NRNP 6566 ADVANCED CARE OF ADULTS IN ACUTE
SETTINGS I WEEK 8 KNOWLEDGE CHECK 2026/2027 |
Questions and Verified Answers | Pass Guaranteed - A+
Graded
Domain 1: Respiratory Acute Care (12 Questions)
Q1: A 68-year-old male with COPD presents with worsening dyspnea over 3 days. Vital
signs: BP 142/88 mmHg, HR 118 bpm, RR 28/min, SpO2 84% on room air, T 37.2°C.
Physical exam reveals distant breath sounds, prolonged expiratory phase, and
accessory muscle use. ABG on 2L NC: pH 7.28, PaCO2 68 mmHg, PaO2 58 mmHg,
HCO3- 32 mEq/L. Chest X-ray shows hyperinflation without infiltrate. Which intervention
is the immediate priority?
A. Initiate high-flow nasal cannula at 40 L/min with FiO2 titrated to SpO2 88-92%
B. Administer IV methylprednisolone 125mg and begin continuous nebulized albuterol
C. Initiate non-invasive positive pressure ventilation with BiPAP (IPAP 12, EPAP 5)
D. Prepare for emergent intubation and mechanical ventilation [CORRECT]
Correct Answer: D
Rationale: This patient presents with acute-on-chronic hypercapnic respiratory failure
with severe acidemia (pH 7.28) despite supplemental oxygen. The ABG demonstrates
acute decompensation with pH < 7.30, which represents a relative indication for
intubation in COPD exacerbation. While BiPAP is often first-line for COPD exacerbations
with hypercapnia, the severity of acidemia, markedly elevated PaCO2 (68 mmHg), and
clinical signs of impending respiratory failure (accessory muscle use, RR 28) suggest
BiPAP may be insufficient. The patient meets criteria for emergent intubation: pH < 7.30
with PaCO2 > 60 mmHg, altered mental status risk, and severe respiratory distress.
,Option A is incorrect because high-flow nasal cannula does not address the
hypercapnic component and may worsen CO2 retention. Option B is appropriate
adjunctive therapy but does not address the immediate need for ventilatory support.
Option C would be appropriate for less severe acidemia (pH 7.30-7.35) but is insufficient
given the severity of this presentation.
Q2: A 54-year-old female is admitted with community-acquired pneumonia. She
develops progressive hypoxemia 48 hours after admission despite appropriate
antibiotics. Vital signs: BP 88/56 mmHg, HR 132 bpm, RR 36/min, SpO2 82% on 15L
NRB. ABG: pH 7.35, PaO2 55 mmHg, PaCO2 32 mmHg, HCO3- 18 mEq/L. Chest X-ray
shows bilateral diffuse infiltrates. The PaO2/FiO2 ratio is calculated at 120 mmHg.
Which diagnosis and immediate management strategy is most appropriate?
A. Severe community-acquired pneumonia; initiate vasopressors and continue current
antibiotic regimen
B. Acute respiratory distress syndrome (ARDS); initiate lung-protective ventilation
strategy [CORRECT]
C. Cardiogenic pulmonary edema; administer IV furosemide 80mg and initiate BiPAP
D. Pulmonary embolism; obtain CT angiography and initiate systemic anticoagulation
Correct Answer: B
Rationale: The patient meets Berlin criteria for moderate ARDS: acute onset within 1
week of known clinical insult (pneumonia), bilateral opacities not fully explained by
cardiac failure or fluid overload, and moderate hypoxemia with PaO2/FiO2 ratio 100-200
mmHg (calculated: 55/0.7 ≈ 79, but on 15L NRB approximately FiO2 0.7). The
immediate priority is lung-protective ventilation with tidal volumes 6 mL/kg predicted
body weight, plateau pressure < 30 cm H2O, and appropriate PEEP. Option A is incorrect
because while she has septic shock requiring vasopressors, the respiratory failure
pattern indicates ARDS requiring specific ventilatory management beyond standard
,pneumonia care. Option C is incorrect because the clinical picture (bilateral infiltrates,
severe hypoxemia, low PaCO2) is inconsistent with cardiogenic edema, and diuresis
could worsen hypovolemia in septic shock. Option D is incorrect because while PE can
cause hypoxemia, the bilateral infiltrates and timing relative to pneumonia make ARDS
the more likely diagnosis; CT angiography would delay critical interventions.
Q3: A 72-year-old male presents with acute onset pleuritic chest pain and dyspnea. Vital
signs: BP 98/64 mmHg, HR 128 bpm, RR 26/min, SpO2 89% on room air. Wells score is
calculated at 6.5 points. CT pulmonary angiography confirms bilateral pulmonary
emboli with right ventricular strain on echocardiogram. Which management strategy is
most appropriate?
A. Initiate therapeutic heparin infusion and obtain serial troponins
B. Administer systemic thrombolysis with alteplase 100mg IV over 2 hours [CORRECT]
C. Proceed with catheter-directed thrombolysis via interventional radiology
D. Place inferior vena cava filter and continue anticoagulation
Correct Answer: B
Rationale: This patient has high-risk (massive) pulmonary embolism with hemodynamic
compromise (systolic BP < 90 mmHg), RV strain, and high pre-test probability. Systemic
thrombolysis is indicated for massive PE with hemodynamic instability, provided no
absolute contraindications exist. The 30-day mortality benefit outweighs bleeding risks
in this scenario. Option A is insufficient as anticoagulation alone has unacceptably high
mortality in massive PE. Option C (catheter-directed thrombolysis) is an alternative for
submassive PE with RV dysfunction but hemodynamic stability, or when systemic
thrombolysis is contraindicated; however, in massive PE with shock, systemic
thrombolysis is preferred for rapid effect. Option D is incorrect because IVC filter
placement does not address the existing emboli causing hemodynamic compromise
, and is reserved for patients with contraindications to anticoagulation or recurrent PE
despite therapeutic anticoagulation.
Q4: A 45-year-old female with asthma presents with severe exacerbation. She is unable
to speak in complete sentences. Vital signs: BP 138/82 mmHg, HR 118 bpm, RR 32/min,
SpO2 91% on 10L face mask. Auscultation reveals minimal air movement bilaterally
with faint wheezing. After 3 doses of nebulized albuterol/ipratropium and IV
methylprednisolone 125mg, there is minimal improvement. ABG: pH 7.32, PaCO2 48
mmHg, PaO2 68 mmHg. Which intervention is most appropriate?
A. Initiate magnesium sulfate 2g IV over 20 minutes and continue aggressive
bronchodilator therapy
B. Prepare for emergent intubation and mechanical ventilation [CORRECT]
C. Initiate BiPAP with IPAP 12 and EPAP 5 cm H2O
D. Administer subcutaneous epinephrine 0.3mg and reassess in 15 minutes
Correct Answer: B
Rationale: This patient presents with life-threatening status asthmaticus characterized
by silent chest (ominous sign indicating minimal air movement), rising PaCO2 (48
mmHg) despite tachypnea, and acidemia. In asthma, hypercapnia indicates severe
airway obstruction and respiratory muscle fatigue, representing impending respiratory
failure. The "silent chest" occurs when air movement is so severely compromised that
wheezing disappears. Immediate intubation is indicated when PaCO2 > 45 mmHg with
acidemia, altered mental status, or hemodynamic instability. Option A is appropriate for
severe asthma but insufficient given the rising CO2 and silent chest. Option C is
relatively contraindicated in asthma due to dynamic hyperinflation risk and difficulty
with synchronization; intubation is preferred when hypercapnic. Option D is
inappropriate as subcutaneous epinephrine offers no advantage over inhaled
beta-agonists in acute severe asthma and delays definitive airway management.
SETTINGS I WEEK 8 KNOWLEDGE CHECK 2026/2027 |
Questions and Verified Answers | Pass Guaranteed - A+
Graded
Domain 1: Respiratory Acute Care (12 Questions)
Q1: A 68-year-old male with COPD presents with worsening dyspnea over 3 days. Vital
signs: BP 142/88 mmHg, HR 118 bpm, RR 28/min, SpO2 84% on room air, T 37.2°C.
Physical exam reveals distant breath sounds, prolonged expiratory phase, and
accessory muscle use. ABG on 2L NC: pH 7.28, PaCO2 68 mmHg, PaO2 58 mmHg,
HCO3- 32 mEq/L. Chest X-ray shows hyperinflation without infiltrate. Which intervention
is the immediate priority?
A. Initiate high-flow nasal cannula at 40 L/min with FiO2 titrated to SpO2 88-92%
B. Administer IV methylprednisolone 125mg and begin continuous nebulized albuterol
C. Initiate non-invasive positive pressure ventilation with BiPAP (IPAP 12, EPAP 5)
D. Prepare for emergent intubation and mechanical ventilation [CORRECT]
Correct Answer: D
Rationale: This patient presents with acute-on-chronic hypercapnic respiratory failure
with severe acidemia (pH 7.28) despite supplemental oxygen. The ABG demonstrates
acute decompensation with pH < 7.30, which represents a relative indication for
intubation in COPD exacerbation. While BiPAP is often first-line for COPD exacerbations
with hypercapnia, the severity of acidemia, markedly elevated PaCO2 (68 mmHg), and
clinical signs of impending respiratory failure (accessory muscle use, RR 28) suggest
BiPAP may be insufficient. The patient meets criteria for emergent intubation: pH < 7.30
with PaCO2 > 60 mmHg, altered mental status risk, and severe respiratory distress.
,Option A is incorrect because high-flow nasal cannula does not address the
hypercapnic component and may worsen CO2 retention. Option B is appropriate
adjunctive therapy but does not address the immediate need for ventilatory support.
Option C would be appropriate for less severe acidemia (pH 7.30-7.35) but is insufficient
given the severity of this presentation.
Q2: A 54-year-old female is admitted with community-acquired pneumonia. She
develops progressive hypoxemia 48 hours after admission despite appropriate
antibiotics. Vital signs: BP 88/56 mmHg, HR 132 bpm, RR 36/min, SpO2 82% on 15L
NRB. ABG: pH 7.35, PaO2 55 mmHg, PaCO2 32 mmHg, HCO3- 18 mEq/L. Chest X-ray
shows bilateral diffuse infiltrates. The PaO2/FiO2 ratio is calculated at 120 mmHg.
Which diagnosis and immediate management strategy is most appropriate?
A. Severe community-acquired pneumonia; initiate vasopressors and continue current
antibiotic regimen
B. Acute respiratory distress syndrome (ARDS); initiate lung-protective ventilation
strategy [CORRECT]
C. Cardiogenic pulmonary edema; administer IV furosemide 80mg and initiate BiPAP
D. Pulmonary embolism; obtain CT angiography and initiate systemic anticoagulation
Correct Answer: B
Rationale: The patient meets Berlin criteria for moderate ARDS: acute onset within 1
week of known clinical insult (pneumonia), bilateral opacities not fully explained by
cardiac failure or fluid overload, and moderate hypoxemia with PaO2/FiO2 ratio 100-200
mmHg (calculated: 55/0.7 ≈ 79, but on 15L NRB approximately FiO2 0.7). The
immediate priority is lung-protective ventilation with tidal volumes 6 mL/kg predicted
body weight, plateau pressure < 30 cm H2O, and appropriate PEEP. Option A is incorrect
because while she has septic shock requiring vasopressors, the respiratory failure
pattern indicates ARDS requiring specific ventilatory management beyond standard
,pneumonia care. Option C is incorrect because the clinical picture (bilateral infiltrates,
severe hypoxemia, low PaCO2) is inconsistent with cardiogenic edema, and diuresis
could worsen hypovolemia in septic shock. Option D is incorrect because while PE can
cause hypoxemia, the bilateral infiltrates and timing relative to pneumonia make ARDS
the more likely diagnosis; CT angiography would delay critical interventions.
Q3: A 72-year-old male presents with acute onset pleuritic chest pain and dyspnea. Vital
signs: BP 98/64 mmHg, HR 128 bpm, RR 26/min, SpO2 89% on room air. Wells score is
calculated at 6.5 points. CT pulmonary angiography confirms bilateral pulmonary
emboli with right ventricular strain on echocardiogram. Which management strategy is
most appropriate?
A. Initiate therapeutic heparin infusion and obtain serial troponins
B. Administer systemic thrombolysis with alteplase 100mg IV over 2 hours [CORRECT]
C. Proceed with catheter-directed thrombolysis via interventional radiology
D. Place inferior vena cava filter and continue anticoagulation
Correct Answer: B
Rationale: This patient has high-risk (massive) pulmonary embolism with hemodynamic
compromise (systolic BP < 90 mmHg), RV strain, and high pre-test probability. Systemic
thrombolysis is indicated for massive PE with hemodynamic instability, provided no
absolute contraindications exist. The 30-day mortality benefit outweighs bleeding risks
in this scenario. Option A is insufficient as anticoagulation alone has unacceptably high
mortality in massive PE. Option C (catheter-directed thrombolysis) is an alternative for
submassive PE with RV dysfunction but hemodynamic stability, or when systemic
thrombolysis is contraindicated; however, in massive PE with shock, systemic
thrombolysis is preferred for rapid effect. Option D is incorrect because IVC filter
placement does not address the existing emboli causing hemodynamic compromise
, and is reserved for patients with contraindications to anticoagulation or recurrent PE
despite therapeutic anticoagulation.
Q4: A 45-year-old female with asthma presents with severe exacerbation. She is unable
to speak in complete sentences. Vital signs: BP 138/82 mmHg, HR 118 bpm, RR 32/min,
SpO2 91% on 10L face mask. Auscultation reveals minimal air movement bilaterally
with faint wheezing. After 3 doses of nebulized albuterol/ipratropium and IV
methylprednisolone 125mg, there is minimal improvement. ABG: pH 7.32, PaCO2 48
mmHg, PaO2 68 mmHg. Which intervention is most appropriate?
A. Initiate magnesium sulfate 2g IV over 20 minutes and continue aggressive
bronchodilator therapy
B. Prepare for emergent intubation and mechanical ventilation [CORRECT]
C. Initiate BiPAP with IPAP 12 and EPAP 5 cm H2O
D. Administer subcutaneous epinephrine 0.3mg and reassess in 15 minutes
Correct Answer: B
Rationale: This patient presents with life-threatening status asthmaticus characterized
by silent chest (ominous sign indicating minimal air movement), rising PaCO2 (48
mmHg) despite tachypnea, and acidemia. In asthma, hypercapnia indicates severe
airway obstruction and respiratory muscle fatigue, representing impending respiratory
failure. The "silent chest" occurs when air movement is so severely compromised that
wheezing disappears. Immediate intubation is indicated when PaCO2 > 45 mmHg with
acidemia, altered mental status, or hemodynamic instability. Option A is appropriate for
severe asthma but insufficient given the rising CO2 and silent chest. Option C is
relatively contraindicated in asthma due to dynamic hyperinflation risk and difficulty
with synchronization; intubation is preferred when hypercapnic. Option D is
inappropriate as subcutaneous epinephrine offers no advantage over inhaled
beta-agonists in acute severe asthma and delays definitive airway management.
