NRNP 6566 ADVANCED CARE OF ADULTS IN ACUTE
SETTINGS I WEEK 3 KNOWLEDGE CHECK 2026/2027 |
Questions and Verified Answers | Pass Guaranteed - A+
Graded
Domain 1: Respiratory Acute Care (15 Questions)
Q1: A 68-year-old male with COPD presents to the ED with acute-on-chronic respiratory
failure. Vital signs: BP 142/88, HR 118, RR 32, SpO2 84% on room air, T 37.2°C. He is
using accessory muscles and appears anxious. ABG on room air: pH 7.28, PaCO2 68
mmHg, PaO2 48 mmHg, HCO3- 32 mEq/L. Which acid-base disorder is present, and
what is the immediate priority intervention?
A. Acute respiratory acidosis; immediate intubation and mechanical ventilation
B. Chronic respiratory acidosis with acute-on-chronic exacerbation; trial of NIV with
BiPAP [CORRECT]
C. Metabolic alkalosis with respiratory compensation; high-flow oxygen via nasal
cannula
D. Mixed respiratory and metabolic acidosis; immediate sedation and intubation
Correct Answer: B
Rationale: The ABG demonstrates chronic respiratory acidosis with acute-on-chronic
exacerbation. The elevated HCO3- (32 mEq/L) indicates renal compensation has
occurred over time, consistent with chronic hypercapnia. The pH of 7.28 reflects an
,acute worsening from baseline. The PaO2 of 48 mmHg and PaCO2 of 68 mmHg
confirm Type II respiratory failure.
Clinical Reasoning: This patient meets criteria for a trial of non-invasive ventilation (NIV)
with BiPAP as first-line therapy. NIV reduces work of breathing, improves ventilation,
decreases intubation rates, and shortens hospital stays in COPD exacerbations with
acute-on-chronic respiratory failure.
Why other options are incorrect:
● A is incorrect because immediate intubation is not indicated without a trial of NIV
first; the pH >7.25 and patient is hemodynamically stable with intact airway
reflexes.
● C is incorrect because high-flow oxygen alone would worsen CO2 retention and
respiratory acidosis by removing hypoxic drive.
● D is incorrect because there is no metabolic acidosis (HCO3- is elevated, not
decreased), and immediate sedation without NIV trial violates evidence-based
COPD management protocols.
Q2: A 72-year-old female with pneumonia develops acute hypoxemic respiratory failure.
SpO2 is 88% on 6L NC. After increasing to 15L non-rebreather, SpO2 improves to 92%.
ABG shows pH 7.36, PaCO2 42 mmHg, PaO2 58 mmHg, HCO3- 24 mEq/L. Which
statement best describes her oxygenation status and management priority?
A. Adequate oxygenation achieved; continue current therapy and monitor
B. Refractory hypoxemia; immediate intubation required
C. Severe hypoxemia despite high-flow oxygen; escalate to high-flow nasal cannula or
consider intubation [CORRECT]
,D. Hypercapnic respiratory failure; initiate BiPAP
Correct Answer: C
Rationale: The patient has severe hypoxemia (PaO2 58 mmHg, P/F ratio ≈ 116 on
estimated FiO2 ~0.6-0.7 with non-rebreather) indicating moderate ARDS by Berlin
criteria. Despite high-flow oxygen, PaO2 remains <60 mmHg with SpO2 only 92%.
Clinical Reasoning: A PaO2 of 58 mmHg on high-flow oxygen represents failure of
conventional oxygen therapy. The P/F ratio calculation (58 ÷ 0.6-0.7) places her in the
moderate ARDS category. Management requires escalation to high-flow nasal cannula
(HFNC) for better oxygenation and PEEP effect, or preparation for intubation if HFNC
unavailable or contraindicated.
Why other options are incorrect:
● A is incorrect because PaO2 58 mmHg is not acceptable; target is PaO2 >60
mmHg or SpO2 88-95% in ARDS (permissive hypoxemia may be tolerated, but
this requires controlled settings).
● B is incorrect because immediate intubation may not be necessary if HFNC can
be trialed first, unless mental status changes or hemodynamic instability
develops.
● D is incorrect because PaCO2 is normal (42 mmHg); this is pure hypoxemic
failure, not hypercapnic failure requiring BiPAP.
Q3: A 55-year-old male with BMI 42 kg/m² presents with acute pulmonary edema. RR
34, SpO2 82% on room air, BP 198/110, bilateral crackles, accessory muscle use. He is
anxious and refusing intubation. Which intervention is most appropriate?
, A. Immediate rapid sequence intubation regardless of patient refusal
B. CPAP 10 cm H2O with high-flow oxygen and IV nitroglycerin [CORRECT]
C. High-flow nasal cannula at 50 L/min with 100% FiO2 alone
D. BiPAP with IPAP 15, EPAP 5 without addressing afterload reduction
Correct Answer: B
Rationale: This patient has acute cardiogenic pulmonary edema with severe hypoxemia
and respiratory distress. CPAP is first-line for cardiogenic pulmonary edema as it
reduces preload and afterload, decreases work of breathing, and improves oxygenation.
Clinical Reasoning: CPAP 10 cm H2O provides PEEP to recruit alveoli and reduce
transmural pressure, improving oxygenation while decreasing cardiac preload.
Combined with afterload reduction (nitroglycerin) and high-flow oxygen, this addresses
both the respiratory failure and underlying cardiac pathology. Studies show CPAP
reduces intubation rates and mortality in acute cardiogenic pulmonary edema.
Why other options are incorrect:
● A is incorrect because the patient has decision-making capacity and is refusing;
NIV is effective in this setting and should be offered first.
● C is incorrect because HFNC alone does not provide the PEEP-mediated
afterload reduction benefits of CPAP in cardiogenic pulmonary edema.
● D is incorrect because while BiPAP can be used, the IPAP/EPAP differential
focuses on ventilation rather than the optimal afterload reduction of CPAP; more
importantly, failing to address afterload reduction with vasodilators misses a
critical therapeutic opportunity.
SETTINGS I WEEK 3 KNOWLEDGE CHECK 2026/2027 |
Questions and Verified Answers | Pass Guaranteed - A+
Graded
Domain 1: Respiratory Acute Care (15 Questions)
Q1: A 68-year-old male with COPD presents to the ED with acute-on-chronic respiratory
failure. Vital signs: BP 142/88, HR 118, RR 32, SpO2 84% on room air, T 37.2°C. He is
using accessory muscles and appears anxious. ABG on room air: pH 7.28, PaCO2 68
mmHg, PaO2 48 mmHg, HCO3- 32 mEq/L. Which acid-base disorder is present, and
what is the immediate priority intervention?
A. Acute respiratory acidosis; immediate intubation and mechanical ventilation
B. Chronic respiratory acidosis with acute-on-chronic exacerbation; trial of NIV with
BiPAP [CORRECT]
C. Metabolic alkalosis with respiratory compensation; high-flow oxygen via nasal
cannula
D. Mixed respiratory and metabolic acidosis; immediate sedation and intubation
Correct Answer: B
Rationale: The ABG demonstrates chronic respiratory acidosis with acute-on-chronic
exacerbation. The elevated HCO3- (32 mEq/L) indicates renal compensation has
occurred over time, consistent with chronic hypercapnia. The pH of 7.28 reflects an
,acute worsening from baseline. The PaO2 of 48 mmHg and PaCO2 of 68 mmHg
confirm Type II respiratory failure.
Clinical Reasoning: This patient meets criteria for a trial of non-invasive ventilation (NIV)
with BiPAP as first-line therapy. NIV reduces work of breathing, improves ventilation,
decreases intubation rates, and shortens hospital stays in COPD exacerbations with
acute-on-chronic respiratory failure.
Why other options are incorrect:
● A is incorrect because immediate intubation is not indicated without a trial of NIV
first; the pH >7.25 and patient is hemodynamically stable with intact airway
reflexes.
● C is incorrect because high-flow oxygen alone would worsen CO2 retention and
respiratory acidosis by removing hypoxic drive.
● D is incorrect because there is no metabolic acidosis (HCO3- is elevated, not
decreased), and immediate sedation without NIV trial violates evidence-based
COPD management protocols.
Q2: A 72-year-old female with pneumonia develops acute hypoxemic respiratory failure.
SpO2 is 88% on 6L NC. After increasing to 15L non-rebreather, SpO2 improves to 92%.
ABG shows pH 7.36, PaCO2 42 mmHg, PaO2 58 mmHg, HCO3- 24 mEq/L. Which
statement best describes her oxygenation status and management priority?
A. Adequate oxygenation achieved; continue current therapy and monitor
B. Refractory hypoxemia; immediate intubation required
C. Severe hypoxemia despite high-flow oxygen; escalate to high-flow nasal cannula or
consider intubation [CORRECT]
,D. Hypercapnic respiratory failure; initiate BiPAP
Correct Answer: C
Rationale: The patient has severe hypoxemia (PaO2 58 mmHg, P/F ratio ≈ 116 on
estimated FiO2 ~0.6-0.7 with non-rebreather) indicating moderate ARDS by Berlin
criteria. Despite high-flow oxygen, PaO2 remains <60 mmHg with SpO2 only 92%.
Clinical Reasoning: A PaO2 of 58 mmHg on high-flow oxygen represents failure of
conventional oxygen therapy. The P/F ratio calculation (58 ÷ 0.6-0.7) places her in the
moderate ARDS category. Management requires escalation to high-flow nasal cannula
(HFNC) for better oxygenation and PEEP effect, or preparation for intubation if HFNC
unavailable or contraindicated.
Why other options are incorrect:
● A is incorrect because PaO2 58 mmHg is not acceptable; target is PaO2 >60
mmHg or SpO2 88-95% in ARDS (permissive hypoxemia may be tolerated, but
this requires controlled settings).
● B is incorrect because immediate intubation may not be necessary if HFNC can
be trialed first, unless mental status changes or hemodynamic instability
develops.
● D is incorrect because PaCO2 is normal (42 mmHg); this is pure hypoxemic
failure, not hypercapnic failure requiring BiPAP.
Q3: A 55-year-old male with BMI 42 kg/m² presents with acute pulmonary edema. RR
34, SpO2 82% on room air, BP 198/110, bilateral crackles, accessory muscle use. He is
anxious and refusing intubation. Which intervention is most appropriate?
, A. Immediate rapid sequence intubation regardless of patient refusal
B. CPAP 10 cm H2O with high-flow oxygen and IV nitroglycerin [CORRECT]
C. High-flow nasal cannula at 50 L/min with 100% FiO2 alone
D. BiPAP with IPAP 15, EPAP 5 without addressing afterload reduction
Correct Answer: B
Rationale: This patient has acute cardiogenic pulmonary edema with severe hypoxemia
and respiratory distress. CPAP is first-line for cardiogenic pulmonary edema as it
reduces preload and afterload, decreases work of breathing, and improves oxygenation.
Clinical Reasoning: CPAP 10 cm H2O provides PEEP to recruit alveoli and reduce
transmural pressure, improving oxygenation while decreasing cardiac preload.
Combined with afterload reduction (nitroglycerin) and high-flow oxygen, this addresses
both the respiratory failure and underlying cardiac pathology. Studies show CPAP
reduces intubation rates and mortality in acute cardiogenic pulmonary edema.
Why other options are incorrect:
● A is incorrect because the patient has decision-making capacity and is refusing;
NIV is effective in this setting and should be offered first.
● C is incorrect because HFNC alone does not provide the PEEP-mediated
afterload reduction benefits of CPAP in cardiogenic pulmonary edema.
● D is incorrect because while BiPAP can be used, the IPAP/EPAP differential
focuses on ventilation rather than the optimal afterload reduction of CPAP; more
importantly, failing to address afterload reduction with vasodilators misses a
critical therapeutic opportunity.
