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 67-year-old man with ST-elevation myocardial infarction (STEMI) is receiving a
continuous alteplase infusion. Thirty minutes later he develops orolingual angioedema.
Which immediate intervention is required?
A. Continue altepase and administer diphenhydramine 25 mg IV
B. Stop alteplase, give methylprednisolone 125 mg IV, and prepare for fiber-optic
intubation
C. Slow alteplase rate by 50 % and observe
D. Switch to tenecteplase 0.5 mg/kg IV push
Correct Answer: B
Rationale: Alteplase-induced orolingual angioedema is an IgE-independent
anaphylactoid reaction; stopping the thrombolytic is mandatory because symptoms can
progress rapidly to airway compromise. High-dose IV corticosteroid reduces
inflammatory mediator release, and fiber-optic intubation equipment must be ready
because standard laryngoscopy may be impossible when edema obscures landmarks.
Continuing (A) or slowing (C) the infusion risks complete airway obstruction. Switching
,to tenecteplase (D) is contraindicated because it is structurally similar to alteplase and
will re-trigger angioedema.
2
A 54-year-old woman in septic shock has received 4 L crystalloid and norepinephrine
0.4 mcg/kg/min; MAP remains 52 mmHg. Bedside echo shows hyper-dynamic LV
function and IVCD < 15 %. Which vasoactive agent is most appropriate?
A. Add vasopressin 0.04 units/min
B. Increase norepinephrine to 0.8 mcg/kg/min
C. Start phenylephrine 200 mcg/min
D. Initiate dobutamine 10 mcg/kg/min
Correct Answer: A
Rationale: Vasopressin provides non-catecholamine vasoconstriction via V1 receptors
and is recommended as first-line adjunct when MAP remains inadequate after moderate
norepinephrine doses, especially when echo shows preserved cardiac output.
Escalating norepinephrine (B) increases arrhythmia risk without proportional benefit.
Phenylephrine (C) would further raise afterload without addressing relative vasopressin
deficiency. Dobutamine (D) is inappropriate because cardiac output is already
hyper-dynamic.
3
A 48-year-old man with acute pancreatitis has a pain score 9/10, HR 115, BP 105/60, RR
26. Which analgesic strategy best preserves hemodynamics and splanchnic perfusion?
A. Ketorolac 30 mg IV q6h
,B. Morphine 10 mg IV q4h PRN
C. Fentanyl 50 mcg IV bolus then 25 mcg/h infusion
D. Hydromorphone 0.5 mg IV q2h PRN
Correct Answer: C
Rationale: Fentanyl provides rapid, potent analgesia with minimal histamine release,
preserving BP and avoiding morphine-induced spasm of the sphincter of Oddi.
Continuous infusion ensures steady analgesia, reducing sympathetic surge and
pancreatic stimulation. Ketorolac (A) risks renal hypoperfusion and GI bleeding.
Morphine (B) may worsen biliary obstruction and vasodilate. PRN hydromorphone (D)
creates peaks/troughs and inadequate background analgesia.
4
A 71-year-old woman with COPD GOLD stage 3 presents with acute hypercapnic
respiratory failure; ABG shows pH 7.26, PaCO2 74, HCO3 34. She is started on BiPAP
16/6. Thirty minutes later she is somnolent and PaCO2 is 88. Which action is priority?
A. Increase IPAP to 20 cmH2O
B. Decrease EPAP to 3 cmH2O
C. Prepare for emergent fiber-optic bronchoscopy
D. Intubate with low-tidal-volume ventilation
Correct Answer: D
Rationale: Worsening hypercapnia with mental status decline despite BiPAP indicates
failure of non-invasive ventilation and need for airway protection. Low-tidal-volume (6
, mL/kg IBW) lung-protective ventilation reduces dynamic hyperinflation and barotrauma.
Increasing IPAP (A) may not be tolerated and does not address airway control. Lowering
EPAP (B) reduces recruitment and worsens V/Q mismatch. Bronchoscopy (C) is not
emergently indicated without secretion plugging or hemoptysis.
5
A 62-year-old diabetic man with acute ischemic stroke (NIHSS 14) receives IV alteplase
at 2 h. While in CT for follow-up scan he develops acute hypertension 210/110. Which
antihypertensive is preferred?
A. Labetalol 10 mg IV push
B. Nicardipine 5 mg/h IV
C. Hydralazine 20 mg IV
D. Nitroprusside 0.5 mcg/kg/min
Correct Answer: B
Rationale: Nicardipine is a titratable dihydropyridine CCB that lowers BP smoothly
without cerebral vasodilation or reflex tachycardia, maintaining cerebral perfusion
pressure after thrombolysis. Labetalol (A) can be used but may drop BP precipitously in
bolus form. Hydralazine (C) is unpredictable and can cause precipitous decline.
Nitroprusside (D) risks cyanide toxicity and increases intracranial pressure via
vasodilation.
6
Adults in Acute Settings I ACTUAL EXAM | ACTUAL
Questions and Verified Answers | Latest
Update – Walden University
1
A 67-year-old man with ST-elevation myocardial infarction (STEMI) is receiving a
continuous alteplase infusion. Thirty minutes later he develops orolingual angioedema.
Which immediate intervention is required?
A. Continue altepase and administer diphenhydramine 25 mg IV
B. Stop alteplase, give methylprednisolone 125 mg IV, and prepare for fiber-optic
intubation
C. Slow alteplase rate by 50 % and observe
D. Switch to tenecteplase 0.5 mg/kg IV push
Correct Answer: B
Rationale: Alteplase-induced orolingual angioedema is an IgE-independent
anaphylactoid reaction; stopping the thrombolytic is mandatory because symptoms can
progress rapidly to airway compromise. High-dose IV corticosteroid reduces
inflammatory mediator release, and fiber-optic intubation equipment must be ready
because standard laryngoscopy may be impossible when edema obscures landmarks.
Continuing (A) or slowing (C) the infusion risks complete airway obstruction. Switching
,to tenecteplase (D) is contraindicated because it is structurally similar to alteplase and
will re-trigger angioedema.
2
A 54-year-old woman in septic shock has received 4 L crystalloid and norepinephrine
0.4 mcg/kg/min; MAP remains 52 mmHg. Bedside echo shows hyper-dynamic LV
function and IVCD < 15 %. Which vasoactive agent is most appropriate?
A. Add vasopressin 0.04 units/min
B. Increase norepinephrine to 0.8 mcg/kg/min
C. Start phenylephrine 200 mcg/min
D. Initiate dobutamine 10 mcg/kg/min
Correct Answer: A
Rationale: Vasopressin provides non-catecholamine vasoconstriction via V1 receptors
and is recommended as first-line adjunct when MAP remains inadequate after moderate
norepinephrine doses, especially when echo shows preserved cardiac output.
Escalating norepinephrine (B) increases arrhythmia risk without proportional benefit.
Phenylephrine (C) would further raise afterload without addressing relative vasopressin
deficiency. Dobutamine (D) is inappropriate because cardiac output is already
hyper-dynamic.
3
A 48-year-old man with acute pancreatitis has a pain score 9/10, HR 115, BP 105/60, RR
26. Which analgesic strategy best preserves hemodynamics and splanchnic perfusion?
A. Ketorolac 30 mg IV q6h
,B. Morphine 10 mg IV q4h PRN
C. Fentanyl 50 mcg IV bolus then 25 mcg/h infusion
D. Hydromorphone 0.5 mg IV q2h PRN
Correct Answer: C
Rationale: Fentanyl provides rapid, potent analgesia with minimal histamine release,
preserving BP and avoiding morphine-induced spasm of the sphincter of Oddi.
Continuous infusion ensures steady analgesia, reducing sympathetic surge and
pancreatic stimulation. Ketorolac (A) risks renal hypoperfusion and GI bleeding.
Morphine (B) may worsen biliary obstruction and vasodilate. PRN hydromorphone (D)
creates peaks/troughs and inadequate background analgesia.
4
A 71-year-old woman with COPD GOLD stage 3 presents with acute hypercapnic
respiratory failure; ABG shows pH 7.26, PaCO2 74, HCO3 34. She is started on BiPAP
16/6. Thirty minutes later she is somnolent and PaCO2 is 88. Which action is priority?
A. Increase IPAP to 20 cmH2O
B. Decrease EPAP to 3 cmH2O
C. Prepare for emergent fiber-optic bronchoscopy
D. Intubate with low-tidal-volume ventilation
Correct Answer: D
Rationale: Worsening hypercapnia with mental status decline despite BiPAP indicates
failure of non-invasive ventilation and need for airway protection. Low-tidal-volume (6
, mL/kg IBW) lung-protective ventilation reduces dynamic hyperinflation and barotrauma.
Increasing IPAP (A) may not be tolerated and does not address airway control. Lowering
EPAP (B) reduces recruitment and worsens V/Q mismatch. Bronchoscopy (C) is not
emergently indicated without secretion plugging or hemoptysis.
5
A 62-year-old diabetic man with acute ischemic stroke (NIHSS 14) receives IV alteplase
at 2 h. While in CT for follow-up scan he develops acute hypertension 210/110. Which
antihypertensive is preferred?
A. Labetalol 10 mg IV push
B. Nicardipine 5 mg/h IV
C. Hydralazine 20 mg IV
D. Nitroprusside 0.5 mcg/kg/min
Correct Answer: B
Rationale: Nicardipine is a titratable dihydropyridine CCB that lowers BP smoothly
without cerebral vasodilation or reflex tachycardia, maintaining cerebral perfusion
pressure after thrombolysis. Labetalol (A) can be used but may drop BP precipitously in
bolus form. Hydralazine (C) is unpredictable and can cause precipitous decline.
Nitroprusside (D) risks cyanide toxicity and increases intracranial pressure via
vasodilation.
6
