NRNP 6566 ADVANCED CARE OF ADULTS IN ACUTE
SETTINGS I WEEK 11 KNOWLEDGE CHECK 2026/2027 |
Questions and Verified Answers | Pass Guaranteed - A+
Graded
Domain 1: Cardiovascular Acute Care (10 Questions)
Q1: A 68-year-old male presents with crushing substernal chest pain radiating to his left
arm for 45 minutes. Vital signs: BP 88/52 mmHg, HR 108 bpm, RR 24/min, SpO₂ 91% on
room air. ECG shows ST-segment elevation in leads II, III, and aVF with reciprocal
changes in I and aVL. Troponin I is pending. The patient is diaphoretic and appears
anxious. Which intervention is the immediate priority?
A. Obtain emergent cardiology consultation for cardiac catheterization laboratory
activation
B. Administer sublingual nitroglycerin 0.4 mg every 5 minutes × 3 doses
C. Initiate rapid crystalloid bolus 1-2 L to restore perfusion pressure [CORRECT]
D. Administer aspirin 325 mg chewable and clopidogrel 600 mg loading dose
Correct Answer: C
Rationale: This patient presents with an inferior wall STEMI (ST elevation in II, III, aVF)
complicated by cardiogenic shock (systolic BP <90 mmHg, signs of hypoperfusion
including diaphoresis and anxiety). While all interventions listed are appropriate for
,STEMI management, the immediate priority is hemodynamic stabilization. The patient is
hypotensive and showing signs of poor perfusion; without adequate preload and
perfusion pressure, other interventions (including reperfusion therapy) will be ineffective
or potentially harmful.
● Option A is incorrect timing: While emergent reperfusion is critical in STEMI, this
patient requires hemodynamic stabilization first. Cardiogenic shock carries >50%
mortality without immediate stabilization.
● Option B is dangerous: Nitrates are contraindicated in inferior STEMI with right
ventricular involvement (common with inferior MI, indicated by ST elevation in
V4R) or hypotension (SBP <90 mmHg). Nitrates reduce preload, which can
precipitate cardiovascular collapse in this scenario.
● Option D is incomplete: Dual antiplatelet therapy is essential but secondary to
immediate hemodynamic resuscitation. Aspirin and clopidogrel loading should
occur simultaneously with fluid resuscitation, not before.
Per ACC/AHA guidelines, patients with STEMI and cardiogenic shock require immediate
fluid resuscitation (500 mL-1L boluses) to optimize preload, followed by vasopressor
support if needed, with emergent revascularization within minutes—not hours.
Q2: A 72-year-old female with acute decompensated heart failure presents with severe
dyspnea, orthopnea, and peripheral edema. Vital signs: BP 156/98 mmHg, HR 112 bpm
(irregularly irregular), RR 28/min, SpO₂ 88% on 2L NC. Physical exam reveals bilateral
crackles to mid-lung fields, JVD 8 cm, and 3+ pitting edema. CXR shows pulmonary
vascular congestion and cardiomegaly. BNP 2,400 pg/mL. Current medications include
metoprolol 50 mg BID and lisinopril 10 mg daily. Which represents the most appropriate
initial pharmacologic strategy?
A. Initiate IV nitroglycerin infusion and IV furosemide 80 mg bolus [CORRECT]
,B. Administer IV metoprolol 5 mg to control ventricular response in atrial fibrillation
C. Begin dobutamine infusion at 2.5 mcg/kg/min for inotropic support
D. Initiate non-invasive positive pressure ventilation (BiPAP) at 10/5 cm H₂O
Correct Answer: A
Rationale: This patient presents with acute decompensated heart failure (ADHF) with
wet-warm profile (volume overloaded with adequate perfusion—BP 156/98 mmHg, no
signs of hypoperfusion). The therapeutic goals are afterload reduction and volume
removal.
● Option A is correct: IV nitroglycerin provides venodilation (reducing preload) and
arterial dilation (reducing afterload), improving myocardial oxygen demand and
relieving pulmonary congestion. IV furosemide promotes rapid diuresis. This
combination addresses both the pressure overload (hypertension) and volume
overload. The atrial fibrillation with rapid ventricular response (RVR) will likely
improve with afterload reduction and volume status optimization.
● Option B is dangerous: Beta-blockers are contraindicated in acute
decompensated heart failure with volume overload and possible hypoperfusion.
While rate control is needed for AF with RVR, beta-blockade in this setting can
precipitate cardiogenic shock.
● Option C is inappropriate: Dobutamine is indicated for cold-wet profile
(cardiogenic shock with congestion) or cold-dry profile (low output without
congestion). This patient has adequate perfusion (elevated BP) and does not
require inotropic support.
● Option D is premature: While BiPAP is indicated for ADHF with respiratory
distress (reduces work of breathing, improves oxygenation, provides afterload
reduction via positive pressure), pharmacologic therapy should be initiated first.
BiPAP becomes necessary if the patient remains hypoxic or develops respiratory
fatigue despite initial therapy.
, Q3: A 58-year-old male presents with sudden onset severe headache, nausea, and
altered mental status. BP 220/130 mmHg, HR 58 bpm, RR 14/min. CT head reveals
acute intracerebral hemorrhage in the left basal ganglia with 15 mL volume and midline
shift of 4 mm. The patient takes warfarin 5 mg daily for atrial fibrillation; INR is 4.2.
Which represents the most appropriate immediate intervention?
A. Administer IV nicardipine infusion to reduce MAP by 25% over first hour [CORRECT]
B. Administer IV labetalol 20 mg bolus to achieve SBP <140 mmHg within 1 hour
C. Administer IV prothrombin complex concentrate (PCC) 50 units/kg and vitamin K 10
mg IV [CORRECT]
D. Initiate IV tissue plasminogen activator (tPA) 0.9 mg/kg for hemorrhagic conversion
Correct Answer: C
Rationale: This patient presents with warfarin-associated intracerebral hemorrhage
(WA-ICH), a neurosurgical emergency with 50% mortality. The immediate priorities are:
(1) reversal of anticoagulation to prevent hematoma expansion, and (2) controlled blood
pressure reduction.
● Option C is correct: Warfarin reversal requires 4-factor prothrombin complex
concentrate (PCC) to rapidly replace vitamin K-dependent factors II, VII, IX, X, plus
IV vitamin K for sustained reversal. PCC is preferred over fresh frozen plasma
(FFP) due to rapid administration (minutes vs. hours) and lower volume (critical
in ICH to prevent volume overload). The INR should be corrected to <1.4 within
30-60 minutes.
● Option A addresses blood pressure but is secondary to anticoagulation reversal.
Per AHA/ASA guidelines, SBP should be reduced to <160 mmHg or MAP <110
mmHg, with nicardipine or clevidipine preferred due to titratability. However,
anticoagulation reversal takes absolute priority.
● Option B is excessive: Aggressive BP reduction (SBP <140 mmHg) is not
recommended in ICH as it may reduce cerebral perfusion pressure and worsen
SETTINGS I WEEK 11 KNOWLEDGE CHECK 2026/2027 |
Questions and Verified Answers | Pass Guaranteed - A+
Graded
Domain 1: Cardiovascular Acute Care (10 Questions)
Q1: A 68-year-old male presents with crushing substernal chest pain radiating to his left
arm for 45 minutes. Vital signs: BP 88/52 mmHg, HR 108 bpm, RR 24/min, SpO₂ 91% on
room air. ECG shows ST-segment elevation in leads II, III, and aVF with reciprocal
changes in I and aVL. Troponin I is pending. The patient is diaphoretic and appears
anxious. Which intervention is the immediate priority?
A. Obtain emergent cardiology consultation for cardiac catheterization laboratory
activation
B. Administer sublingual nitroglycerin 0.4 mg every 5 minutes × 3 doses
C. Initiate rapid crystalloid bolus 1-2 L to restore perfusion pressure [CORRECT]
D. Administer aspirin 325 mg chewable and clopidogrel 600 mg loading dose
Correct Answer: C
Rationale: This patient presents with an inferior wall STEMI (ST elevation in II, III, aVF)
complicated by cardiogenic shock (systolic BP <90 mmHg, signs of hypoperfusion
including diaphoresis and anxiety). While all interventions listed are appropriate for
,STEMI management, the immediate priority is hemodynamic stabilization. The patient is
hypotensive and showing signs of poor perfusion; without adequate preload and
perfusion pressure, other interventions (including reperfusion therapy) will be ineffective
or potentially harmful.
● Option A is incorrect timing: While emergent reperfusion is critical in STEMI, this
patient requires hemodynamic stabilization first. Cardiogenic shock carries >50%
mortality without immediate stabilization.
● Option B is dangerous: Nitrates are contraindicated in inferior STEMI with right
ventricular involvement (common with inferior MI, indicated by ST elevation in
V4R) or hypotension (SBP <90 mmHg). Nitrates reduce preload, which can
precipitate cardiovascular collapse in this scenario.
● Option D is incomplete: Dual antiplatelet therapy is essential but secondary to
immediate hemodynamic resuscitation. Aspirin and clopidogrel loading should
occur simultaneously with fluid resuscitation, not before.
Per ACC/AHA guidelines, patients with STEMI and cardiogenic shock require immediate
fluid resuscitation (500 mL-1L boluses) to optimize preload, followed by vasopressor
support if needed, with emergent revascularization within minutes—not hours.
Q2: A 72-year-old female with acute decompensated heart failure presents with severe
dyspnea, orthopnea, and peripheral edema. Vital signs: BP 156/98 mmHg, HR 112 bpm
(irregularly irregular), RR 28/min, SpO₂ 88% on 2L NC. Physical exam reveals bilateral
crackles to mid-lung fields, JVD 8 cm, and 3+ pitting edema. CXR shows pulmonary
vascular congestion and cardiomegaly. BNP 2,400 pg/mL. Current medications include
metoprolol 50 mg BID and lisinopril 10 mg daily. Which represents the most appropriate
initial pharmacologic strategy?
A. Initiate IV nitroglycerin infusion and IV furosemide 80 mg bolus [CORRECT]
,B. Administer IV metoprolol 5 mg to control ventricular response in atrial fibrillation
C. Begin dobutamine infusion at 2.5 mcg/kg/min for inotropic support
D. Initiate non-invasive positive pressure ventilation (BiPAP) at 10/5 cm H₂O
Correct Answer: A
Rationale: This patient presents with acute decompensated heart failure (ADHF) with
wet-warm profile (volume overloaded with adequate perfusion—BP 156/98 mmHg, no
signs of hypoperfusion). The therapeutic goals are afterload reduction and volume
removal.
● Option A is correct: IV nitroglycerin provides venodilation (reducing preload) and
arterial dilation (reducing afterload), improving myocardial oxygen demand and
relieving pulmonary congestion. IV furosemide promotes rapid diuresis. This
combination addresses both the pressure overload (hypertension) and volume
overload. The atrial fibrillation with rapid ventricular response (RVR) will likely
improve with afterload reduction and volume status optimization.
● Option B is dangerous: Beta-blockers are contraindicated in acute
decompensated heart failure with volume overload and possible hypoperfusion.
While rate control is needed for AF with RVR, beta-blockade in this setting can
precipitate cardiogenic shock.
● Option C is inappropriate: Dobutamine is indicated for cold-wet profile
(cardiogenic shock with congestion) or cold-dry profile (low output without
congestion). This patient has adequate perfusion (elevated BP) and does not
require inotropic support.
● Option D is premature: While BiPAP is indicated for ADHF with respiratory
distress (reduces work of breathing, improves oxygenation, provides afterload
reduction via positive pressure), pharmacologic therapy should be initiated first.
BiPAP becomes necessary if the patient remains hypoxic or develops respiratory
fatigue despite initial therapy.
, Q3: A 58-year-old male presents with sudden onset severe headache, nausea, and
altered mental status. BP 220/130 mmHg, HR 58 bpm, RR 14/min. CT head reveals
acute intracerebral hemorrhage in the left basal ganglia with 15 mL volume and midline
shift of 4 mm. The patient takes warfarin 5 mg daily for atrial fibrillation; INR is 4.2.
Which represents the most appropriate immediate intervention?
A. Administer IV nicardipine infusion to reduce MAP by 25% over first hour [CORRECT]
B. Administer IV labetalol 20 mg bolus to achieve SBP <140 mmHg within 1 hour
C. Administer IV prothrombin complex concentrate (PCC) 50 units/kg and vitamin K 10
mg IV [CORRECT]
D. Initiate IV tissue plasminogen activator (tPA) 0.9 mg/kg for hemorrhagic conversion
Correct Answer: C
Rationale: This patient presents with warfarin-associated intracerebral hemorrhage
(WA-ICH), a neurosurgical emergency with 50% mortality. The immediate priorities are:
(1) reversal of anticoagulation to prevent hematoma expansion, and (2) controlled blood
pressure reduction.
● Option C is correct: Warfarin reversal requires 4-factor prothrombin complex
concentrate (PCC) to rapidly replace vitamin K-dependent factors II, VII, IX, X, plus
IV vitamin K for sustained reversal. PCC is preferred over fresh frozen plasma
(FFP) due to rapid administration (minutes vs. hours) and lower volume (critical
in ICH to prevent volume overload). The INR should be corrected to <1.4 within
30-60 minutes.
● Option A addresses blood pressure but is secondary to anticoagulation reversal.
Per AHA/ASA guidelines, SBP should be reduced to <160 mmHg or MAP <110
mmHg, with nicardipine or clevidipine preferred due to titratability. However,
anticoagulation reversal takes absolute priority.
● Option B is excessive: Aggressive BP reduction (SBP <140 mmHg) is not
recommended in ICH as it may reduce cerebral perfusion pressure and worsen
