PCCN PROGRESSIVE CARE/STEP-DOWN UNIT
NURSES COMPREHENSIVE EXAM GUIDE 2026
Q&A
1 A patient in the progressive care unit has a heart rate of 140
bpm, blood pressure of 88/52 mmHg, and narrow-complex
tachycardia on the monitor. The patient is alert but reports
dizziness. What is the most appropriate initial intervention?
A. Administer amiodarone 150 mg IV over 10 minutes
B. Perform synchronized cardioversion at 100 J
C. Administer adenosine 6 mg IV push
D. Insert a peripheral IV line and obtain labs
Correct Answer: B
Explanation: This patient has unstable supraventricular
tachycardia (SVT) with hypotension and symptoms (dizziness).
According to ACLS guidelines, unstable tachycardia with a pulse
requires synchronized cardioversion. Adenosine is for stable
SVT, amiodarone is for stable wide-complex tachycardia or
atrial fibrillation, and obtaining labs delays critical treatment.
2 A 68-year-old patient with chronic obstructive pulmonary
disease (COPD) presents with increased dyspnea, increased
sputum production, and oxygen saturation of 88% on room air.
Arterial blood gas shows pH 7.28, PaCO2 58 mmHg, PaO2 55
mmHg, HCO3 26 mEq/L. What is the most appropriate initial
respiratory intervention?
A. Intubate and initiate mechanical ventilation
B. Administer high-flow oxygen at 15 L/min via non-rebreather
C. Initiate non-invasive positive pressure ventilation (BiPAP)
D. Administer 2 L/min oxygen via nasal cannula
,Correct Answer: C
Explanation: This patient has acute hypercapnic respiratory
failure (pH <7.35, elevated PaCO2) with COPD exacerbation.
Non-invasive ventilation (BiPAP) is the first-line intervention for
COPD exacerbation with respiratory acidosis, as it improves
ventilation and avoids intubation. High-flow oxygen can worsen
hypercapnia in CO2 retainers, and intubation is reserved for
patients who fail non-invasive ventilation.
3 A patient with septic shock has received 30 mL/kg of crystalloid
fluids and now has a mean arterial pressure (MAP) of 58 mmHg.
Which vasoactive medication should be initiated first?
A. Dopamine
B. Norepinephrine
C. Epinephrine
D. Vasopressin
Correct Answer: B
Explanation: Norepinephrine is the first-line vasopressor for
septic shock according to Surviving Sepsis Campaign guidelines.
It provides alpha-adrenergic vasoconstriction with minimal
beta-adrenergic effects, effectively increasing MAP with less
tachycardia than dopamine or epinephrine. Vasopressin is
typically added as a second-line agent if norepinephrine alone is
insufficient.
4 A 55-year-old patient with type 2 diabetes presents with blood
glucose of 420 mg/dL, serum osmolality of 335 mOsm/kg, and
positive serum ketones. The patient is alert but confused. What is
the priority nursing intervention?
,A. Administer regular insulin 10 units subcutaneously
B. Initiate IV fluid resuscitation with 0.9% normal saline
C. Administer IV bicarbonate to correct acidosis
D. Give IM glucagon 1 mg
Correct Answer: B
Explanation: This patient has hyperosmolar hyperglycemic state
(HHS) or possibly diabetic ketoacidosis (DKA). IV fluid
resuscitation is the priority to restore intravascular volume and
improve tissue perfusion. Insulin should be started after initial
fluid resuscitation to prevent hypokalemia. Bicarbonate is rarely
indicated unless pH <6.9, and glucagon is used for
hypoglycemia, not hyperglycemia.
5 A patient in the step-down unit develops sudden onset of left-
sided weakness and facial drooping. The last known well time was
2 hours ago. CT head shows no hemorrhage. What is the most
appropriate intervention?
A. Administer aspirin 325 mg orally
B. Initiate intravenous alteplase (tPA)
C. Start heparin anticoagulation
D. Transfer to neurology ward for observation
Correct Answer: B
Explanation: This patient is within the 4.5-hour window for IV
thrombolysis (tPA) for acute ischemic stroke. The CT ruled out
hemorrhage, and symptoms started 2 hours ago. tPA is the
standard of care for eligible patients. Aspirin is given after tPA is
contraindicated or 24 hours after tPA administration. Heparin is
not recommended for acute ischemic stroke.
, 6 A post-operative patient 24 hours after abdominal surgery
develops sudden chest pain, shortness of breath, and oxygen
saturation of 89% on 3 L/min nasal cannula. Heart rate is 118
bpm, and ECG shows sinus tachycardia. What is the most likely
diagnosis?
A. Myocardial infarction
B. Pulmonary embolism
C. Pneumothorax
D. Pneumonia
Correct Answer: B
Explanation: This patient has classic signs of pulmonary
embolism (PE): sudden onset dyspnea, chest pain, tachycardia,
hypoxemia, and recent surgery (risk factor for DVT/PE). PE is a
common complication in post-operative patients. MI would
typically show ECG changes beyond sinus tachycardia,
pneumothorax would show decreased breath sounds, and
pneumonia develops more gradually.
7 A patient with acute kidney injury (AKI) has a serum potassium
of 6.8 mEq/L and ECG shows peaked T waves. What is the most
appropriate immediate intervention?
A. Administer sodium polystyrene sulfonate (Kayexalate) 30 g
orally
B. Give IV calcium gluconate 10 mL of 10% solution
C. Administer furosemide 40 mg IV
D. Initiate hemodialysis
Correct Answer: B
Explanation: This patient has life-threatening hyperkalemia
with ECG changes. IV calcium gluconate stabilizes cardiac
membranes and is the first-line treatment to prevent cardiac
arrest. Kayexalate works too slowly (hours), furosemide may not
NURSES COMPREHENSIVE EXAM GUIDE 2026
Q&A
1 A patient in the progressive care unit has a heart rate of 140
bpm, blood pressure of 88/52 mmHg, and narrow-complex
tachycardia on the monitor. The patient is alert but reports
dizziness. What is the most appropriate initial intervention?
A. Administer amiodarone 150 mg IV over 10 minutes
B. Perform synchronized cardioversion at 100 J
C. Administer adenosine 6 mg IV push
D. Insert a peripheral IV line and obtain labs
Correct Answer: B
Explanation: This patient has unstable supraventricular
tachycardia (SVT) with hypotension and symptoms (dizziness).
According to ACLS guidelines, unstable tachycardia with a pulse
requires synchronized cardioversion. Adenosine is for stable
SVT, amiodarone is for stable wide-complex tachycardia or
atrial fibrillation, and obtaining labs delays critical treatment.
2 A 68-year-old patient with chronic obstructive pulmonary
disease (COPD) presents with increased dyspnea, increased
sputum production, and oxygen saturation of 88% on room air.
Arterial blood gas shows pH 7.28, PaCO2 58 mmHg, PaO2 55
mmHg, HCO3 26 mEq/L. What is the most appropriate initial
respiratory intervention?
A. Intubate and initiate mechanical ventilation
B. Administer high-flow oxygen at 15 L/min via non-rebreather
C. Initiate non-invasive positive pressure ventilation (BiPAP)
D. Administer 2 L/min oxygen via nasal cannula
,Correct Answer: C
Explanation: This patient has acute hypercapnic respiratory
failure (pH <7.35, elevated PaCO2) with COPD exacerbation.
Non-invasive ventilation (BiPAP) is the first-line intervention for
COPD exacerbation with respiratory acidosis, as it improves
ventilation and avoids intubation. High-flow oxygen can worsen
hypercapnia in CO2 retainers, and intubation is reserved for
patients who fail non-invasive ventilation.
3 A patient with septic shock has received 30 mL/kg of crystalloid
fluids and now has a mean arterial pressure (MAP) of 58 mmHg.
Which vasoactive medication should be initiated first?
A. Dopamine
B. Norepinephrine
C. Epinephrine
D. Vasopressin
Correct Answer: B
Explanation: Norepinephrine is the first-line vasopressor for
septic shock according to Surviving Sepsis Campaign guidelines.
It provides alpha-adrenergic vasoconstriction with minimal
beta-adrenergic effects, effectively increasing MAP with less
tachycardia than dopamine or epinephrine. Vasopressin is
typically added as a second-line agent if norepinephrine alone is
insufficient.
4 A 55-year-old patient with type 2 diabetes presents with blood
glucose of 420 mg/dL, serum osmolality of 335 mOsm/kg, and
positive serum ketones. The patient is alert but confused. What is
the priority nursing intervention?
,A. Administer regular insulin 10 units subcutaneously
B. Initiate IV fluid resuscitation with 0.9% normal saline
C. Administer IV bicarbonate to correct acidosis
D. Give IM glucagon 1 mg
Correct Answer: B
Explanation: This patient has hyperosmolar hyperglycemic state
(HHS) or possibly diabetic ketoacidosis (DKA). IV fluid
resuscitation is the priority to restore intravascular volume and
improve tissue perfusion. Insulin should be started after initial
fluid resuscitation to prevent hypokalemia. Bicarbonate is rarely
indicated unless pH <6.9, and glucagon is used for
hypoglycemia, not hyperglycemia.
5 A patient in the step-down unit develops sudden onset of left-
sided weakness and facial drooping. The last known well time was
2 hours ago. CT head shows no hemorrhage. What is the most
appropriate intervention?
A. Administer aspirin 325 mg orally
B. Initiate intravenous alteplase (tPA)
C. Start heparin anticoagulation
D. Transfer to neurology ward for observation
Correct Answer: B
Explanation: This patient is within the 4.5-hour window for IV
thrombolysis (tPA) for acute ischemic stroke. The CT ruled out
hemorrhage, and symptoms started 2 hours ago. tPA is the
standard of care for eligible patients. Aspirin is given after tPA is
contraindicated or 24 hours after tPA administration. Heparin is
not recommended for acute ischemic stroke.
, 6 A post-operative patient 24 hours after abdominal surgery
develops sudden chest pain, shortness of breath, and oxygen
saturation of 89% on 3 L/min nasal cannula. Heart rate is 118
bpm, and ECG shows sinus tachycardia. What is the most likely
diagnosis?
A. Myocardial infarction
B. Pulmonary embolism
C. Pneumothorax
D. Pneumonia
Correct Answer: B
Explanation: This patient has classic signs of pulmonary
embolism (PE): sudden onset dyspnea, chest pain, tachycardia,
hypoxemia, and recent surgery (risk factor for DVT/PE). PE is a
common complication in post-operative patients. MI would
typically show ECG changes beyond sinus tachycardia,
pneumothorax would show decreased breath sounds, and
pneumonia develops more gradually.
7 A patient with acute kidney injury (AKI) has a serum potassium
of 6.8 mEq/L and ECG shows peaked T waves. What is the most
appropriate immediate intervention?
A. Administer sodium polystyrene sulfonate (Kayexalate) 30 g
orally
B. Give IV calcium gluconate 10 mL of 10% solution
C. Administer furosemide 40 mg IV
D. Initiate hemodialysis
Correct Answer: B
Explanation: This patient has life-threatening hyperkalemia
with ECG changes. IV calcium gluconate stabilizes cardiac
membranes and is the first-line treatment to prevent cardiac
arrest. Kayexalate works too slowly (hours), furosemide may not
