NR 571 Actual Midterm Exam Review: Complex
Diagnosis & Management in Acute Care
(2026/2027) – Advanced Clinical Guide
SECTION 1: Acute Cardiovascular & Respiratory Crises (18 Questions)
Q1 (Multiple Choice) - Clinical Synthesis:
A 58-year-old male presents with 45 minutes of crushing substernal chest pain radiating
to his jaw. ECG shows 2mm ST-segment elevation in leads II, III, and aVF. Vital signs: BP
90/60, HR 48, RR 24, SpO2 92% on room air. The nurse practitioner's immediate priority
action is to:
A. Administer sublingual nitroglycerin
B. Prepare for emergent percutaneous coronary intervention (PCI)
C. Administer atropine 0.5 mg IV for bradycardia
D. Start a dopamine infusion for hypotension
Correct Answer: B
Verified Rationale: Per the 2023 ACC/AHA Guideline for the Management of STEMI,
emergent reperfusion therapy is the cornerstone of treatment for acute STEMI, with a
goal of primary PCI within 90 minutes of first medical contact. This patient presents
with an inferior wall STEMI (leads II, III, aVF) with hemodynamic compromise suggestive
of possible right ventricular involvement. While bradycardia and hypotension require
,monitoring, definitive reperfusion is the priority intervention that will address the
underlying ischemia. Nitrates (A) are contraindicated in RV infarction due to preload
dependence; atropine (C) and vasopressors (D) are supportive but secondary to
reperfusion.
Q2 (Select All That Apply) - Advanced Analysis:
A patient with COPD is intubated for hypercapnic respiratory failure and is on
assist-control volume ventilation (AC-VC). Which parameters should the nurse
practitioner monitor to assess for the development of auto-PEEP (intrinsic PEEP)?
(Select all that apply)
1. Expiratory flow waveform that does not return to baseline before the next breath
2. Difficulty delivering set tidal volume with rising peak pressures
3. Progressive hypotension, especially after initiation of sedation
4. A plateau pressure significantly lower than peak inspiratory pressure
5. Decreased PaCO2 despite unchanged minute ventilation
Correct Answers: 1, 2, 3
Verified Rationale: Per ARDSNet and critical care ventilation protocols, auto-PEEP (air
trapping) is identified by: incomplete exhalation visible on the flow-time scalar where
expiratory flow does not return to zero before the next breath (1); increased resistance
to delivering the set tidal volume manifesting as rising peak inspiratory pressures (2);
and hemodynamic compromise due to reduced venous return from elevated
intrathoracic pressure, often worsened by sedation that removes respiratory drive (3). A
large peak-plateau pressure gradient (4) indicates increased airway resistance, not
specifically auto-PEEP. Rising PaCO2 (5) occurs with air trapping due to decreased
effective alveolar ventilation, not decreased PaCO2.
Q3 (Multiple Choice) - Clinical Synthesis:
,A 72-year-old female with a history of heart failure presents with acute dyspnea. Vital
signs: BP 180/110, HR 110, RR 32, SpO2 88% on 2L NC. Physical exam reveals bilateral
crackles to the apices, JVD at 8cm, and 3+ pitting edema. Chest X-ray shows bilateral
infiltrates and cardiomegaly. BNP is 1,200 pg/mL. The most appropriate initial
pharmacologic intervention is:
A. Furosemide 80 mg IV push
B. Nitroglycerin 0.4 mg sublingual every 5 minutes
C. Dobutamine 5 mcg/kg/min IV infusion
D. Enalaprilat 1.25 mg IV every 6 hours
Correct Answer: A
Verified Rationale: Per the 2022 AHA/ACC/HFSA Guideline for the Management of
Heart Failure, acute decompensated heart failure with volume overload (cardiogenic
pulmonary edema) requires immediate diuresis with IV loop diuretics. Furosemide
reduces preload through venodilation and subsequent diuresis, rapidly improving
dyspnea and oxygenation. While nitrates (B) reduce preload and afterload, they are
adjunctive and insufficient as monotherapy for severe volume overload. Dobutamine (C)
is indicated for low-output states with adequate volume, not hypertensive pulmonary
edema. ACE inhibitors (D) are for chronic management, not acute stabilization.
Q4 (Multiple Choice) - Advanced Analysis:
A patient in the ICU develops sudden onset of narrow-complex tachycardia at 180 bpm.
Blood pressure is 78/50 mmHg. The patient is confused but responsive. 12-lead ECG
shows regular rhythm with no discernible P waves and QRS duration 0.08 seconds.
After supplemental oxygen and IV access, the next priority intervention is:
, A. Adenosine 6 mg rapid IV push followed by 20 mL saline flush
B. Synchronized cardioversion at 100-200 J biphasic
C. Amiodarone 150 mg IV over 10 minutes
D. Vagal maneuvers and carotid sinus massage
Correct Answer: B
Verified Rationale: Per the 2020 ACLS Guidelines, unstable tachycardia with signs of
poor perfusion (hypotension, altered mental status) requires immediate synchronized
cardioversion regardless of the specific rhythm. This patient presents with probable
supraventricular tachycardia (SVT) with hemodynamic compromise; electrical
cardioversion is indicated when the patient is unstable. Adenosine (A) and vagal
maneuvers (D) are appropriate for stable SVT. Amiodarone (C) is for stable
wide-complex tachycardia or as an alternative for unstable atrial fibrillation when
cardioversion fails or is contraindicated.
Q5 (Multiple Choice) - Clinical Synthesis:
A 45-year-old male with acute pancreatitis develops worsening hypoxemia 48 hours
after admission. Current settings: SpO2 86% on 15L non-rebreather mask. ABG: pH 7.48,
PaCO2 32, PaO2 58, HCO3 24, FiO2 0.8. Chest X-ray shows diffuse bilateral infiltrates.
The most appropriate next step is:
A. Increase oxygen to 100% non-rebreather and reassess in 1 hour
B. Initiate non-invasive positive pressure ventilation (BiPAP)
C. Intubate and initiate mechanical ventilation with lung-protective strategy
Diagnosis & Management in Acute Care
(2026/2027) – Advanced Clinical Guide
SECTION 1: Acute Cardiovascular & Respiratory Crises (18 Questions)
Q1 (Multiple Choice) - Clinical Synthesis:
A 58-year-old male presents with 45 minutes of crushing substernal chest pain radiating
to his jaw. ECG shows 2mm ST-segment elevation in leads II, III, and aVF. Vital signs: BP
90/60, HR 48, RR 24, SpO2 92% on room air. The nurse practitioner's immediate priority
action is to:
A. Administer sublingual nitroglycerin
B. Prepare for emergent percutaneous coronary intervention (PCI)
C. Administer atropine 0.5 mg IV for bradycardia
D. Start a dopamine infusion for hypotension
Correct Answer: B
Verified Rationale: Per the 2023 ACC/AHA Guideline for the Management of STEMI,
emergent reperfusion therapy is the cornerstone of treatment for acute STEMI, with a
goal of primary PCI within 90 minutes of first medical contact. This patient presents
with an inferior wall STEMI (leads II, III, aVF) with hemodynamic compromise suggestive
of possible right ventricular involvement. While bradycardia and hypotension require
,monitoring, definitive reperfusion is the priority intervention that will address the
underlying ischemia. Nitrates (A) are contraindicated in RV infarction due to preload
dependence; atropine (C) and vasopressors (D) are supportive but secondary to
reperfusion.
Q2 (Select All That Apply) - Advanced Analysis:
A patient with COPD is intubated for hypercapnic respiratory failure and is on
assist-control volume ventilation (AC-VC). Which parameters should the nurse
practitioner monitor to assess for the development of auto-PEEP (intrinsic PEEP)?
(Select all that apply)
1. Expiratory flow waveform that does not return to baseline before the next breath
2. Difficulty delivering set tidal volume with rising peak pressures
3. Progressive hypotension, especially after initiation of sedation
4. A plateau pressure significantly lower than peak inspiratory pressure
5. Decreased PaCO2 despite unchanged minute ventilation
Correct Answers: 1, 2, 3
Verified Rationale: Per ARDSNet and critical care ventilation protocols, auto-PEEP (air
trapping) is identified by: incomplete exhalation visible on the flow-time scalar where
expiratory flow does not return to zero before the next breath (1); increased resistance
to delivering the set tidal volume manifesting as rising peak inspiratory pressures (2);
and hemodynamic compromise due to reduced venous return from elevated
intrathoracic pressure, often worsened by sedation that removes respiratory drive (3). A
large peak-plateau pressure gradient (4) indicates increased airway resistance, not
specifically auto-PEEP. Rising PaCO2 (5) occurs with air trapping due to decreased
effective alveolar ventilation, not decreased PaCO2.
Q3 (Multiple Choice) - Clinical Synthesis:
,A 72-year-old female with a history of heart failure presents with acute dyspnea. Vital
signs: BP 180/110, HR 110, RR 32, SpO2 88% on 2L NC. Physical exam reveals bilateral
crackles to the apices, JVD at 8cm, and 3+ pitting edema. Chest X-ray shows bilateral
infiltrates and cardiomegaly. BNP is 1,200 pg/mL. The most appropriate initial
pharmacologic intervention is:
A. Furosemide 80 mg IV push
B. Nitroglycerin 0.4 mg sublingual every 5 minutes
C. Dobutamine 5 mcg/kg/min IV infusion
D. Enalaprilat 1.25 mg IV every 6 hours
Correct Answer: A
Verified Rationale: Per the 2022 AHA/ACC/HFSA Guideline for the Management of
Heart Failure, acute decompensated heart failure with volume overload (cardiogenic
pulmonary edema) requires immediate diuresis with IV loop diuretics. Furosemide
reduces preload through venodilation and subsequent diuresis, rapidly improving
dyspnea and oxygenation. While nitrates (B) reduce preload and afterload, they are
adjunctive and insufficient as monotherapy for severe volume overload. Dobutamine (C)
is indicated for low-output states with adequate volume, not hypertensive pulmonary
edema. ACE inhibitors (D) are for chronic management, not acute stabilization.
Q4 (Multiple Choice) - Advanced Analysis:
A patient in the ICU develops sudden onset of narrow-complex tachycardia at 180 bpm.
Blood pressure is 78/50 mmHg. The patient is confused but responsive. 12-lead ECG
shows regular rhythm with no discernible P waves and QRS duration 0.08 seconds.
After supplemental oxygen and IV access, the next priority intervention is:
, A. Adenosine 6 mg rapid IV push followed by 20 mL saline flush
B. Synchronized cardioversion at 100-200 J biphasic
C. Amiodarone 150 mg IV over 10 minutes
D. Vagal maneuvers and carotid sinus massage
Correct Answer: B
Verified Rationale: Per the 2020 ACLS Guidelines, unstable tachycardia with signs of
poor perfusion (hypotension, altered mental status) requires immediate synchronized
cardioversion regardless of the specific rhythm. This patient presents with probable
supraventricular tachycardia (SVT) with hemodynamic compromise; electrical
cardioversion is indicated when the patient is unstable. Adenosine (A) and vagal
maneuvers (D) are appropriate for stable SVT. Amiodarone (C) is for stable
wide-complex tachycardia or as an alternative for unstable atrial fibrillation when
cardioversion fails or is contraindicated.
Q5 (Multiple Choice) - Clinical Synthesis:
A 45-year-old male with acute pancreatitis develops worsening hypoxemia 48 hours
after admission. Current settings: SpO2 86% on 15L non-rebreather mask. ABG: pH 7.48,
PaCO2 32, PaO2 58, HCO3 24, FiO2 0.8. Chest X-ray shows diffuse bilateral infiltrates.
The most appropriate next step is:
A. Increase oxygen to 100% non-rebreather and reassess in 1 hour
B. Initiate non-invasive positive pressure ventilation (BiPAP)
C. Intubate and initiate mechanical ventilation with lung-protective strategy
