NRNP 6566 Advanced Care of Adults in Acute
Settings I – Final Exam Questions and Answers
with Rationales 2026/2027 Update
Question 1
A 58 year old male is in septic shock secondary to pneumonia. Despite
adequate fluid resuscitation with crystalloids, his mean arterial pressure
is 54 mmHg and systemic vascular resistance is low. Which agent
should be initiated first?
A) Dopamine
B) Norepinephrine
C) Phenylephrine
D) Epinephrine
Answer: B) Norepinephrine
Rationale: Norepinephrine is the first line vasopressor recommended in
septic shock to restore vascular tone via alpha 1 agonism while
providing mild beta 1 inotropic support.
Question 2
Which hemodynamic parameter directly reflects left ventricular end
diastolic pressure in a patient with a pulmonary artery catheter when no
mitral valve disease is present?
A) Central Venous Pressure
, B) Pulmonary Artery Systolic Pressure
C) Pulmonary Artery Wedge Pressure
D) Systemic Vascular Resistance
Answer: C) Pulmonary Artery Wedge Pressure
Rationale: When the balloon is inflated, pulmonary artery wedge
pressure reflects left atrial pressure, which serves as a reliable surrogate
for left ventricular end diastolic pressure preload.
Question 3
A patient with acute respiratory distress syndrome on mechanical
ventilation has persistent refractory hypoxemia despite low tidal
volumes. What is the most appropriate next step?
A) Increase the positive end expiratory pressure
B) Increase the tidal volume to 10 mL per kg
C) Switch to synchronized intermittent mandatory ventilation mode
immediately
D) Administer high dose loop diuretics
Answer: A) Increase the positive end expiratory pressure
Rationale: Optimizing positive end expiratory pressure helps recruit
collapsed alveoli, reduce intrapulmonary shunting, and improve
oxygenation without risking volutrauma from high tidal volumes.
Question 4
A mechanically ventilated patient develops sudden hypotension, absent
breath sounds on the right side, and high peak inspiratory pressures.
What is the immediate priority?
, A) Order a STAT portable chest X ray
B) Draw an arterial blood gas
C) Perform needle decompression of the right chest
D) Increase the ventilator respiratory rate
Answer: C) Perform needle decompression of the right chest
Rationale: These findings indicate a life threatening tension
pneumothorax, requiring immediate decompression before diagnostic
imaging.
Question 5
A patient presents with lethargy, pH 7.28, PaO2 90, PaCO2 30, HCO3
14, Na 138, Cl 102, K 5.2. What is the acid base disorder?
A) High anion gap metabolic acidosis with appropriate respiratory
compensation
B) Normal anion gap metabolic acidosis with respiratory alkalosis
C) Metabolic alkalosis with respiratory acidosis
D) Primary respiratory acidosis with metabolic compensation
Answer: A) High anion gap metabolic acidosis with appropriate
respiratory compensation
Rationale: The anion gap is 22 calculated as sodium minus chloride plus
bicarbonate, indicating a high anion gap metabolic acidosis. The PaCO2
matches expected respiratory compensation using Winters formula.
Question 6
, A patient with rhabdomyolysis has a potassium of 6.8 mEq per liter and
peaked T waves on the ECG. Which treatment must be given first to
protect the heart?
A) Intravenous regular insulin with 50 percent dextrose
B) Intravenous calcium gluconate
C) Oral sodium polystyrene sulfonate
D) Intravenous sodium bicarbonate
Answer: B) Intravenous calcium gluconate
Rationale: Intravenous calcium stabilizes the cardiac cell membrane
against lethal arrhythmias within minutes, whereas insulin and dextrose
and binders take longer to shift or eliminate potassium.
Question 7
A patient receiving heparin develops a platelet drop from 240000 to
70000 per microliter on day 6, along with a new deep vein thrombosis.
What is the correct next step?
A) Decrease heparin infusion by half and recheck platelets in 24
hours
B) Stop all heparin products and initiate a direct thrombin inhibitor
like argatroban
C) Administer a platelet transfusion immediately and continue
heparin
D) Switch from unfractionated heparin to low molecular weight
heparin
Answer: B) Stop all heparin products and initiate a direct thrombin
inhibitor like argatroban
Settings I – Final Exam Questions and Answers
with Rationales 2026/2027 Update
Question 1
A 58 year old male is in septic shock secondary to pneumonia. Despite
adequate fluid resuscitation with crystalloids, his mean arterial pressure
is 54 mmHg and systemic vascular resistance is low. Which agent
should be initiated first?
A) Dopamine
B) Norepinephrine
C) Phenylephrine
D) Epinephrine
Answer: B) Norepinephrine
Rationale: Norepinephrine is the first line vasopressor recommended in
septic shock to restore vascular tone via alpha 1 agonism while
providing mild beta 1 inotropic support.
Question 2
Which hemodynamic parameter directly reflects left ventricular end
diastolic pressure in a patient with a pulmonary artery catheter when no
mitral valve disease is present?
A) Central Venous Pressure
, B) Pulmonary Artery Systolic Pressure
C) Pulmonary Artery Wedge Pressure
D) Systemic Vascular Resistance
Answer: C) Pulmonary Artery Wedge Pressure
Rationale: When the balloon is inflated, pulmonary artery wedge
pressure reflects left atrial pressure, which serves as a reliable surrogate
for left ventricular end diastolic pressure preload.
Question 3
A patient with acute respiratory distress syndrome on mechanical
ventilation has persistent refractory hypoxemia despite low tidal
volumes. What is the most appropriate next step?
A) Increase the positive end expiratory pressure
B) Increase the tidal volume to 10 mL per kg
C) Switch to synchronized intermittent mandatory ventilation mode
immediately
D) Administer high dose loop diuretics
Answer: A) Increase the positive end expiratory pressure
Rationale: Optimizing positive end expiratory pressure helps recruit
collapsed alveoli, reduce intrapulmonary shunting, and improve
oxygenation without risking volutrauma from high tidal volumes.
Question 4
A mechanically ventilated patient develops sudden hypotension, absent
breath sounds on the right side, and high peak inspiratory pressures.
What is the immediate priority?
, A) Order a STAT portable chest X ray
B) Draw an arterial blood gas
C) Perform needle decompression of the right chest
D) Increase the ventilator respiratory rate
Answer: C) Perform needle decompression of the right chest
Rationale: These findings indicate a life threatening tension
pneumothorax, requiring immediate decompression before diagnostic
imaging.
Question 5
A patient presents with lethargy, pH 7.28, PaO2 90, PaCO2 30, HCO3
14, Na 138, Cl 102, K 5.2. What is the acid base disorder?
A) High anion gap metabolic acidosis with appropriate respiratory
compensation
B) Normal anion gap metabolic acidosis with respiratory alkalosis
C) Metabolic alkalosis with respiratory acidosis
D) Primary respiratory acidosis with metabolic compensation
Answer: A) High anion gap metabolic acidosis with appropriate
respiratory compensation
Rationale: The anion gap is 22 calculated as sodium minus chloride plus
bicarbonate, indicating a high anion gap metabolic acidosis. The PaCO2
matches expected respiratory compensation using Winters formula.
Question 6
, A patient with rhabdomyolysis has a potassium of 6.8 mEq per liter and
peaked T waves on the ECG. Which treatment must be given first to
protect the heart?
A) Intravenous regular insulin with 50 percent dextrose
B) Intravenous calcium gluconate
C) Oral sodium polystyrene sulfonate
D) Intravenous sodium bicarbonate
Answer: B) Intravenous calcium gluconate
Rationale: Intravenous calcium stabilizes the cardiac cell membrane
against lethal arrhythmias within minutes, whereas insulin and dextrose
and binders take longer to shift or eliminate potassium.
Question 7
A patient receiving heparin develops a platelet drop from 240000 to
70000 per microliter on day 6, along with a new deep vein thrombosis.
What is the correct next step?
A) Decrease heparin infusion by half and recheck platelets in 24
hours
B) Stop all heparin products and initiate a direct thrombin inhibitor
like argatroban
C) Administer a platelet transfusion immediately and continue
heparin
D) Switch from unfractionated heparin to low molecular weight
heparin
Answer: B) Stop all heparin products and initiate a direct thrombin
inhibitor like argatroban
