Final Exam: NRNP 6566 / NRNP6566 Advanced Care of
Adults in Acute Settings I | ACTUAL EXAM | ACTUAL
Questions and Verified Answers | Latest
Update – Walden University
1. A 68-year-old man with a history of COPD presents to the ED with increasing
dyspnea, tachypnea, and accessory muscle use. ABG on 6 L NC: pH 7.28, PaCO₂
72 mmHg, PaO₂ 58 mmHg, HCO₃⁻ 34 mEq/L. Which acid-base disorder is
present?
A. Acute respiratory acidosis
B. Acute metabolic acidosis
C. Chronic respiratory acidosis with acute-on-chronic exacerbation
D. Chronic metabolic alkalosis
Correct Answer: C
Rationale: pH is acidemic, PaCO₂ is markedly elevated (consistent with respiratory
acidosis), and HCO₃⁻ is elevated (renal compensation). The degree of HCO₃⁻ elevation
(>30 mEq/L) indicates chronic compensation; the pH still being low reflects an
acute-on-chronic exacerbation. Acute respiratory acidosis (A) would show normal or
near-normal HCO₃⁻. Metabolic acidosis (B) would have low HCO₃⁻. Metabolic alkalosis
(D) would have elevated pH.
, 2. A 54-year-old woman post-MI develops sudden-onset pulmonary edema and a
new holosystolic murmur at the apex radiating to the axilla. BP 88/50 mmHg, HR
110 bpm. Which is the most likely cause?
A. Acute mitral regurgitation from papillary-muscle rupture
B. Acute aortic stenosis
C. Ventricular septal defect
D. Pericarditis
Correct Answer: A
Rationale: Papillary-muscle rupture post-MI causes acute MR, presenting with
pulmonary edema and a new holosystolic murmur. The murmur of VSD (C) is heard at
the left sternal border. AS (B) would have a crescendo-decrescendo murmur and chronic
history. Pericarditis (D) presents with friction rub and chest pain, not murmur.
3. A 72-year-old woman presents with acute ischemic stroke (NIHSS 14) and is
within the IV tPA window. CT shows no hemorrhage. BP 190/105 mmHg. Which
action is required before tPA?
A. Administer labetalol 10 mg IV to lower BP to ≤185/110 mmHg
B. Begin nicardipine infusion to lower BP to <160/90 mmHg
C. No BP management needed if asymptomatic
D. Administer nitroglycerin paste
Correct Answer: A
,Rationale: AHA guidelines require BP ≤185/110 mmHg before and for 24 h after tPA.
Labetalol is first-line for rapid control. Nicardipine (B) is acceptable but not listed as
first. Nitropaste (D) is unpredictable. Option C violates safety protocols.
4. A 28-year-old man presents with severe epigastric pain radiating to the back,
nausea, and vomiting. Lipase 3,400 U/L. CT shows peripancreatic fluid and
necrosis >30 %. Which scoring system best predicts mortality in acute
pancreatitis?
A. CURB-65
B. Ranson criteria
C. Alvarado score
D. Wells score
Correct Answer: B
Rationale: Ranson criteria assess severity and mortality risk in acute pancreatitis.
CURB-65 (A) predicts pneumonia mortality. Alvarado (C) diagnoses appendicitis. Wells
(D) estimates DVT/PE risk.
5. A 61-year-old diabetic patient on metformin is admitted with lactic acidosis (pH
7.20, lactate 6 mmol/L). Cr 2.8 mg/dL. Which is the priority intervention?
A. Continue metformin at half dose
B. Initiate hemodialysis
, C. Start sodium bicarbonate drip
D. Switch to insulin drip only
Correct Answer: B
Rationale: Metformin-associated lactic acidosis with renal failure and lactate >5 mmol/L
is a dialyzable toxin emergency. Hemodialysis clears metformin and corrects acidosis.
Bicarbonate (C) is adjunct. Continuing metformin (A) is contraindicated.
6. A 45-year-old woman presents with acute asthma exacerbation. Peak flow 45 %
predicted, SpO₂ 89 %, unable to speak in phrases. Which medication is most
appropriate next?
A. Albuterol 2.5 mg nebulizer
B. Magnesium sulfate 2 g IV
C. Epinephrine 0.5 mg IM
D. Cromolyn nebulizer
Correct Answer: B
Rationale: Severe exacerbation (peak flow <50 %, SpO₂ <90 %) unresponsive to initial
bronchodilators warrants IV magnesium to reduce inflammation and improve FEV₁.
Albuterol (A) already given. Epinephrine (C) is for anaphylaxis. Cromolyn (D) is
preventive, not acute.
Adults in Acute Settings I | ACTUAL EXAM | ACTUAL
Questions and Verified Answers | Latest
Update – Walden University
1. A 68-year-old man with a history of COPD presents to the ED with increasing
dyspnea, tachypnea, and accessory muscle use. ABG on 6 L NC: pH 7.28, PaCO₂
72 mmHg, PaO₂ 58 mmHg, HCO₃⁻ 34 mEq/L. Which acid-base disorder is
present?
A. Acute respiratory acidosis
B. Acute metabolic acidosis
C. Chronic respiratory acidosis with acute-on-chronic exacerbation
D. Chronic metabolic alkalosis
Correct Answer: C
Rationale: pH is acidemic, PaCO₂ is markedly elevated (consistent with respiratory
acidosis), and HCO₃⁻ is elevated (renal compensation). The degree of HCO₃⁻ elevation
(>30 mEq/L) indicates chronic compensation; the pH still being low reflects an
acute-on-chronic exacerbation. Acute respiratory acidosis (A) would show normal or
near-normal HCO₃⁻. Metabolic acidosis (B) would have low HCO₃⁻. Metabolic alkalosis
(D) would have elevated pH.
, 2. A 54-year-old woman post-MI develops sudden-onset pulmonary edema and a
new holosystolic murmur at the apex radiating to the axilla. BP 88/50 mmHg, HR
110 bpm. Which is the most likely cause?
A. Acute mitral regurgitation from papillary-muscle rupture
B. Acute aortic stenosis
C. Ventricular septal defect
D. Pericarditis
Correct Answer: A
Rationale: Papillary-muscle rupture post-MI causes acute MR, presenting with
pulmonary edema and a new holosystolic murmur. The murmur of VSD (C) is heard at
the left sternal border. AS (B) would have a crescendo-decrescendo murmur and chronic
history. Pericarditis (D) presents with friction rub and chest pain, not murmur.
3. A 72-year-old woman presents with acute ischemic stroke (NIHSS 14) and is
within the IV tPA window. CT shows no hemorrhage. BP 190/105 mmHg. Which
action is required before tPA?
A. Administer labetalol 10 mg IV to lower BP to ≤185/110 mmHg
B. Begin nicardipine infusion to lower BP to <160/90 mmHg
C. No BP management needed if asymptomatic
D. Administer nitroglycerin paste
Correct Answer: A
,Rationale: AHA guidelines require BP ≤185/110 mmHg before and for 24 h after tPA.
Labetalol is first-line for rapid control. Nicardipine (B) is acceptable but not listed as
first. Nitropaste (D) is unpredictable. Option C violates safety protocols.
4. A 28-year-old man presents with severe epigastric pain radiating to the back,
nausea, and vomiting. Lipase 3,400 U/L. CT shows peripancreatic fluid and
necrosis >30 %. Which scoring system best predicts mortality in acute
pancreatitis?
A. CURB-65
B. Ranson criteria
C. Alvarado score
D. Wells score
Correct Answer: B
Rationale: Ranson criteria assess severity and mortality risk in acute pancreatitis.
CURB-65 (A) predicts pneumonia mortality. Alvarado (C) diagnoses appendicitis. Wells
(D) estimates DVT/PE risk.
5. A 61-year-old diabetic patient on metformin is admitted with lactic acidosis (pH
7.20, lactate 6 mmol/L). Cr 2.8 mg/dL. Which is the priority intervention?
A. Continue metformin at half dose
B. Initiate hemodialysis
, C. Start sodium bicarbonate drip
D. Switch to insulin drip only
Correct Answer: B
Rationale: Metformin-associated lactic acidosis with renal failure and lactate >5 mmol/L
is a dialyzable toxin emergency. Hemodialysis clears metformin and corrects acidosis.
Bicarbonate (C) is adjunct. Continuing metformin (A) is contraindicated.
6. A 45-year-old woman presents with acute asthma exacerbation. Peak flow 45 %
predicted, SpO₂ 89 %, unable to speak in phrases. Which medication is most
appropriate next?
A. Albuterol 2.5 mg nebulizer
B. Magnesium sulfate 2 g IV
C. Epinephrine 0.5 mg IM
D. Cromolyn nebulizer
Correct Answer: B
Rationale: Severe exacerbation (peak flow <50 %, SpO₂ <90 %) unresponsive to initial
bronchodilators warrants IV magnesium to reduce inflammation and improve FEV₁.
Albuterol (A) already given. Epinephrine (C) is for anaphylaxis. Cromolyn (D) is
preventive, not acute.
