NR571 Complex Diagnosis & Management
in Acute Care ACTUAL EXAM 2024/2025 |
Midterm Exam Comprehensive Review |
Chamberlain University | Latest Update |
Verified Q&A | Pass Guaranteed - A+
Graded
SECTION 1: HEMODYNAMIC MONITORING AND SHOCK
STATES (25 Questions)
Q1: A 62-year-old patient in the ICU has a pulmonary artery catheter in place. Hemodynamic
parameters reveal: Cardiac Index 1.8 L/min/m², SVR 1600 dynes/sec/cm⁻⁵, CVP 16 mmHg,
PCWP 22 mmHg. What is the most likely diagnosis?
A. Hypovolemic shock
B. Distributive shock
C. Cardiogenic shock [CORRECT]
D. Obstructive shock
Correct Answer: C
Rationale: The patient has a low cardiac index (<2.2 L/min/m²) with elevated filling pressures
(CVP >12 mmHg, PCWP >18 mmHg) and elevated SVR, consistent with cardiogenic shock.
This pattern indicates primary pump failure with compensatory vasoconstriction.
Hypovolemic shock (A) would have low filling pressures. Distributive shock (B) would have
low SVR. Obstructive shock (D) may have elevated filling pressures with mechanical
obstruction but typically without primary pump failure.
Chamberlain Note: Remember the shock classification by hemodynamics: Cardiogenic = Low
CI + High SVR + High filling pressures; Hypovolemic = Low CI + High SVR + Low filling
,pressures; Distributive = Normal/High CI + Low SVR + Variable filling pressures; Obstructive =
Low CI + High SVR + Variable filling pressures.
Q2: A patient with septic shock is receiving norepinephrine infusion titrated to maintain MAP
>65 mmHg. The patient remains hypotensive with MAP 58 mmHg despite norepinephrine 30
mcg/min. What is the most appropriate next step in management?
A. Increase norepinephrine to 50 mcg/min
B. Add vasopressin as second-line vasopressor [CORRECT]
C. Administer a 500 mL fluid bolus
D. Start dobutamine for inotropic support
Correct Answer: B
Rationale: According to Surviving Sepsis Campaign 2021 guidelines, when norepinephrine
doses exceed 15-20 mcg/min, vasopressin (0.03 units/min) is recommended as a second-line
vasopressor to reduce norepinephrine dose and improve outcomes. Increasing
norepinephrine alone (A) may increase adverse effects without proportional benefit. Fluid
resuscitation (C) should be completed early in sepsis; at this stage, the patient is likely
euvolemic or overloaded. Dobutamine (D) is indicated for low cardiac output states, not
primarily for refractory hypotension.
Q3: During pulmonary artery catheter insertion, the waveform changes from a CVP pattern to
a pulmonary artery pressure pattern after advancing 15 cm. What does this indicate?
A. The catheter is in the right ventricle
B. The catheter has wedged in the pulmonary artery [CORRECT]
C. The catheter is in the pulmonary vein
D. The catheter is coiled in the right atrium
Correct Answer: B
Rationale: The transition from CVP waveform (a, c, v waves) to pulmonary artery waveform
(systolic peak, diastolic trough with dicrotic notch) indicates the catheter has advanced into
the pulmonary artery. The normal distance from right internal jugular insertion to pulmonary
artery is approximately 40-50 cm. A 15 cm advancement from CVP position suggests the
catheter has passed through the right ventricle and entered the pulmonary artery.
,Chamberlain Note: Normal catheter advancement distances: RA (20 cm) → RV (30-35 cm) →
PA (40-45 cm) → PCWP (45-50 cm). Always confirm placement with chest X-ray.
Q4: A 58-year-old patient post-cardiac surgery has the following hemodynamics: MAP 72
mmHg, CVP 14 mmHg, PCWP 18 mmHg, CI 2.2 L/min/m². The patient has cool extremities
and decreased urine output. What is the best interpretation?
A. Adequate perfusion with normal hemodynamics
B. Low cardiac output state requiring inotropic support [CORRECT]
C. Hypovolemia requiring fluid bolus
D. Vasodilatory shock requiring vasopressors
Correct Answer: B
Rationale: The patient has borderline low cardiac index (2.2 L/min/m², normal 2.5-4.0) with
elevated filling pressures (CVP 14, PCWP 18), indicating cardiac dysfunction despite adequate
blood pressure. The clinical picture of cool extremities and oliguria confirms inadequate
tissue perfusion. This represents a low cardiac output state requiring inotropic support
(dobutamine or milrinone) rather than more fluids or vasopressors.
Q5: Which of the following is the most reliable indicator of fluid responsiveness in a
mechanically ventilated patient with sinus rhythm?
A. Central venous pressure (CVP) >12 mmHg
B. Pulse pressure variation (PPV) >13% [CORRECT]
C. Mean arterial pressure (MAP) <65 mmHg
D. Mixed venous oxygen saturation (SvO2) <65%
Correct Answer: B
Rationale: Pulse pressure variation (PPV) >13% is the most reliable dynamic predictor of fluid
responsiveness in mechanically ventilated patients with sinus rhythm. PPV measures the
variation in pulse pressure during the respiratory cycle; values >13% indicate the patient will
respond to fluid loading. CVP (A) is a poor predictor of fluid responsiveness. MAP (C)
indicates perfusion pressure but not volume status. SvO2 (D) reflects oxygen extraction but
not fluid responsiveness.
, Q6: A patient in septic shock has the following parameters: MAP 55 mmHg, CVP 6 mmHg, CI
4.5 L/min/m², SVR 400 dynes/sec/cm⁻⁵. What is the primary hemodynamic problem?
A. Cardiac pump failure
B. Vasodilation with relative hypovolemia [CORRECT]
C. Mechanical obstruction
D. Absolute hypovolemia
Correct Answer: B
Rationale: This pattern demonstrates distributive shock: high cardiac index (4.5 L/min/m²)
with very low systemic vascular resistance (400 dynes/sec/cm⁻⁵) and low CVP. The primary
problem is massive vasodilation causing relative hypovolemia (increased capacitance)
despite adequate cardiac output. This is classic septic shock pathophysiology requiring
vasopressor support (norepinephrine) and continued fluid resuscitation.
Q7: During a passive leg raise (PLR) test, which hemodynamic change best indicates fluid
responsiveness?
A. Increase in heart rate >10 bpm
B. Increase in stroke volume or cardiac output >10% [CORRECT]
C. Increase in CVP >5 mmHg
D. Decrease in systemic vascular resistance
Correct Answer: B
Rationale: The passive leg raise test assesses "preload reserve" or fluid responsiveness by
measuring the change in stroke volume or cardiac output (measured by echocardiography,
pulse contour analysis, or other methods) when leg elevation increases venous return. An
increase >10% predicts fluid responsiveness. Heart rate changes (A) are not reliable
indicators. CVP changes (C) are poor predictors of volume response.
Q8: A patient has an arterial line in the radial artery. The waveform shows a systolic peak of
140 mmHg with a gradual decline and dicrotic notch, but the diastolic pressure reads 85
mmHg. The non-invasive BP cuff measures 120/80 mmHg. What explains this discrepancy?
A. The arterial line is overdamped
in Acute Care ACTUAL EXAM 2024/2025 |
Midterm Exam Comprehensive Review |
Chamberlain University | Latest Update |
Verified Q&A | Pass Guaranteed - A+
Graded
SECTION 1: HEMODYNAMIC MONITORING AND SHOCK
STATES (25 Questions)
Q1: A 62-year-old patient in the ICU has a pulmonary artery catheter in place. Hemodynamic
parameters reveal: Cardiac Index 1.8 L/min/m², SVR 1600 dynes/sec/cm⁻⁵, CVP 16 mmHg,
PCWP 22 mmHg. What is the most likely diagnosis?
A. Hypovolemic shock
B. Distributive shock
C. Cardiogenic shock [CORRECT]
D. Obstructive shock
Correct Answer: C
Rationale: The patient has a low cardiac index (<2.2 L/min/m²) with elevated filling pressures
(CVP >12 mmHg, PCWP >18 mmHg) and elevated SVR, consistent with cardiogenic shock.
This pattern indicates primary pump failure with compensatory vasoconstriction.
Hypovolemic shock (A) would have low filling pressures. Distributive shock (B) would have
low SVR. Obstructive shock (D) may have elevated filling pressures with mechanical
obstruction but typically without primary pump failure.
Chamberlain Note: Remember the shock classification by hemodynamics: Cardiogenic = Low
CI + High SVR + High filling pressures; Hypovolemic = Low CI + High SVR + Low filling
,pressures; Distributive = Normal/High CI + Low SVR + Variable filling pressures; Obstructive =
Low CI + High SVR + Variable filling pressures.
Q2: A patient with septic shock is receiving norepinephrine infusion titrated to maintain MAP
>65 mmHg. The patient remains hypotensive with MAP 58 mmHg despite norepinephrine 30
mcg/min. What is the most appropriate next step in management?
A. Increase norepinephrine to 50 mcg/min
B. Add vasopressin as second-line vasopressor [CORRECT]
C. Administer a 500 mL fluid bolus
D. Start dobutamine for inotropic support
Correct Answer: B
Rationale: According to Surviving Sepsis Campaign 2021 guidelines, when norepinephrine
doses exceed 15-20 mcg/min, vasopressin (0.03 units/min) is recommended as a second-line
vasopressor to reduce norepinephrine dose and improve outcomes. Increasing
norepinephrine alone (A) may increase adverse effects without proportional benefit. Fluid
resuscitation (C) should be completed early in sepsis; at this stage, the patient is likely
euvolemic or overloaded. Dobutamine (D) is indicated for low cardiac output states, not
primarily for refractory hypotension.
Q3: During pulmonary artery catheter insertion, the waveform changes from a CVP pattern to
a pulmonary artery pressure pattern after advancing 15 cm. What does this indicate?
A. The catheter is in the right ventricle
B. The catheter has wedged in the pulmonary artery [CORRECT]
C. The catheter is in the pulmonary vein
D. The catheter is coiled in the right atrium
Correct Answer: B
Rationale: The transition from CVP waveform (a, c, v waves) to pulmonary artery waveform
(systolic peak, diastolic trough with dicrotic notch) indicates the catheter has advanced into
the pulmonary artery. The normal distance from right internal jugular insertion to pulmonary
artery is approximately 40-50 cm. A 15 cm advancement from CVP position suggests the
catheter has passed through the right ventricle and entered the pulmonary artery.
,Chamberlain Note: Normal catheter advancement distances: RA (20 cm) → RV (30-35 cm) →
PA (40-45 cm) → PCWP (45-50 cm). Always confirm placement with chest X-ray.
Q4: A 58-year-old patient post-cardiac surgery has the following hemodynamics: MAP 72
mmHg, CVP 14 mmHg, PCWP 18 mmHg, CI 2.2 L/min/m². The patient has cool extremities
and decreased urine output. What is the best interpretation?
A. Adequate perfusion with normal hemodynamics
B. Low cardiac output state requiring inotropic support [CORRECT]
C. Hypovolemia requiring fluid bolus
D. Vasodilatory shock requiring vasopressors
Correct Answer: B
Rationale: The patient has borderline low cardiac index (2.2 L/min/m², normal 2.5-4.0) with
elevated filling pressures (CVP 14, PCWP 18), indicating cardiac dysfunction despite adequate
blood pressure. The clinical picture of cool extremities and oliguria confirms inadequate
tissue perfusion. This represents a low cardiac output state requiring inotropic support
(dobutamine or milrinone) rather than more fluids or vasopressors.
Q5: Which of the following is the most reliable indicator of fluid responsiveness in a
mechanically ventilated patient with sinus rhythm?
A. Central venous pressure (CVP) >12 mmHg
B. Pulse pressure variation (PPV) >13% [CORRECT]
C. Mean arterial pressure (MAP) <65 mmHg
D. Mixed venous oxygen saturation (SvO2) <65%
Correct Answer: B
Rationale: Pulse pressure variation (PPV) >13% is the most reliable dynamic predictor of fluid
responsiveness in mechanically ventilated patients with sinus rhythm. PPV measures the
variation in pulse pressure during the respiratory cycle; values >13% indicate the patient will
respond to fluid loading. CVP (A) is a poor predictor of fluid responsiveness. MAP (C)
indicates perfusion pressure but not volume status. SvO2 (D) reflects oxygen extraction but
not fluid responsiveness.
, Q6: A patient in septic shock has the following parameters: MAP 55 mmHg, CVP 6 mmHg, CI
4.5 L/min/m², SVR 400 dynes/sec/cm⁻⁵. What is the primary hemodynamic problem?
A. Cardiac pump failure
B. Vasodilation with relative hypovolemia [CORRECT]
C. Mechanical obstruction
D. Absolute hypovolemia
Correct Answer: B
Rationale: This pattern demonstrates distributive shock: high cardiac index (4.5 L/min/m²)
with very low systemic vascular resistance (400 dynes/sec/cm⁻⁵) and low CVP. The primary
problem is massive vasodilation causing relative hypovolemia (increased capacitance)
despite adequate cardiac output. This is classic septic shock pathophysiology requiring
vasopressor support (norepinephrine) and continued fluid resuscitation.
Q7: During a passive leg raise (PLR) test, which hemodynamic change best indicates fluid
responsiveness?
A. Increase in heart rate >10 bpm
B. Increase in stroke volume or cardiac output >10% [CORRECT]
C. Increase in CVP >5 mmHg
D. Decrease in systemic vascular resistance
Correct Answer: B
Rationale: The passive leg raise test assesses "preload reserve" or fluid responsiveness by
measuring the change in stroke volume or cardiac output (measured by echocardiography,
pulse contour analysis, or other methods) when leg elevation increases venous return. An
increase >10% predicts fluid responsiveness. Heart rate changes (A) are not reliable
indicators. CVP changes (C) are poor predictors of volume response.
Q8: A patient has an arterial line in the radial artery. The waveform shows a systolic peak of
140 mmHg with a gradual decline and dicrotic notch, but the diastolic pressure reads 85
mmHg. The non-invasive BP cuff measures 120/80 mmHg. What explains this discrepancy?
A. The arterial line is overdamped
