NRNP 6566 ADVANCED CARE OF ADULTS IN ACUTE
SETTINGS I WEEK 7 KNOWLEDGE CHECK 2026/2027 |
Questions and Verified Answers | Pass Guaranteed - A+
Graded
Domain 1: Cardiovascular Acute Care (15 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 110 bpm, RR 24, SpO2 92% on
room air. ECG shows ST-segment elevation in leads V1-V4 with reciprocal changes in II,
III, and aVF. Troponin I is pending. The patient is diaphoretic and anxious. What is the
most appropriate immediate management priority?
A. Administer IV morphine 4 mg and wait for cardiac catheterization team to arrive
B. Initiate IV nitroglycerin infusion to reduce afterload and improve coronary perfusion
C. Activate the cath lab for primary PCI and initiate IV fluid resuscitation with
norepinephrine if needed to support blood pressure
D. Administer thrombolytic therapy immediately due to hemodynamic instability
Correct Answer: C
Rationale: This patient presents with an anterior ST-elevation myocardial infarction
(STEMI) complicated by cardiogenic shock (systolic BP <90 mmHg with signs of
hypoperfusion). The 2021 ACC/AHA/SCAI Guideline for Coronary Artery
Revascularization recommends immediate activation of the cardiac catheterization
laboratory for primary PCI within 90 minutes of first medical contact, regardless of
,hemodynamic status. In cardiogenic shock, vasopressor support with norepinephrine
(first-line) should be initiated to maintain MAP >65 mmHg while preparing for
revascularization. Option A delays definitive therapy. Option B is contraindicated due to
hypotension (nitroglycerin causes venodilation and further BP reduction). Option D
(thrombolytics) is inferior to PCI in cardiogenic shock and should only be considered if
PCI is unavailable within 120 minutes.
Q2: A 72-year-old female with a history of atrial fibrillation on warfarin presents with
acute-onset severe chest pain and dyspnea. BP is 156/94 mmHg, HR 118 bpm
irregularly irregular, RR 28, SpO2 89% on 2L NC. Chest X-ray shows pulmonary edema.
ECG reveals new ST-segment depression in the lateral leads and rapid ventricular
response. Bedside echocardiogram shows severe mitral regurgitation with a flail
posterior leaflet. What is the definitive management?
A. Immediate synchronized cardioversion at 200J after transesophageal
echocardiography to rule out left atrial thrombus
B. Emergency cardiothoracic surgery consultation for mitral valve repair or replacement
C. Initiate IV diltiazem for rate control and heparin bridge for therapeutic anticoagulation
D. Administer IV furosemide 80 mg and initiate BiPAP for afterload reduction
Correct Answer: B
Rationale: This patient has acute severe mitral regurgitation (MR) secondary to papillary
muscle rupture or chordal rupture (flail leaflet), causing acute pulmonary edema. This is
a surgical emergency requiring emergent mitral valve repair or replacement. Medical
therapy (diuretics, afterload reduction) is temporizing only. While rate control (Option C)
and afterload reduction (Option D) may provide temporary stabilization, they do not
,address the mechanical problem. Cardioversion (Option A) is inappropriate as the
primary issue is not atrial fibrillation with hemodynamic instability from the arrhythmia
itself, but rather acute valvular catastrophe causing heart failure. The 2020 ACC/AHA
Guidelines for the Management of Patients With Valvular Heart Disease recommend
emergent surgery for acute severe MR causing refractory heart failure.
Q3: A 58-year-old male with a history of hypertension presents with tearing chest pain
radiating to his back. BP is 186/112 mmHg in the right arm and 154/98 mmHg in the
left arm. HR 96 bpm. CT angiography reveals a Stanford Type A aortic dissection
extending from the ascending aorta to the descending thoracic aorta. What is the
immediate management priority?
A. Initiate IV esmolol infusion to achieve heart rate <60 bpm and systolic BP <120
mmHg, followed by emergent surgical consultation
B. Administer IV nitroprusside immediately to reduce afterload without beta-blockade
C. Perform emergent percutaneous aortic stent grafting in the interventional radiology
suite
D. Initiate IV tissue plasminogen activator (tPA) for suspected mesenteric ischemia
Correct Answer: A
Rationale: Stanford Type A aortic dissection involving the ascending aorta requires
emergent surgical repair. Immediate medical management includes IV beta-blockade
(esmolol or labetalol) to reduce heart rate (<60 bpm) and contractility (dP/dt), followed
by vasodilators to achieve systolic BP <120 mmHg or MAP <80 mmHg. Beta-blockade
must precede vasodilation to prevent reflex catecholamine surge that could increase
aortic shear stress and propagation of the dissection. Option B is dangerous without
, beta-blockade. Option C (TEVAR) is indicated for Type B dissections, not Type A. Option
D is contraindicated and dangerous in aortic dissection.
Q4: A 64-year-old male presents with chest pain at rest for 20 minutes. Vital signs: BP
142/88 mmHg, HR 76 bpm, RR 18. ECG shows 1 mm ST-segment depression in leads
V4-V6 and T-wave inversions in the anterior leads. Troponin I returns at 0.45 ng/mL
(normal <0.04). The patient has continued intermittent chest discomfort. What is the
most appropriate next step in management?
A. Immediate coronary angiography within 2 hours given elevated troponin and dynamic
ECG changes
B. Administer aspirin, clopidogrel, heparin, and schedule stress testing within 72 hours
C. Administer aspirin, ticagrelor, anticoagulation, and high-intensity statin; risk stratify
using GRACE score to determine timing of angiography
D. Administer IV thrombolytics due to NSTEMI diagnosis
Correct Answer: C
Rationale: This patient has non-ST-elevation myocardial infarction (NSTEMI) based on
elevated troponin and ischemic symptoms with ECG changes. Current guidelines
recommend initial medical management with dual antiplatelet therapy (aspirin + P2Y12
inhibitor), anticoagulation, and high-intensity statin therapy. Risk stratification using the
GRACE score determines timing of invasive strategy: very high-risk patients (GRACE
>140) undergo angiography within 2 hours; high-risk (GRACE 109-140) within 24 hours;
intermediate-risk within 72 hours. Immediate angiography (Option A) is reserved for
hemodynamic instability, refractory angina, malignant arrhythmias, or acute heart
failure. Thrombolytics (Option D) have no role in NSTEMI management.
SETTINGS I WEEK 7 KNOWLEDGE CHECK 2026/2027 |
Questions and Verified Answers | Pass Guaranteed - A+
Graded
Domain 1: Cardiovascular Acute Care (15 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 110 bpm, RR 24, SpO2 92% on
room air. ECG shows ST-segment elevation in leads V1-V4 with reciprocal changes in II,
III, and aVF. Troponin I is pending. The patient is diaphoretic and anxious. What is the
most appropriate immediate management priority?
A. Administer IV morphine 4 mg and wait for cardiac catheterization team to arrive
B. Initiate IV nitroglycerin infusion to reduce afterload and improve coronary perfusion
C. Activate the cath lab for primary PCI and initiate IV fluid resuscitation with
norepinephrine if needed to support blood pressure
D. Administer thrombolytic therapy immediately due to hemodynamic instability
Correct Answer: C
Rationale: This patient presents with an anterior ST-elevation myocardial infarction
(STEMI) complicated by cardiogenic shock (systolic BP <90 mmHg with signs of
hypoperfusion). The 2021 ACC/AHA/SCAI Guideline for Coronary Artery
Revascularization recommends immediate activation of the cardiac catheterization
laboratory for primary PCI within 90 minutes of first medical contact, regardless of
,hemodynamic status. In cardiogenic shock, vasopressor support with norepinephrine
(first-line) should be initiated to maintain MAP >65 mmHg while preparing for
revascularization. Option A delays definitive therapy. Option B is contraindicated due to
hypotension (nitroglycerin causes venodilation and further BP reduction). Option D
(thrombolytics) is inferior to PCI in cardiogenic shock and should only be considered if
PCI is unavailable within 120 minutes.
Q2: A 72-year-old female with a history of atrial fibrillation on warfarin presents with
acute-onset severe chest pain and dyspnea. BP is 156/94 mmHg, HR 118 bpm
irregularly irregular, RR 28, SpO2 89% on 2L NC. Chest X-ray shows pulmonary edema.
ECG reveals new ST-segment depression in the lateral leads and rapid ventricular
response. Bedside echocardiogram shows severe mitral regurgitation with a flail
posterior leaflet. What is the definitive management?
A. Immediate synchronized cardioversion at 200J after transesophageal
echocardiography to rule out left atrial thrombus
B. Emergency cardiothoracic surgery consultation for mitral valve repair or replacement
C. Initiate IV diltiazem for rate control and heparin bridge for therapeutic anticoagulation
D. Administer IV furosemide 80 mg and initiate BiPAP for afterload reduction
Correct Answer: B
Rationale: This patient has acute severe mitral regurgitation (MR) secondary to papillary
muscle rupture or chordal rupture (flail leaflet), causing acute pulmonary edema. This is
a surgical emergency requiring emergent mitral valve repair or replacement. Medical
therapy (diuretics, afterload reduction) is temporizing only. While rate control (Option C)
and afterload reduction (Option D) may provide temporary stabilization, they do not
,address the mechanical problem. Cardioversion (Option A) is inappropriate as the
primary issue is not atrial fibrillation with hemodynamic instability from the arrhythmia
itself, but rather acute valvular catastrophe causing heart failure. The 2020 ACC/AHA
Guidelines for the Management of Patients With Valvular Heart Disease recommend
emergent surgery for acute severe MR causing refractory heart failure.
Q3: A 58-year-old male with a history of hypertension presents with tearing chest pain
radiating to his back. BP is 186/112 mmHg in the right arm and 154/98 mmHg in the
left arm. HR 96 bpm. CT angiography reveals a Stanford Type A aortic dissection
extending from the ascending aorta to the descending thoracic aorta. What is the
immediate management priority?
A. Initiate IV esmolol infusion to achieve heart rate <60 bpm and systolic BP <120
mmHg, followed by emergent surgical consultation
B. Administer IV nitroprusside immediately to reduce afterload without beta-blockade
C. Perform emergent percutaneous aortic stent grafting in the interventional radiology
suite
D. Initiate IV tissue plasminogen activator (tPA) for suspected mesenteric ischemia
Correct Answer: A
Rationale: Stanford Type A aortic dissection involving the ascending aorta requires
emergent surgical repair. Immediate medical management includes IV beta-blockade
(esmolol or labetalol) to reduce heart rate (<60 bpm) and contractility (dP/dt), followed
by vasodilators to achieve systolic BP <120 mmHg or MAP <80 mmHg. Beta-blockade
must precede vasodilation to prevent reflex catecholamine surge that could increase
aortic shear stress and propagation of the dissection. Option B is dangerous without
, beta-blockade. Option C (TEVAR) is indicated for Type B dissections, not Type A. Option
D is contraindicated and dangerous in aortic dissection.
Q4: A 64-year-old male presents with chest pain at rest for 20 minutes. Vital signs: BP
142/88 mmHg, HR 76 bpm, RR 18. ECG shows 1 mm ST-segment depression in leads
V4-V6 and T-wave inversions in the anterior leads. Troponin I returns at 0.45 ng/mL
(normal <0.04). The patient has continued intermittent chest discomfort. What is the
most appropriate next step in management?
A. Immediate coronary angiography within 2 hours given elevated troponin and dynamic
ECG changes
B. Administer aspirin, clopidogrel, heparin, and schedule stress testing within 72 hours
C. Administer aspirin, ticagrelor, anticoagulation, and high-intensity statin; risk stratify
using GRACE score to determine timing of angiography
D. Administer IV thrombolytics due to NSTEMI diagnosis
Correct Answer: C
Rationale: This patient has non-ST-elevation myocardial infarction (NSTEMI) based on
elevated troponin and ischemic symptoms with ECG changes. Current guidelines
recommend initial medical management with dual antiplatelet therapy (aspirin + P2Y12
inhibitor), anticoagulation, and high-intensity statin therapy. Risk stratification using the
GRACE score determines timing of invasive strategy: very high-risk patients (GRACE
>140) undergo angiography within 2 hours; high-risk (GRACE 109-140) within 24 hours;
intermediate-risk within 72 hours. Immediate angiography (Option A) is reserved for
hemodynamic instability, refractory angina, malignant arrhythmias, or acute heart
failure. Thrombolytics (Option D) have no role in NSTEMI management.
