NRNP 6566 Common Diagnosis & Management
in Acute Care Practicum Final Exam Review |
Comprehensive Study Guide | 2026/2027
Instructions: This 55-question review simulates the ACNP final exam. Each item
requires graduate-level synthesis of pathophysiology, current evidence, and acute-care
management.
Format: 47 single-best-answer MCQs, 6 SATA, 2 ordered-response.
Scope: ED → ICU → inpatient triage, independent ACNP practice.
SECTION 1 – CARDIOVASCULAR & RESPIRATORY EMERGENCIES
Q1. A 65-year-old male arrives via EMS with 45 min of crushing substernal chest pain,
diaphoresis, and syncope. BP 85/50, HR 38, RR 26, SpO₂ 88% RA. ECG shows complete
heart block with ventricular escape at 35 bpm and 3 mm ST-elevation in II, III, aVF. The
ACNP’s immediate action is:
A) Trans-cutaneous pace and prepare dopamine infusion.
B) Give atropine 0.5 mg IV while calling the cath lab.
C) Start high-flow O₂, obtain ABG, and defer pacing until after lab results.
D) Initiate transvenous pacing via femoral vein and activate cath lab.
Correct: D
,Rationale: Inferior STEMI with symptomatic bradycardia and hypotension suggests RV
involvement; transvenous pacing (D) provides reliable capture and allows rapid
transition to cath lab. TCP (A) is painful and often ineffective. Atropine (B) is unlikely to
improve infranodal block. Delaying pacing (C) risks asystole.
Q2. A 58-year-old woman with HFrEF (EF 25%) presents with acute dyspnea, frothy pink
sputum, BP 180/110, HR 120, SpO₂ 85% on NRB. ABG: pH 7.18, PaCO₂ 58, PaO₂ 58 on
FiO₂ 1.0. The ACNP should first:
A) Administer furosemide 80 mg IV and morphine 2 mg IV.
B) Initiate NIV with BiPAP IPAP 18 / EPAP 8 cm H₂O.
C) Insert arterial line and start nitroprusside infusion.
D) Give diazepam 5 mg IV for anxiety-related hyperventilation.
Correct: B
Rationale: Acute cardiogenic pulmonary edema with hypercapnic failure; NIV (B) rapidly
reduces preload/afterload, improves oxygenation, and decreases intubation risk (Class
I, AHA). Diuretics (A) are adjunctive. Nitroprusside (C) is useful after airway stabilized.
Diazepam (D) worsens CO₂ retention.
Q3. [SATA] A 70-year-old man arrives 90 min after witnessed collapse. ROSC achieved
after 3 shocks; currently intubated, sedated. BP 70/40, HR 135, Temp 38.2 °C, lactate 6
mmol/L. Which interventions are ACNP priority within 1 h (Surviving Sepsis / post-ROSC
bundles)?
A) 30 mL/kg balanced crystalloid
,B) Blood cultures × 2 before antibiotics
C) Start norepinephrine to MAP ≥65 mm Hg
D) Targeted temperature management 36 °C
E) Emergent cardiac cath regardless of ECG
F) Start empirific broad-spectrum ABX
Correct: A, B, C, D, F
Rationale: Post-ROSC shock is common; rapid fluid (A), cultures (B), pressors (C), and
early ABX (F) address possible sepsis. TTM (D) improves neurologic outcome.
Emergent cath (E) is indicated only if STEMI or shock of presumed cardiac etiology—not
automatic for all.
Q4. A 32-year-old asthmatic presents with silent chest, HR 130, RR 32, SpO₂ 89% on 6 L
NC, ABG pH 7.22 / PaCO₂ 48 / PaO₂ 58. After 3 albuterol-ipratropium nebs, solumedrol
125 mg, and 2 g MgSO₄ IV, wheezes return but exhaustion persists. Next best step:
A) Start BiPAP while arranging ICU bed.
B) Intubate with 8.0 ETT and ketamine/roc.
C) Give terbutaline 0.25 mg SC.
D) Repeat MgSO₄ 2 g IV over 20 min.
Correct: A
Rationale: Improving air exchange but impending fatigue; NIV (A) unloads respiratory
muscles, buys time, and reduces intubation (evidence-based). Immediate intubation (B)
, is reserved for coma or arrest. Additional Mg (D) has marginal benefit; terbutaline (C) is
not superior to continuous albuterol.
Q5. [Ordered Response] Sequence the ACNP actions for a 55-year-old with massive PE
(saddle, RV strain, BP 70/40, HR 125) within the first 30 min.
1. Administer heparin 80 units/kg bolus then 18 units/kg/h
2. Start norepinephrine infusion
3. Give tPA 100 mg IV over 2 h
4. Obtain point-of-care echo
5. Activate interventional radiology for catheter-directed lysis
Correct: 2 → 4 → 1 → 3 → 5
Rationale: Stabilize BP (2) to maintain coronary perfusion; confirm RV dysfunction (4);
anticoagulate (1) before lysis; systemic tPA (3) is guideline first-line for massive PE; IR
rescue (5) if contraindication or shock persists.
SECTION 2 – NEUROLOGIC & METABOLIC CRISES
Q6. A 62-year-old woman with DM, HTN, presents 90 min after acute left arm drift and
gaze preference. NIHSS 14. CT shows no hemorrhage; BP 185/110, glucose 280 mg/dL.
The ACNP should first:
A) Lower BP with nicardipine to <185/110 before tPA.
B) Administer tPA 0.9 mg/kg (max 90 mg) now.
C) Start insulin infusion to correct glucose >180.
D) Obtain CT-angio to assess for LVO before lysis decision.
Correct: B
in Acute Care Practicum Final Exam Review |
Comprehensive Study Guide | 2026/2027
Instructions: This 55-question review simulates the ACNP final exam. Each item
requires graduate-level synthesis of pathophysiology, current evidence, and acute-care
management.
Format: 47 single-best-answer MCQs, 6 SATA, 2 ordered-response.
Scope: ED → ICU → inpatient triage, independent ACNP practice.
SECTION 1 – CARDIOVASCULAR & RESPIRATORY EMERGENCIES
Q1. A 65-year-old male arrives via EMS with 45 min of crushing substernal chest pain,
diaphoresis, and syncope. BP 85/50, HR 38, RR 26, SpO₂ 88% RA. ECG shows complete
heart block with ventricular escape at 35 bpm and 3 mm ST-elevation in II, III, aVF. The
ACNP’s immediate action is:
A) Trans-cutaneous pace and prepare dopamine infusion.
B) Give atropine 0.5 mg IV while calling the cath lab.
C) Start high-flow O₂, obtain ABG, and defer pacing until after lab results.
D) Initiate transvenous pacing via femoral vein and activate cath lab.
Correct: D
,Rationale: Inferior STEMI with symptomatic bradycardia and hypotension suggests RV
involvement; transvenous pacing (D) provides reliable capture and allows rapid
transition to cath lab. TCP (A) is painful and often ineffective. Atropine (B) is unlikely to
improve infranodal block. Delaying pacing (C) risks asystole.
Q2. A 58-year-old woman with HFrEF (EF 25%) presents with acute dyspnea, frothy pink
sputum, BP 180/110, HR 120, SpO₂ 85% on NRB. ABG: pH 7.18, PaCO₂ 58, PaO₂ 58 on
FiO₂ 1.0. The ACNP should first:
A) Administer furosemide 80 mg IV and morphine 2 mg IV.
B) Initiate NIV with BiPAP IPAP 18 / EPAP 8 cm H₂O.
C) Insert arterial line and start nitroprusside infusion.
D) Give diazepam 5 mg IV for anxiety-related hyperventilation.
Correct: B
Rationale: Acute cardiogenic pulmonary edema with hypercapnic failure; NIV (B) rapidly
reduces preload/afterload, improves oxygenation, and decreases intubation risk (Class
I, AHA). Diuretics (A) are adjunctive. Nitroprusside (C) is useful after airway stabilized.
Diazepam (D) worsens CO₂ retention.
Q3. [SATA] A 70-year-old man arrives 90 min after witnessed collapse. ROSC achieved
after 3 shocks; currently intubated, sedated. BP 70/40, HR 135, Temp 38.2 °C, lactate 6
mmol/L. Which interventions are ACNP priority within 1 h (Surviving Sepsis / post-ROSC
bundles)?
A) 30 mL/kg balanced crystalloid
,B) Blood cultures × 2 before antibiotics
C) Start norepinephrine to MAP ≥65 mm Hg
D) Targeted temperature management 36 °C
E) Emergent cardiac cath regardless of ECG
F) Start empirific broad-spectrum ABX
Correct: A, B, C, D, F
Rationale: Post-ROSC shock is common; rapid fluid (A), cultures (B), pressors (C), and
early ABX (F) address possible sepsis. TTM (D) improves neurologic outcome.
Emergent cath (E) is indicated only if STEMI or shock of presumed cardiac etiology—not
automatic for all.
Q4. A 32-year-old asthmatic presents with silent chest, HR 130, RR 32, SpO₂ 89% on 6 L
NC, ABG pH 7.22 / PaCO₂ 48 / PaO₂ 58. After 3 albuterol-ipratropium nebs, solumedrol
125 mg, and 2 g MgSO₄ IV, wheezes return but exhaustion persists. Next best step:
A) Start BiPAP while arranging ICU bed.
B) Intubate with 8.0 ETT and ketamine/roc.
C) Give terbutaline 0.25 mg SC.
D) Repeat MgSO₄ 2 g IV over 20 min.
Correct: A
Rationale: Improving air exchange but impending fatigue; NIV (A) unloads respiratory
muscles, buys time, and reduces intubation (evidence-based). Immediate intubation (B)
, is reserved for coma or arrest. Additional Mg (D) has marginal benefit; terbutaline (C) is
not superior to continuous albuterol.
Q5. [Ordered Response] Sequence the ACNP actions for a 55-year-old with massive PE
(saddle, RV strain, BP 70/40, HR 125) within the first 30 min.
1. Administer heparin 80 units/kg bolus then 18 units/kg/h
2. Start norepinephrine infusion
3. Give tPA 100 mg IV over 2 h
4. Obtain point-of-care echo
5. Activate interventional radiology for catheter-directed lysis
Correct: 2 → 4 → 1 → 3 → 5
Rationale: Stabilize BP (2) to maintain coronary perfusion; confirm RV dysfunction (4);
anticoagulate (1) before lysis; systemic tPA (3) is guideline first-line for massive PE; IR
rescue (5) if contraindication or shock persists.
SECTION 2 – NEUROLOGIC & METABOLIC CRISES
Q6. A 62-year-old woman with DM, HTN, presents 90 min after acute left arm drift and
gaze preference. NIHSS 14. CT shows no hemorrhage; BP 185/110, glucose 280 mg/dL.
The ACNP should first:
A) Lower BP with nicardipine to <185/110 before tPA.
B) Administer tPA 0.9 mg/kg (max 90 mg) now.
C) Start insulin infusion to correct glucose >180.
D) Obtain CT-angio to assess for LVO before lysis decision.
Correct: B
