NRNP 6566 Advanced Care of Adults in Acute
Settings I – Midterm Exam Questions and Answers
with Rationales 2026/2027 Update
Question 1
A 62 year old patient is admitted to the intensive care unit with septic
shock. Despite initial fluid resuscitation with 30 mL per kg of
crystalloids, their mean arterial pressure is 58 mmHg and systemic
vascular resistance is markedly low. Which vasoactive agent is
recommended as the first line therapy?
A) Dopamine
B) Norepinephrine
C) Phenylephrine
D) Epinephrine
Answer: B) Norepinephrine
Rationale: Norepinephrine is the first line vasopressor recommended in
international guidelines for septic shock. It provides potent alpha 1
vasoconstriction to restore systemic vascular resistance and mean
arterial pressure, along with modest beta 1 inotropic support.
Question 2
Which hemodynamic parameter directly reflects left ventricular end
diastolic pressure in the absence of mitral valve disease or pulmonary
hypertension?
A) Central Venous Pressure
B) Pulmonary Artery Systolic Pressure
, C) Pulmonary Artery Wedge Pressure
D) Systemic Vascular Resistance Index
Answer: C) Pulmonary Artery Wedge Pressure
Rationale: When the pulmonary artery catheter balloon is inflated, it
occludes forward flow and measures downstream pressure from the left
atrium, which serves as a reliable surrogate for left ventricular end
diastolic pressure and preload.
Question 3
An adult patient with acute respiratory distress syndrome is
mechanically ventilated using lung protective strategies. Which
parameter is critical to monitor and keep below 30 cmH2O to prevent
ventilator induced lung injury or volutrauma?
A) Peak inspiratory pressure
B) Plateau pressure
C) Positive end expiratory pressure
D) Mean airway pressure
Answer: B) Plateau pressure
Rationale: Keeping plateau pressure below 30 cmH2O minimizes
alveolar overdistension and reduces the risk of barotrauma and
volutrauma in patients with acute respiratory distress syndrome.
Question 4
A mechanically ventilated patient in the surgical intensive care unit
suddenly develops acute respiratory distress, tracheal deviation to the
left, absent breath sounds on the right hemithorax, and profound
hypotension. What is the immediate priority action?
, A) Order an urgent portable chest X ray
B) Perform needle decompression of the right chest
C) Increase the ventilator positive end expiratory pressure
D) Administer IV loop diuretics
Answer: B) Perform needle decompression of the right chest
Rationale: These findings are classic for a life threatening tension
pneumothorax, which causes obstructive shock. Immediate needle
decompression in the second intercostal space at the midclavicular line
is required before any diagnostic imaging.
Question 5
A patient presents with lethargy, deep Kussmaul respirations, and an
arterial blood gas showing pH 7.26, PaO2 92 mmHg, PaCO2 31 mmHg,
and HCO3 13 mEq per liter. Serum sodium is 138 mEq per liter and
chloride is 102 mEq per liter. What is the primary acid base disorder?
A) High anion gap metabolic acidosis with appropriate respiratory
compensation
B) Normal anion gap metabolic acidosis with respiratory alkalosis
C) Primary respiratory acidosis with metabolic compensation
D) Metabolic alkalosis with respiratory acidosis
Answer: A) High anion gap metabolic acidosis with appropriate
respiratory compensation
Rationale: The anion gap is 23 calculated as sodium minus chloride plus
bicarbonate, indicating a high anion gap metabolic acidosis. The low
PaCO2 reflects appropriate respiratory compensation via
hyperventilation using Winters formula.
, Question 6
A patient with severe rhabdomyolysis has a serum potassium of 7.1 mEq
per liter and peaked T waves on the electrocardiogram. Which
medication must be administered first to stabilize the cardiac membrane
against lethal arrhythmias?
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 salts act within minutes to stabilize the
myocardial cell membrane and prevent lethal arrhythmias during severe
hyperkalemia, whereas shifts and elimination agents take longer to work.
Question 7
A patient receiving unfractionated heparin therapy develops a drop in
platelet count from 250000 to 65000 per microliter on day 7, alongside a
new deep vein thrombosis. What is the mandatory next step?
A) Decrease the heparin infusion rate by half and recheck platelets in
12 hours
B) Stop all heparin products immediately and start a direct thrombin
inhibitor like argatroban
C) Administer a stat platelet transfusion and continue heparin
D) Switch from unfractionated heparin to low molecular weight
heparin
Settings I – Midterm Exam Questions and Answers
with Rationales 2026/2027 Update
Question 1
A 62 year old patient is admitted to the intensive care unit with septic
shock. Despite initial fluid resuscitation with 30 mL per kg of
crystalloids, their mean arterial pressure is 58 mmHg and systemic
vascular resistance is markedly low. Which vasoactive agent is
recommended as the first line therapy?
A) Dopamine
B) Norepinephrine
C) Phenylephrine
D) Epinephrine
Answer: B) Norepinephrine
Rationale: Norepinephrine is the first line vasopressor recommended in
international guidelines for septic shock. It provides potent alpha 1
vasoconstriction to restore systemic vascular resistance and mean
arterial pressure, along with modest beta 1 inotropic support.
Question 2
Which hemodynamic parameter directly reflects left ventricular end
diastolic pressure in the absence of mitral valve disease or pulmonary
hypertension?
A) Central Venous Pressure
B) Pulmonary Artery Systolic Pressure
, C) Pulmonary Artery Wedge Pressure
D) Systemic Vascular Resistance Index
Answer: C) Pulmonary Artery Wedge Pressure
Rationale: When the pulmonary artery catheter balloon is inflated, it
occludes forward flow and measures downstream pressure from the left
atrium, which serves as a reliable surrogate for left ventricular end
diastolic pressure and preload.
Question 3
An adult patient with acute respiratory distress syndrome is
mechanically ventilated using lung protective strategies. Which
parameter is critical to monitor and keep below 30 cmH2O to prevent
ventilator induced lung injury or volutrauma?
A) Peak inspiratory pressure
B) Plateau pressure
C) Positive end expiratory pressure
D) Mean airway pressure
Answer: B) Plateau pressure
Rationale: Keeping plateau pressure below 30 cmH2O minimizes
alveolar overdistension and reduces the risk of barotrauma and
volutrauma in patients with acute respiratory distress syndrome.
Question 4
A mechanically ventilated patient in the surgical intensive care unit
suddenly develops acute respiratory distress, tracheal deviation to the
left, absent breath sounds on the right hemithorax, and profound
hypotension. What is the immediate priority action?
, A) Order an urgent portable chest X ray
B) Perform needle decompression of the right chest
C) Increase the ventilator positive end expiratory pressure
D) Administer IV loop diuretics
Answer: B) Perform needle decompression of the right chest
Rationale: These findings are classic for a life threatening tension
pneumothorax, which causes obstructive shock. Immediate needle
decompression in the second intercostal space at the midclavicular line
is required before any diagnostic imaging.
Question 5
A patient presents with lethargy, deep Kussmaul respirations, and an
arterial blood gas showing pH 7.26, PaO2 92 mmHg, PaCO2 31 mmHg,
and HCO3 13 mEq per liter. Serum sodium is 138 mEq per liter and
chloride is 102 mEq per liter. What is the primary acid base disorder?
A) High anion gap metabolic acidosis with appropriate respiratory
compensation
B) Normal anion gap metabolic acidosis with respiratory alkalosis
C) Primary respiratory acidosis with metabolic compensation
D) Metabolic alkalosis with respiratory acidosis
Answer: A) High anion gap metabolic acidosis with appropriate
respiratory compensation
Rationale: The anion gap is 23 calculated as sodium minus chloride plus
bicarbonate, indicating a high anion gap metabolic acidosis. The low
PaCO2 reflects appropriate respiratory compensation via
hyperventilation using Winters formula.
, Question 6
A patient with severe rhabdomyolysis has a serum potassium of 7.1 mEq
per liter and peaked T waves on the electrocardiogram. Which
medication must be administered first to stabilize the cardiac membrane
against lethal arrhythmias?
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 salts act within minutes to stabilize the
myocardial cell membrane and prevent lethal arrhythmias during severe
hyperkalemia, whereas shifts and elimination agents take longer to work.
Question 7
A patient receiving unfractionated heparin therapy develops a drop in
platelet count from 250000 to 65000 per microliter on day 7, alongside a
new deep vein thrombosis. What is the mandatory next step?
A) Decrease the heparin infusion rate by half and recheck platelets in
12 hours
B) Stop all heparin products immediately and start a direct thrombin
inhibitor like argatroban
C) Administer a stat platelet transfusion and continue heparin
D) Switch from unfractionated heparin to low molecular weight
heparin
