NR 575 ACUTE CARE PRACTICUM II
COMPREHENSIVE EXAMINATION: ADVANCED
PRACTICE NURSING ACUTE CARE CLINICAL
MANAGEMENT STUDY GUIDE
SECTION 1: ADVANCED RESPIRATORY MANAGEMENT AND CRITICAL CARE
1. A patient in the ICU has a PaO2 of 55 mmHg, PaCO2 of 52 mmHg, and pH of 7.28 on
room air. Which interpretation is most accurate?
[ ] A. Metabolic acidosis with partial compensation
[ ] B. Respiratory alkalosis with metabolic compensation
[x] C. Respiratory acidosis with hypoxemia
[ ] D. Mixed metabolic and respiratory alkalosis
Rationale: Elevated PaCO2 with low pH indicates respiratory acidosis. The low PaO2
confirms concurrent hypoxemia, consistent with acute respiratory failure.
,2. Which ventilator setting change is most appropriate for a patient with ARDS who
develops worsening hypoxemia despite FiO2 of 60%?
[ ] A. Increase tidal volume to 10 mL/kg
[x] B. Increase PEEP incrementally
[ ] C. Decrease respiratory rate
[ ] D. Switch to volumecontrolled SIMV only
Rationale: Increasing PEEP recruits collapsed alveoli and improves oxygenation in ARDS.
Tidal volumes should remain low at 6 mL/kg to prevent volutrauma.
3. A patient intubated for acute respiratory failure develops sudden hypotension, absent
breath sounds on the left, and tracheal deviation to the right. The ACNP's priority
intervention is:
[ ] A. Order a STAT chest Xray
[ ] B. Increase the FiO2 to 100%
[x] C. Perform needle decompression at the second intercostal space
[ ] D. Reposition the endotracheal tube
Rationale: The clinical triad of absent breath sounds, tracheal deviation, and hypotension
indicates a tension pneumothorax requiring immediate needle decompression.
,4. Which parameter best guides successful extubation readiness in a mechanically
ventilated patient?
[ ] A. PaCO2 less than 60 mmHg
[x] B. Rapid Shallow Breathing Index (RSBI) less than 105
[ ] C. FiO2 of 80% or higher
[ ] D. PEEP greater than 10 cm H2O
Rationale: An RSBI below 105 breaths/min/L indicates the patient can likely sustain
spontaneous breathing and is a widely used extubation predictor.
5. A hospitalized patient develops fever, purulent sputum, new infiltrate on chest Xray, and
leukocytosis 72 hours after intubation. The most likely diagnosis is:
[ ] A. Aspiration pneumonitis
[x] B. Ventilatorassociated pneumonia
[ ] C. Pulmonary embolism
[ ] D. ARDS
Rationale: VAP is defined as pneumonia occurring more than 48 hours after intubation
and is characterized by new infiltrates, fever, and purulent secretions.
, 6. Which protective lung strategy is most evidencebased for ARDS management?
[ ] A. Tidal volume of 1012 mL/kg ideal body weight
[x] B. Low tidal volume ventilation at 6 mL/kg ideal body weight
[ ] C. Highfrequency oscillation in all patients
[ ] D. Prone positioning for all ARDS patients regardless of severity
Rationale: ARDSNet protocols established low tidal volume ventilation (6 mL/kg IBW) as
the gold standard, reducing mortality significantly.
7. A patient with COPD exacerbation is increasingly somnolent with a pH of 7.30 and
PaCO2 of 72 mmHg despite BiPAP therapy. The next appropriate step is:
[x] A. Intubation and mechanical ventilation
[ ] B. Increase BiPAP pressure settings and observe for 6 more hours
[ ] C. Add oral theophylline
[ ] D. Administer highflow oxygen at 15 L/min
Rationale: Worsening somnolence with deteriorating ABGs despite NIV indicates BiPAP
failure and the need for invasive mechanical ventilation.
8. Prone positioning in ARDS is indicated when the PaO2/FiO2 ratio is:
COMPREHENSIVE EXAMINATION: ADVANCED
PRACTICE NURSING ACUTE CARE CLINICAL
MANAGEMENT STUDY GUIDE
SECTION 1: ADVANCED RESPIRATORY MANAGEMENT AND CRITICAL CARE
1. A patient in the ICU has a PaO2 of 55 mmHg, PaCO2 of 52 mmHg, and pH of 7.28 on
room air. Which interpretation is most accurate?
[ ] A. Metabolic acidosis with partial compensation
[ ] B. Respiratory alkalosis with metabolic compensation
[x] C. Respiratory acidosis with hypoxemia
[ ] D. Mixed metabolic and respiratory alkalosis
Rationale: Elevated PaCO2 with low pH indicates respiratory acidosis. The low PaO2
confirms concurrent hypoxemia, consistent with acute respiratory failure.
,2. Which ventilator setting change is most appropriate for a patient with ARDS who
develops worsening hypoxemia despite FiO2 of 60%?
[ ] A. Increase tidal volume to 10 mL/kg
[x] B. Increase PEEP incrementally
[ ] C. Decrease respiratory rate
[ ] D. Switch to volumecontrolled SIMV only
Rationale: Increasing PEEP recruits collapsed alveoli and improves oxygenation in ARDS.
Tidal volumes should remain low at 6 mL/kg to prevent volutrauma.
3. A patient intubated for acute respiratory failure develops sudden hypotension, absent
breath sounds on the left, and tracheal deviation to the right. The ACNP's priority
intervention is:
[ ] A. Order a STAT chest Xray
[ ] B. Increase the FiO2 to 100%
[x] C. Perform needle decompression at the second intercostal space
[ ] D. Reposition the endotracheal tube
Rationale: The clinical triad of absent breath sounds, tracheal deviation, and hypotension
indicates a tension pneumothorax requiring immediate needle decompression.
,4. Which parameter best guides successful extubation readiness in a mechanically
ventilated patient?
[ ] A. PaCO2 less than 60 mmHg
[x] B. Rapid Shallow Breathing Index (RSBI) less than 105
[ ] C. FiO2 of 80% or higher
[ ] D. PEEP greater than 10 cm H2O
Rationale: An RSBI below 105 breaths/min/L indicates the patient can likely sustain
spontaneous breathing and is a widely used extubation predictor.
5. A hospitalized patient develops fever, purulent sputum, new infiltrate on chest Xray, and
leukocytosis 72 hours after intubation. The most likely diagnosis is:
[ ] A. Aspiration pneumonitis
[x] B. Ventilatorassociated pneumonia
[ ] C. Pulmonary embolism
[ ] D. ARDS
Rationale: VAP is defined as pneumonia occurring more than 48 hours after intubation
and is characterized by new infiltrates, fever, and purulent secretions.
, 6. Which protective lung strategy is most evidencebased for ARDS management?
[ ] A. Tidal volume of 1012 mL/kg ideal body weight
[x] B. Low tidal volume ventilation at 6 mL/kg ideal body weight
[ ] C. Highfrequency oscillation in all patients
[ ] D. Prone positioning for all ARDS patients regardless of severity
Rationale: ARDSNet protocols established low tidal volume ventilation (6 mL/kg IBW) as
the gold standard, reducing mortality significantly.
7. A patient with COPD exacerbation is increasingly somnolent with a pH of 7.30 and
PaCO2 of 72 mmHg despite BiPAP therapy. The next appropriate step is:
[x] A. Intubation and mechanical ventilation
[ ] B. Increase BiPAP pressure settings and observe for 6 more hours
[ ] C. Add oral theophylline
[ ] D. Administer highflow oxygen at 15 L/min
Rationale: Worsening somnolence with deteriorating ABGs despite NIV indicates BiPAP
failure and the need for invasive mechanical ventilation.
8. Prone positioning in ARDS is indicated when the PaO2/FiO2 ratio is:
