathing trials, not for ongoing hypercapnia. Bicarbonate
(D) may transiently raise pH but does not address the root cause and may
worsen intracellular acidosis.
3
,A 72-year-old man with a history of heart failure with reduced ejection fraction
(30 %) is admitted with flash pulmonary edema. BP 200/110 mm Hg, HR
120/min, crackles to apices, SpO2 85 % on 6 L NC. Which IV agent is FIRST-LINE
to reduce afterload?
A. Nitroprusside
B. Dobutamine
C. Milrinone
D. Dopamine
Correct Answer: A
Rationale: Nitroprusside is a potent arterial and venous vasodilator that rapidly
decreases preload and afterload, making it ideal for hypertensive flash
pulmonary edema. Dobutamine (B) is an inotrope used when the patient is
hypotensive or in low-output states. Milrinone (C) provides inodilation but may
worsen hypotension. Dopamine (D) increases afterload and is inappropriate in
hypertensive crisis.
4
A 29-year-old woman is admitted with severe asthma exacerbation. After 3
back-to-back albuterol–ipratropium nebulizers, IV methylprednisolone 125 mg,
and 1 g of magnesium sulfate, she remains dyspneic and peak flow is 35 % of
predicted. ABG reveals pH 7.28, PaCO2 48 mm Hg, PaO2 70 mm Hg on 6 L O2.
Which intervention is NEXT?
, A. Initiate non-invasive positive-pressure ventilation (NIPPV)
B. Start heliox-driven albuterol
C. Administer terbutaline 0.25 mg subcutaneously
D. Intubate with ketamine and propofol
Correct Answer: A
Rationale: The patient has impending respiratory failure suggested by a rising
PaCO2 in a severe asthma exacerbation. Guidelines recommend NIPPV (BiPAP)
to unload respiratory muscles, decrease work of breathing, and improve gas
exchange while medical therapy continues. Heliox (B) may be tried but evidence
is mixed and it does not address work of breathing. Terbutaline (C) offers
marginal additional bronchodilation. Immediate intubation (D) is reserved for
apnea, severe acidemia, or altered mental status; NIPPV is attempted first if no
contraindication.
5
A 61-year-old diabetic patient on metformin presents with lethargy, Kussmaul
respirations, and glucose 480 mg/dL. ABG: pH 7.12, HCO3 8 mEq/L, PaCO2 22
mm Hg. Serum ketones positive. Which order is MOST urgent?
A. Start regular insulin 0.1 unit/kg/h IV
B. Infuse 3 % saline 100 mL bolus
C. Intubate for airway protection
of Adults in Acute Settings I | ACTUAL EXAM | ACTUAL
Questions and Verified Answers | Latest
Update – Walden University
1
A 68-year-old man is rushed to the resuscitation bay with crushing chest pain,
diaphoresis, and ST-segment elevation in leads V1–V4. Blood pressure 80/50
mm Hg, heart rate 110 beats/min. He is receiving high-flow oxygen and has two
large-bore IVs. Which action is the IMMEDIATE next priority?
A. Administer tissue plasminogen activator (tPA)
B. Obtain a stat echocardiogram
C. Start a norepinephrine infusion
D. Activate the cardiac catheterization laboratory
Correct Answer: D
Rationale: The patient is in cardiogenic shock secondary to an acute anterior
ST-segment elevation myocardial infarction (STEMI). Current AHA/ACC
guidelines prioritize rapid reperfusion; therefore activating the cath lab for
emergent percutaneous coronary intervention (PCI) is the single most important
determinant of survival. Administering fibrinolytics (A) is reasonable only if PCI
cannot be performed within 120 minutes, but this patient is already in the ED with
,access to PCI. A stat echo (B) would delay definitive care. Starting
norepinephrine (C) may be necessary if hypotension persists after PCI, but
revascularization is the definitive treatment for shock.
2
A 54-year-old woman with COPD is intubated for acute hypercapnic respiratory
failure. After 30 min her ABG shows pH 7.18, PaCO2 85 mm Hg, PaO2 68 mm Hg
on assist-control 14/min, VT 450 mL, PEEP 5 cm H2O, FiO2 0.5. Which ventilator
change is MOST appropriate?
A. Increase respiratory rate to 18/min
B. Increase PEEP to 8 cm H2O
C. Switch to pressure-support ventilation
D. Administer IV sodium bicarbonate
Correct Answer: A
Rationale: The primary abnormality is severe acute hypercapnia with acidemia.
Minute ventilation equals respiratory rate × tidal volume; increasing the rate will
increase alveolar ventilation and lower PaCO2. Raising PEEP (B) improves
oxygenation but has minimal effect on CO2 removal. Pressure support (C) is
used for spontaneous breathing trials, not for ongoing hypercapnia. Bicarbonate
(D) may transiently raise pH but does not address the root cause and may
worsen intracellular acidosis.
3
,A 72-year-old man with a history of heart failure with reduced ejection fraction
(30 %) is admitted with flash pulmonary edema. BP 200/110 mm Hg, HR
120/min, crackles to apices, SpO2 85 % on 6 L NC. Which IV agent is FIRST-LINE
to reduce afterload?
A. Nitroprusside
B. Dobutamine
C. Milrinone
D. Dopamine
Correct Answer: A
Rationale: Nitroprusside is a potent arterial and venous vasodilator that rapidly
decreases preload and afterload, making it ideal for hypertensive flash
pulmonary edema. Dobutamine (B) is an inotrope used when the patient is
hypotensive or in low-output states. Milrinone (C) provides inodilation but may
worsen hypotension. Dopamine (D) increases afterload and is inappropriate in
hypertensive crisis.
4
A 29-year-old woman is admitted with severe asthma exacerbation. After 3
back-to-back albuterol–ipratropium nebulizers, IV methylprednisolone 125 mg,
and 1 g of magnesium sulfate, she remains dyspneic and peak flow is 35 % of
predicted. ABG reveals pH 7.28, PaCO2 48 mm Hg, PaO2 70 mm Hg on 6 L O2.
Which intervention is NEXT?
, A. Initiate non-invasive positive-pressure ventilation (NIPPV)
B. Start heliox-driven albuterol
C. Administer terbutaline 0.25 mg subcutaneously
D. Intubate with ketamine and propofol
Correct Answer: A
Rationale: The patient has impending respiratory failure suggested by a rising
PaCO2 in a severe asthma exacerbation. Guidelines recommend NIPPV (BiPAP)
to unload respiratory muscles, decrease work of breathing, and improve gas
exchange while medical therapy continues. Heliox (B) may be tried but evidence
is mixed and it does not address work of breathing. Terbutaline (C) offers
marginal additional bronchodilation. Immediate intubation (D) is reserved for
apnea, severe acidemia, or altered mental status; NIPPV is attempted first if no
contraindication.
5
A 61-year-old diabetic patient on metformin presents with lethargy, Kussmaul
respirations, and glucose 480 mg/dL. ABG: pH 7.12, HCO3 8 mEq/L, PaCO2 22
mm Hg. Serum ketones positive. Which order is MOST urgent?
A. Start regular insulin 0.1 unit/kg/h IV
B. Infuse 3 % saline 100 mL bolus
C. Intubate for airway protection
