ACCS ADULT CRITICAL CARE EXAM HIGH-YIELD
QUESTIONS WITH VERIFIED ANSWERS & DETAILED
RATIONALES
1. A 45-year-old is admitted after cardiac arrest with ROSC after 8 minutes. He
remains comatose with a GCS of 5. What is the single best predictor of poor
neurological outcome at 72 hours post-arrest?
A) Absent pupillary light reflex
B) Myoclonus status epilepticus
C) Bilateral absent N20 wave on somatosensory evoked potentials
D) Serum NSE > 60 μg/L
Correct answer: C
Rationale: Bilateral absence of the N20 waveform on SSEP has a false-positive rate
near 0% for poor outcome if performed at ≥ 72 hours after arrest. Absent pupillary
reflexes have a false-positive rate around 5-10%. Myoclonus can be benign. NSE is
less specific.
2. Which ventilator setting directly determines the inspiratory-to-expiratory (I:E)
ratio in pressure-controlled ventilation?
A) Tidal volume
B) Peak inspiratory pressure
C) Inspiratory time and respiratory rate
D) Flow rate
Correct answer: C
Rationale: In pressure control, I:E ratio is determined by set inspiratory time and
total cycle time (which depends on rate). Tidal volume is variable. Peak inspiratory
pressure is set, not derived from flow.
,3. A 62-year-old with septic shock on norepinephrine 0.3 mcg/kg/min has a MAP
of 58 mmHg. CVP is 8 mmHg, ScvO2 is 58%. What is the most appropriate next
step?
A) Increase norepinephrine
B) Give 500 mL crystalloid bolus
C) Start dobutamine
D) Start hydrocortisone
Correct answer: C
Rationale: ScvO2 < 70% despite adequate MAP (target >65) and CVP (8–12)
suggests ongoing oxygen extraction. Dobutamine improves oxygen delivery if
preload is adequate. Increasing vasopressors worsens perfusion. Steroids are not
first-line here.
4. Following a motor vehicle accident, a 28-year-old has an open tibial fracture
and is hypotensive with narrow pulse pressure and distended neck veins. What is
the most likely diagnosis?
A) Hemorrhagic shock
B) Tension pneumothorax
C) Cardiac tamponade
D) Neurogenic shock
Correct answer: C
Rationale: Hypotension + narrow pulse pressure + distended neck veins in trauma
suggests tamponade (Beck’s triad). Tension pneumothorax has absent breath
sounds; hemorrhagic shock has flat neck veins.
5. In a patient with severe metabolic acidosis (pH 7.10, PaCO2 25 mmHg, HCO3 8
mmol/L), which calculation confirms appropriate respiratory compensation?
A) Winter’s formula: expected PaCO2 = 1.5 × HCO3 + 8 ± 2
B) Anion gap = Na – (Cl + HCO3)
,C) Delta gap = (AG – 12) / (24 – HCO3)
D) PaO2/FiO2 ratio
Correct answer: A
Rationale: Winter’s formula predicts appropriate respiratory compensation in
metabolic acidosis. Here expected PaCO2 = 1.5×8+8 = 20 ± 2; actual PaCO2 25 →
mild hypoventilation (or mixed disorder).
6. Which inotrope is most appropriate for a patient with acute decompensated
heart failure, systolic BP 80 mmHg, and severe peripheral edema?
A) Dobutamine
B) Milrinone
C) Levosimendan
D) Epinephrine
Correct answer: B
Rationale: Milrinone (phosphodiesterase inhibitor) has inotropic and vasodilatory
effects, beneficial in low-output heart failure with congestion and without severe
hypotension. Dobutamine causes more tachycardia.
7. A 55-year-old post-cardiac surgery has sudden desaturation, hypotension, and
distended neck veins. Bedside echo shows a hyperdynamic left ventricle with a
dilated, akinetic right ventricle. What is the most likely diagnosis?
A) Massive pulmonary embolism
B) Tamponade
C) Tension pneumothorax
D) Left ventricular failure
Correct answer: A
Rationale: Acute right ventricular dilation and hypokinesis with preserved left
ventricular function in a postoperative patient suggests pulmonary embolism.
Tamponade would show diastolic collapse.
, 8. For a patient with acute liver failure and grade III hepatic encephalopathy, what
is the most effective measure to reduce intracranial pressure?
A) Lactulose
B) Hyperventilation to PaCO2 28 mmHg
C) Mannitol 0.5 g/kg
D) Therapeutic hypothermia (32–34°C)
Correct answer: C
Rationale: Mannitol is first-line for acute ICP elevation in liver failure.
Hyperventilation is only temporary bridge. Hypothermia not standard first-line.
Lactulose treats encephalopathy but not acutely elevated ICP.
9. Which electrolyte abnormality is most characteristic of refeeding syndrome?
A) Hyperkalemia
B) Hypophosphatemia
C) Hypermagnesemia
D) Hypernatremia
Correct answer: B
Rationale: Refeeding syndrome causes intracellular shift of phosphate, leading to
severe hypophosphatemia, which can cause respiratory failure and cardiac
dysfunction.
10. A patient with community-acquired pneumonia has a CURB-65 score of 3.
What is the recommended site of care?
A) Outpatient with oral antibiotics
B) Hospital ward
C) High dependency unit
D) Intensive care
Correct answer: D
Rationale: CURB-65 score 3–5 indicates severe pneumonia requiring ICU
admission (mortality up to 30–40%). Score 0–1 outpatient, 2 consider short-stay
hospital.
QUESTIONS WITH VERIFIED ANSWERS & DETAILED
RATIONALES
1. A 45-year-old is admitted after cardiac arrest with ROSC after 8 minutes. He
remains comatose with a GCS of 5. What is the single best predictor of poor
neurological outcome at 72 hours post-arrest?
A) Absent pupillary light reflex
B) Myoclonus status epilepticus
C) Bilateral absent N20 wave on somatosensory evoked potentials
D) Serum NSE > 60 μg/L
Correct answer: C
Rationale: Bilateral absence of the N20 waveform on SSEP has a false-positive rate
near 0% for poor outcome if performed at ≥ 72 hours after arrest. Absent pupillary
reflexes have a false-positive rate around 5-10%. Myoclonus can be benign. NSE is
less specific.
2. Which ventilator setting directly determines the inspiratory-to-expiratory (I:E)
ratio in pressure-controlled ventilation?
A) Tidal volume
B) Peak inspiratory pressure
C) Inspiratory time and respiratory rate
D) Flow rate
Correct answer: C
Rationale: In pressure control, I:E ratio is determined by set inspiratory time and
total cycle time (which depends on rate). Tidal volume is variable. Peak inspiratory
pressure is set, not derived from flow.
,3. A 62-year-old with septic shock on norepinephrine 0.3 mcg/kg/min has a MAP
of 58 mmHg. CVP is 8 mmHg, ScvO2 is 58%. What is the most appropriate next
step?
A) Increase norepinephrine
B) Give 500 mL crystalloid bolus
C) Start dobutamine
D) Start hydrocortisone
Correct answer: C
Rationale: ScvO2 < 70% despite adequate MAP (target >65) and CVP (8–12)
suggests ongoing oxygen extraction. Dobutamine improves oxygen delivery if
preload is adequate. Increasing vasopressors worsens perfusion. Steroids are not
first-line here.
4. Following a motor vehicle accident, a 28-year-old has an open tibial fracture
and is hypotensive with narrow pulse pressure and distended neck veins. What is
the most likely diagnosis?
A) Hemorrhagic shock
B) Tension pneumothorax
C) Cardiac tamponade
D) Neurogenic shock
Correct answer: C
Rationale: Hypotension + narrow pulse pressure + distended neck veins in trauma
suggests tamponade (Beck’s triad). Tension pneumothorax has absent breath
sounds; hemorrhagic shock has flat neck veins.
5. In a patient with severe metabolic acidosis (pH 7.10, PaCO2 25 mmHg, HCO3 8
mmol/L), which calculation confirms appropriate respiratory compensation?
A) Winter’s formula: expected PaCO2 = 1.5 × HCO3 + 8 ± 2
B) Anion gap = Na – (Cl + HCO3)
,C) Delta gap = (AG – 12) / (24 – HCO3)
D) PaO2/FiO2 ratio
Correct answer: A
Rationale: Winter’s formula predicts appropriate respiratory compensation in
metabolic acidosis. Here expected PaCO2 = 1.5×8+8 = 20 ± 2; actual PaCO2 25 →
mild hypoventilation (or mixed disorder).
6. Which inotrope is most appropriate for a patient with acute decompensated
heart failure, systolic BP 80 mmHg, and severe peripheral edema?
A) Dobutamine
B) Milrinone
C) Levosimendan
D) Epinephrine
Correct answer: B
Rationale: Milrinone (phosphodiesterase inhibitor) has inotropic and vasodilatory
effects, beneficial in low-output heart failure with congestion and without severe
hypotension. Dobutamine causes more tachycardia.
7. A 55-year-old post-cardiac surgery has sudden desaturation, hypotension, and
distended neck veins. Bedside echo shows a hyperdynamic left ventricle with a
dilated, akinetic right ventricle. What is the most likely diagnosis?
A) Massive pulmonary embolism
B) Tamponade
C) Tension pneumothorax
D) Left ventricular failure
Correct answer: A
Rationale: Acute right ventricular dilation and hypokinesis with preserved left
ventricular function in a postoperative patient suggests pulmonary embolism.
Tamponade would show diastolic collapse.
, 8. For a patient with acute liver failure and grade III hepatic encephalopathy, what
is the most effective measure to reduce intracranial pressure?
A) Lactulose
B) Hyperventilation to PaCO2 28 mmHg
C) Mannitol 0.5 g/kg
D) Therapeutic hypothermia (32–34°C)
Correct answer: C
Rationale: Mannitol is first-line for acute ICP elevation in liver failure.
Hyperventilation is only temporary bridge. Hypothermia not standard first-line.
Lactulose treats encephalopathy but not acutely elevated ICP.
9. Which electrolyte abnormality is most characteristic of refeeding syndrome?
A) Hyperkalemia
B) Hypophosphatemia
C) Hypermagnesemia
D) Hypernatremia
Correct answer: B
Rationale: Refeeding syndrome causes intracellular shift of phosphate, leading to
severe hypophosphatemia, which can cause respiratory failure and cardiac
dysfunction.
10. A patient with community-acquired pneumonia has a CURB-65 score of 3.
What is the recommended site of care?
A) Outpatient with oral antibiotics
B) Hospital ward
C) High dependency unit
D) Intensive care
Correct answer: D
Rationale: CURB-65 score 3–5 indicates severe pneumonia requiring ICU
admission (mortality up to 30–40%). Score 0–1 outpatient, 2 consider short-stay
hospital.
