NRNP 6566 Advanced Care of Adults in Acute
Settings I – Exam V1 Questions and Answers
with Rationales 2026/2027 Update
Question 1
A 68-year-old male is admitted with crushing substernal chest pain and
ST-segment elevation in leads II, III, and aVF. His initial cardiac
troponin is significantly elevated. What is the immediate priority
reperfusion strategy?
A) Administration of systemic alteplase within 3 hours
B) Urgent percutaneous coronary intervention (PCI) within 90
minutes
C) Conservative medical management with beta-blockers and dual
antiplatelet therapy
D) Emergent coronary artery bypass graft surgery
Answer: B) Urgent percutaneous coronary intervention (PCI) within 90
minutes
Rationale: This patient is presenting with an acute inferior STEMI.
Primary PCI is the gold standard reperfusion strategy and should be
performed within 90 minutes of first medical contact. Fibrinolytics are
reserved only if PCI cannot be achieved within 120 minutes and no
contraindications exist.
Question 2
According to the Surviving Sepsis Campaign guidelines, which agent is
recommended as the first-line vasopressor of choice for managing
persistent hypotension in septic shock?
, A) Dopamine
B) Phenylephrine
C) Norepinephrine
D) Epinephrine
Answer: C) Norepinephrine
Rationale: Norepinephrine provides potent alpha-1 vasoconstriction to
restore systemic vascular resistance and mean arterial pressure,
alongside minimal beta-1 inotropic effects, making it superior and safer
than dopamine for septic shock.
Question 3
A patient in the intensive care unit with diabetic ketoacidosis has an
initial serum potassium level of 3.1 mEq/L. Which clinical action must
be performed prior to initiating the continuous regular insulin infusion?
A) Administer a 500 mL normal saline bolus only
B) Administer intravenous potassium repletion and withhold
insulin until potassium exceeds 3.3 mEq/L
C) Start a bicarbonate drip to correct the acidosis
D) Proceed directly with standard weight-based insulin dosing
Answer: B) Administer intravenous potassium repletion and withhold
insulin until potassium exceeds 3.3 mEq/L
Rationale: Insulin shifts potassium from the extracellular space into
intracellular compartments. If insulin is given when serum potassium is
below 3.3 mEq/L, it can precipitate life-threatening cardiac arrhythmias
and profound muscle paralysis.
Question 4
A mechanically ventilated patient with status asthmaticus and chronic
obstructive pulmonary disease develops sudden severe hypotension and
,elevated peak inspiratory pressures. High levels of auto-PEEP (intrinsic
PEEP) are identified. Which ventilator adjustments should be made?
A) Increase the tidal volume and increase the respiratory rate
B) Decrease the respiratory rate and decrease the tidal volume to
allow longer expiratory time
C) Increase the fraction of inspired oxygen and add extra external
PEEP
D) Switch from volume control to continuous positive airway
pressure
Answer: B) Decrease the respiratory rate and decrease the tidal volume
to allow longer expiratory time
Rationale: Auto-PEEP occurs due to incomplete exhalation and air
trapping. Reducing the respiratory rate and tidal volume lengthens the
expiratory phase, letting trapped air escape and restoring hemodynamic
stability.
Question 5
A 66-year-old female is admitted to the ICU with hospital-acquired
pneumonia involving consolidation of the right lower lobe. Arterial
blood gases reveal a PaO2 of 55 mmHg on room air. Which
physiological mechanism primarily accounts for this patient's
hypoxemia?
A) Alveolar hypoventilation
B) Diffusion limitation
C) Ventilation-perfusion (V/Q) mismatch
D) Right-to-left anatomical shunt
Answer: C) Ventilation-perfusion (V/Q) mismatch
Rationale: Pneumonia causes alveolar exudate and collapse, meaning
blood passes through poorly ventilated alveoli without picking up
adequate oxygen, resulting in a classic ventilation-perfusion mismatch.
, Question 6
A 46-year-old male with normal baseline renal function is diagnosed
with heparin-induced thrombocytopenia (HIT). In addition to
immediately stopping all heparin products, which pharmacological agent
should be initiated for alternative anticoagulation?
A) Low-molecular-weight heparin like enoxaparin
B) Direct thrombin inhibitor like argatroban
C) Oral warfarin loading dose as monotherapy
D) Therapeutic prophylactic aspirin and clopidogrel
Answer: B) Direct thrombin inhibitor like argatroban
Rationale: HIT is an immune-mediated thrombotic condition. All
sources of heparin must cease, and a non-heparin anticoagulant—such as
the direct thrombin inhibitor argatroban or bivalirudin—must be started
to manage ongoing thrombosis risk.
Question 7
A 56-year-old male with newly diagnosed multiple myeloma presents
with severe back pain and a serum calcium level of 12.7 mg/dL. Which
initial combination therapy is indicated for acute management of this
severe hypercalcemia?
A) Aggressive intravenous normal saline hydration and loop
diuretics (after volume status is optimized)
B) Fluid restriction and oral potassium supplements
C) High-dose oral calcium and thiazide diuretics
D) Immediate hemodialysis without prior fluid resuscitation
Answer: A) Aggressive intravenous normal saline hydration and loop
diuretics (after volume status is optimized)
Rationale: Severe hypercalcemia requires immediate volume expansion
with isotonic saline to restore intravascular volume and promote renal
Settings I – Exam V1 Questions and Answers
with Rationales 2026/2027 Update
Question 1
A 68-year-old male is admitted with crushing substernal chest pain and
ST-segment elevation in leads II, III, and aVF. His initial cardiac
troponin is significantly elevated. What is the immediate priority
reperfusion strategy?
A) Administration of systemic alteplase within 3 hours
B) Urgent percutaneous coronary intervention (PCI) within 90
minutes
C) Conservative medical management with beta-blockers and dual
antiplatelet therapy
D) Emergent coronary artery bypass graft surgery
Answer: B) Urgent percutaneous coronary intervention (PCI) within 90
minutes
Rationale: This patient is presenting with an acute inferior STEMI.
Primary PCI is the gold standard reperfusion strategy and should be
performed within 90 minutes of first medical contact. Fibrinolytics are
reserved only if PCI cannot be achieved within 120 minutes and no
contraindications exist.
Question 2
According to the Surviving Sepsis Campaign guidelines, which agent is
recommended as the first-line vasopressor of choice for managing
persistent hypotension in septic shock?
, A) Dopamine
B) Phenylephrine
C) Norepinephrine
D) Epinephrine
Answer: C) Norepinephrine
Rationale: Norepinephrine provides potent alpha-1 vasoconstriction to
restore systemic vascular resistance and mean arterial pressure,
alongside minimal beta-1 inotropic effects, making it superior and safer
than dopamine for septic shock.
Question 3
A patient in the intensive care unit with diabetic ketoacidosis has an
initial serum potassium level of 3.1 mEq/L. Which clinical action must
be performed prior to initiating the continuous regular insulin infusion?
A) Administer a 500 mL normal saline bolus only
B) Administer intravenous potassium repletion and withhold
insulin until potassium exceeds 3.3 mEq/L
C) Start a bicarbonate drip to correct the acidosis
D) Proceed directly with standard weight-based insulin dosing
Answer: B) Administer intravenous potassium repletion and withhold
insulin until potassium exceeds 3.3 mEq/L
Rationale: Insulin shifts potassium from the extracellular space into
intracellular compartments. If insulin is given when serum potassium is
below 3.3 mEq/L, it can precipitate life-threatening cardiac arrhythmias
and profound muscle paralysis.
Question 4
A mechanically ventilated patient with status asthmaticus and chronic
obstructive pulmonary disease develops sudden severe hypotension and
,elevated peak inspiratory pressures. High levels of auto-PEEP (intrinsic
PEEP) are identified. Which ventilator adjustments should be made?
A) Increase the tidal volume and increase the respiratory rate
B) Decrease the respiratory rate and decrease the tidal volume to
allow longer expiratory time
C) Increase the fraction of inspired oxygen and add extra external
PEEP
D) Switch from volume control to continuous positive airway
pressure
Answer: B) Decrease the respiratory rate and decrease the tidal volume
to allow longer expiratory time
Rationale: Auto-PEEP occurs due to incomplete exhalation and air
trapping. Reducing the respiratory rate and tidal volume lengthens the
expiratory phase, letting trapped air escape and restoring hemodynamic
stability.
Question 5
A 66-year-old female is admitted to the ICU with hospital-acquired
pneumonia involving consolidation of the right lower lobe. Arterial
blood gases reveal a PaO2 of 55 mmHg on room air. Which
physiological mechanism primarily accounts for this patient's
hypoxemia?
A) Alveolar hypoventilation
B) Diffusion limitation
C) Ventilation-perfusion (V/Q) mismatch
D) Right-to-left anatomical shunt
Answer: C) Ventilation-perfusion (V/Q) mismatch
Rationale: Pneumonia causes alveolar exudate and collapse, meaning
blood passes through poorly ventilated alveoli without picking up
adequate oxygen, resulting in a classic ventilation-perfusion mismatch.
, Question 6
A 46-year-old male with normal baseline renal function is diagnosed
with heparin-induced thrombocytopenia (HIT). In addition to
immediately stopping all heparin products, which pharmacological agent
should be initiated for alternative anticoagulation?
A) Low-molecular-weight heparin like enoxaparin
B) Direct thrombin inhibitor like argatroban
C) Oral warfarin loading dose as monotherapy
D) Therapeutic prophylactic aspirin and clopidogrel
Answer: B) Direct thrombin inhibitor like argatroban
Rationale: HIT is an immune-mediated thrombotic condition. All
sources of heparin must cease, and a non-heparin anticoagulant—such as
the direct thrombin inhibitor argatroban or bivalirudin—must be started
to manage ongoing thrombosis risk.
Question 7
A 56-year-old male with newly diagnosed multiple myeloma presents
with severe back pain and a serum calcium level of 12.7 mg/dL. Which
initial combination therapy is indicated for acute management of this
severe hypercalcemia?
A) Aggressive intravenous normal saline hydration and loop
diuretics (after volume status is optimized)
B) Fluid restriction and oral potassium supplements
C) High-dose oral calcium and thiazide diuretics
D) Immediate hemodialysis without prior fluid resuscitation
Answer: A) Aggressive intravenous normal saline hydration and loop
diuretics (after volume status is optimized)
Rationale: Severe hypercalcemia requires immediate volume expansion
with isotonic saline to restore intravascular volume and promote renal
