NRNP 6566 Final Examination Advanced Care of Adults in
Acute Settings I Actual Questions & Verified Answers
2025–2026 Academic Year – Walden University
1. A 67-year-old man is admitted to the progressive-care unit with acute
decompensated heart failure (ADHF). His blood pressure is 78/52 mm Hg, heart
rate 112 beats/min, and he is cool and clammy. Pulmonary-artery catheter
reveals a cardiac index of 1.7 L/min/m² and pulmonary-capillary wedge pressure
(PCWP) 26 mm Hg. Which intervention is MOST appropriate?
A. Initiate dobutamine 5 μg/kg/min IV
B. Administer furosemide 80 mg IV push
C. Begin high-dose carvedilol orally
D. Infuse 0.9 % saline 500 mL bolus
Correct Answer: A
Rationale: The patient presents with cardiogenic shock secondary to ADHF (low CI,
elevated PCWP, hypotension, hypoperfusion). Positive inotropic support with
dobutamine improves contractility and cardiac output. Diuresis alone (B) does not
address the low forward flow. β-blockade (C) is contraindicated in acute shock. Volume
loading (D) would further increase already elevated PCWP and worsen pulmonary
edema.
2. A 54-year-old woman with COPD is receiving bilevel NIV for hypercapnic
respiratory failure. After 1 h her pH improves from 7.28 to 7.32, but she becomes
agitated and tachypneic. Plateau pressure is 18 cm H₂O. Which action is BEST?
A. Increase IPAP by 4 cm H₂O
B. Administer IV fentanyl 25 μg
, C. Perform urgent endotracheal intubation
D. Evaluate mask fit and suction secretions
Correct Answer: D
Rationale: Agitation during NIV is frequently due to poorly fitting mask causing air-leak
or retained secretions. Addressing these issues improves synchrony and avoids
escalation. Increasing pressure (A) without confirming leak may worsen leak. IV opioids
(B) risk respiratory depression. Intubation (C) is premature when reversible factors exist.
3. A 48-year-old man presents to the ED with 2 h of severe chest pain and
ST-segment elevation in leads V₂–V₄. He is wheezing and states he “can’t take
aspirin because it causes bronchospasm.” Which antiplatelet regimen is MOST
appropriate?
A. Clopidogrel 600 mg PO + ticagrelor 180 mg PO
B. Prasugrel 60 mg PO alone
C. Clopidogrel 600 mg PO alone
D. Ticagrelor 180 mg PO alone
Correct Answer: C
Rationale: Aspirin allergy precludes aspirin; clopidogrel is the safest P2Y₁₂ inhibitor in
patients with asthma/COPD because ticagrelor and prasugrel can cause
dyspnea/bronchospasm. Guidelines support clopidogrel 600 mg loading dose in
aspirin-intolerant STEMI.
4. A 72-year-old woman is admitted with urosepsis. Blood cultures grow
ESBL-producing E. coli. She is intolerant of carbapenems (previous rash). Which
agent is BEST?
A. Ceftriaxone 2 g IV daily
, B. Piperacillin-tazobactam 4.5 g q8 h
C. Ertapenem 1 g IV daily
D. Cefiderocol 2 g q8 h
Correct Answer: D
Rationale: Cefiderocol is a novel siderophore cephalosporin with activity against ESBL
organisms and is an option in carbapenem-intolerant patients. Ceftriaxone and
piperacillin-tazobactam are inactive against ESBL producers. Ertapenem is a
carbapenem and therefore contraindicated.
5. A 63-year-old man with acute ischemic stroke (left MCA, NIHSS 14) arrives 90
min after onset. BP is 178/96 mm Hg. Which intervention is MOST appropriate
BEFORE IV tPA?
A. Administer labetalol 10 mg IV to target BP <185/110
B. Initiate nicardipine infusion at 5 mg/h
C. Give sublingual nifedipine 10 mg
D. Observe; BP will fall spontaneously
Correct Answer: A
Rationale: IV tPA requires SBP <185 and DBP <110 mm Hg. IV labetalol is rapid,
titratable, and guideline-endorsed. Nicardipine infusion (B) is acceptable but more
resource-intensive. Sublingual nifedipine risks precipitous drop. Observation (D) delays
reperfusion.
6. A 59-year-old diabetic patient is in septic shock on norepinephrine 0.4 μg/kg/min.
Lactate is 4.2 mmol/L, urine output 15 mL/h. After 2 L crystalloid, CVP is 14 mm
Hg. Which NEXT intervention is MOST appropriate?
A. Start vasopressin 0.03 U/min
, B. Infuse 2 L 0.9 % saline rapidly
C. Administer hydrocortisone 200 mg IV
D. Initiate dobutamine 5 μg/kg/min
Correct Answer: A
Rationale: Persistent vasodilatory shock despite adequate filling (CVP 14) warrants
addition of vasopressin to norepinephrine to achieve MAP ≥65 mm Hg and reduce NE
exposure. Further fluid (B) risks overload. Hydrocortisone is reasonable adjunct but not
next immediate step. Dobutamine (D) is not indicated in pure vasodilatory shock
without low CI.
7. A 38-year-old woman with acute asthma is intubated for fatigue. Peak airway
pressure is 45 cm H₂O and plateau 28 cm H₂O. Breath sounds are silent. Which
intervention is MOST urgent?
A. Increase PEEP to 12 cm H₂O
B. Administer methylprednisolone 125 mg IV
C. Perform chest tube decompression
D. Nebulized albuterol-ipratropium
Correct Answer: C
Rationale: Markedly elevated peak with normal plateau suggests airway obstruction or
extra-thoracic pressure (tension pneumothorax, biting, secretions). Silent breath sounds
strongly suggest tension pneumothorax requiring immediate decompression. Other
options do not address life-threatening air-pressure build-up.
8. A 55-year-old man with acute pancreatitis develops dyspnea and hypoxemia
(SpO₂ 88 % on 6 L NC). CT shows diffuse ground-glass opacities. Which
ventilator strategy is MOST appropriate if he requires intubation?
Acute Settings I Actual Questions & Verified Answers
2025–2026 Academic Year – Walden University
1. A 67-year-old man is admitted to the progressive-care unit with acute
decompensated heart failure (ADHF). His blood pressure is 78/52 mm Hg, heart
rate 112 beats/min, and he is cool and clammy. Pulmonary-artery catheter
reveals a cardiac index of 1.7 L/min/m² and pulmonary-capillary wedge pressure
(PCWP) 26 mm Hg. Which intervention is MOST appropriate?
A. Initiate dobutamine 5 μg/kg/min IV
B. Administer furosemide 80 mg IV push
C. Begin high-dose carvedilol orally
D. Infuse 0.9 % saline 500 mL bolus
Correct Answer: A
Rationale: The patient presents with cardiogenic shock secondary to ADHF (low CI,
elevated PCWP, hypotension, hypoperfusion). Positive inotropic support with
dobutamine improves contractility and cardiac output. Diuresis alone (B) does not
address the low forward flow. β-blockade (C) is contraindicated in acute shock. Volume
loading (D) would further increase already elevated PCWP and worsen pulmonary
edema.
2. A 54-year-old woman with COPD is receiving bilevel NIV for hypercapnic
respiratory failure. After 1 h her pH improves from 7.28 to 7.32, but she becomes
agitated and tachypneic. Plateau pressure is 18 cm H₂O. Which action is BEST?
A. Increase IPAP by 4 cm H₂O
B. Administer IV fentanyl 25 μg
, C. Perform urgent endotracheal intubation
D. Evaluate mask fit and suction secretions
Correct Answer: D
Rationale: Agitation during NIV is frequently due to poorly fitting mask causing air-leak
or retained secretions. Addressing these issues improves synchrony and avoids
escalation. Increasing pressure (A) without confirming leak may worsen leak. IV opioids
(B) risk respiratory depression. Intubation (C) is premature when reversible factors exist.
3. A 48-year-old man presents to the ED with 2 h of severe chest pain and
ST-segment elevation in leads V₂–V₄. He is wheezing and states he “can’t take
aspirin because it causes bronchospasm.” Which antiplatelet regimen is MOST
appropriate?
A. Clopidogrel 600 mg PO + ticagrelor 180 mg PO
B. Prasugrel 60 mg PO alone
C. Clopidogrel 600 mg PO alone
D. Ticagrelor 180 mg PO alone
Correct Answer: C
Rationale: Aspirin allergy precludes aspirin; clopidogrel is the safest P2Y₁₂ inhibitor in
patients with asthma/COPD because ticagrelor and prasugrel can cause
dyspnea/bronchospasm. Guidelines support clopidogrel 600 mg loading dose in
aspirin-intolerant STEMI.
4. A 72-year-old woman is admitted with urosepsis. Blood cultures grow
ESBL-producing E. coli. She is intolerant of carbapenems (previous rash). Which
agent is BEST?
A. Ceftriaxone 2 g IV daily
, B. Piperacillin-tazobactam 4.5 g q8 h
C. Ertapenem 1 g IV daily
D. Cefiderocol 2 g q8 h
Correct Answer: D
Rationale: Cefiderocol is a novel siderophore cephalosporin with activity against ESBL
organisms and is an option in carbapenem-intolerant patients. Ceftriaxone and
piperacillin-tazobactam are inactive against ESBL producers. Ertapenem is a
carbapenem and therefore contraindicated.
5. A 63-year-old man with acute ischemic stroke (left MCA, NIHSS 14) arrives 90
min after onset. BP is 178/96 mm Hg. Which intervention is MOST appropriate
BEFORE IV tPA?
A. Administer labetalol 10 mg IV to target BP <185/110
B. Initiate nicardipine infusion at 5 mg/h
C. Give sublingual nifedipine 10 mg
D. Observe; BP will fall spontaneously
Correct Answer: A
Rationale: IV tPA requires SBP <185 and DBP <110 mm Hg. IV labetalol is rapid,
titratable, and guideline-endorsed. Nicardipine infusion (B) is acceptable but more
resource-intensive. Sublingual nifedipine risks precipitous drop. Observation (D) delays
reperfusion.
6. A 59-year-old diabetic patient is in septic shock on norepinephrine 0.4 μg/kg/min.
Lactate is 4.2 mmol/L, urine output 15 mL/h. After 2 L crystalloid, CVP is 14 mm
Hg. Which NEXT intervention is MOST appropriate?
A. Start vasopressin 0.03 U/min
, B. Infuse 2 L 0.9 % saline rapidly
C. Administer hydrocortisone 200 mg IV
D. Initiate dobutamine 5 μg/kg/min
Correct Answer: A
Rationale: Persistent vasodilatory shock despite adequate filling (CVP 14) warrants
addition of vasopressin to norepinephrine to achieve MAP ≥65 mm Hg and reduce NE
exposure. Further fluid (B) risks overload. Hydrocortisone is reasonable adjunct but not
next immediate step. Dobutamine (D) is not indicated in pure vasodilatory shock
without low CI.
7. A 38-year-old woman with acute asthma is intubated for fatigue. Peak airway
pressure is 45 cm H₂O and plateau 28 cm H₂O. Breath sounds are silent. Which
intervention is MOST urgent?
A. Increase PEEP to 12 cm H₂O
B. Administer methylprednisolone 125 mg IV
C. Perform chest tube decompression
D. Nebulized albuterol-ipratropium
Correct Answer: C
Rationale: Markedly elevated peak with normal plateau suggests airway obstruction or
extra-thoracic pressure (tension pneumothorax, biting, secretions). Silent breath sounds
strongly suggest tension pneumothorax requiring immediate decompression. Other
options do not address life-threatening air-pressure build-up.
8. A 55-year-old man with acute pancreatitis develops dyspnea and hypoxemia
(SpO₂ 88 % on 6 L NC). CT shows diffuse ground-glass opacities. Which
ventilator strategy is MOST appropriate if he requires intubation?
