The Ultimate and Complete ACLS Advanced Cardiovascular Life Support
Study Guide 2025, Covering Cardiac Arrest Algorithms, BLS and ACLS
Integration, Airway Management Techniques, ECG Rhythm Interpretation,
Pharmacology for ACLS, Megacode Scenarios, Team Dynamics and
Communication, Post-Cardiac Arrest Care, Stroke and Acute Coronary
Syndrome Management, Defibrillation and Cardioversion Procedures,
Practice Questions with Detailed Rationales, Real-Life Emergency Scenarios,
Step-by-Step Algorithms, and Proven Strategies to Successfully Pass the
ACLS Certification Exam on the First Attempt
Question 1: During a cardiac arrest, the rhythm check reveals ventricular fibrillation. After
initiating high-quality CPR and delivering the first defibrillation shock, what is the immediate
next action according to ACLS guidelines?
A. Administer epinephrine 1 mg IV/IO
B. Check for a pulse and rhythm
C. Resume CPR immediately for 2 minutes
D. Administer amiodarone 300 mg IV/IO
CORRECT ANSWER: C. Resume CPR immediately for 2 minutes
RATIONALE: According to the 2020 AHA ACLS guidelines, after a defibrillation shock is delivered
for VF/pVT, CPR should be resumed immediately without delay for rhythm or pulse check. This
minimizes interruptions in chest compressions and supports coronary and cerebral perfusion.
Epinephrine and antiarrhythmics are administered after the second rhythm check following 2
minutes of CPR.
Question 2: Which of the following is the recommended initial dose of epinephrine for adult
cardiac arrest?
A. 0.5 mg IV/IO
B. 1 mg IV/IO
C. 2 mg IV/IO
D. 0.1 mg/kg IV/IO
CORRECT ANSWER: B. 1 mg IV/IO
RATIONALE: The standard initial and subsequent dose of epinephrine in adult cardiac arrest is 1
mg IV/IO every 3-5 minutes. This dose is supported by AHA ACLS guidelines to enhance
coronary and cerebral perfusion pressure during CPR without excessive adverse effects.
Question 3: A patient presents with symptomatic bradycardia, heart rate 38 bpm, blood
pressure 80/50 mmHg, and altered mental status. After establishing IV access and
administering oxygen, what is the first-line pharmacologic intervention?
,A. Atropine 0.5 mg IV
B. Epinephrine infusion 2-10 mcg/min
C. Dopamine infusion 5-20 mcg/kg/min
D. Transcutaneous pacing
CORRECT ANSWER: A. Atropine 0.5 mg IV
RATIONALE: For symptomatic bradycardia with adequate IV access, atropine 0.5 mg IV is the
first-line medication per ACLS algorithms. It may be repeated every 3-5 minutes to a maximum
of 3 mg. If ineffective, transcutaneous pacing or catecholamine infusions (epinephrine or
dopamine) are indicated.
Question 4: Which rhythm is characterized by a regular narrow-complex tachycardia with a
rate of 180 bpm and no visible P waves?
A. Atrial fibrillation
B. Atrial flutter
C. Supraventricular tachycardia (SVT)
D. Ventricular tachycardia
CORRECT ANSWER: C. Supraventricular tachycardia (SVT)
RATIONALE: SVT typically presents as a regular narrow-complex tachycardia with rates between
150-250 bpm. P waves are often buried in the QRS complex or not visible. Atrial fibrillation is
irregularly irregular; atrial flutter shows sawtooth flutter waves; ventricular tachycardia is
usually wide-complex.
Question 5: During post-cardiac arrest care, a patient remains comatose after ROSC. What is
the recommended target temperature range for targeted temperature management (TTM)?
A. 32°C to 34°C
B. 32°C to 36°C
C. 35°C to 37°C
D. 36°C to 38°C
CORRECT ANSWER: B. 32°C to 36°C
RATIONALE: The 2020 AHA guidelines recommend TTM for comatose adult patients after ROSC,
maintaining a constant target temperature between 32°C and 36°C for at least 24 hours. This
range is associated with improved neurologic outcomes and is more flexible than prior
narrower recommendations.
Question 6: A patient in cardiac arrest has a rhythm of asystole confirmed on two leads. What
is the appropriate next step after starting high-quality CPR?
,A. Defibrillate at 200 J
B. Administer epinephrine 1 mg IV/IO
C. Administer atropine 1 mg IV
D. Perform transcutaneous pacing
CORRECT ANSWER: B. Administer epinephrine 1 mg IV/IO
RATIONALE: Asystole is a non-shockable rhythm. After confirming asystole and initiating CPR,
epinephrine 1 mg IV/IO should be administered as soon as feasible, repeated every 3-5
minutes. Atropine is no longer recommended for asystole in current ACLS guidelines.
Defibrillation and pacing are not indicated for asystole.
Question 7: Which medication is preferred for stable monomorphic ventricular tachycardia
with a pulse when pharmacologic conversion is indicated?
A. Lidocaine 1-1.5 mg/kg IV
B. Amiodarone 150 mg IV over 10 minutes
C. Procainamide 20-50 mg/min IV
D. Adenosine 6 mg IV rapid push
CORRECT ANSWER: B. Amiodarone 150 mg IV over 10 minutes
RATIONALE: For stable monomorphic VT with a pulse, amiodarone 150 mg IV infused over 10
minutes is the preferred antiarrhythmic per ACLS. Procainamide is an alternative if amiodarone
is unavailable and the patient has preserved LV function. Lidocaine is less effective; adenosine is
only for stable wide-complex tachycardia of uncertain origin when SVT with aberrancy is
suspected.
Question 8: What is the recommended compression-to-ventilation ratio for adult CPR with an
advanced airway in place during cardiac arrest?
A. 15:2
B. 30:2
C. Continuous compressions with asynchronous ventilations
D. 10:1
CORRECT ANSWER: C. Continuous compressions with asynchronous ventilations
RATIONALE: When an advanced airway (endotracheal tube or supraglottic device) is in place
during adult cardiac arrest, rescuers should perform continuous chest compressions without
pausing for ventilations. Ventilations are delivered asynchronously at a rate of 1 breath every 6
seconds (10 breaths per minute).
Question 9: A patient with acute coronary syndrome presents with chest pain, ST-segment
elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?
, A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
CORRECT ANSWER: C. Right coronary artery
RATIONALE: ST-elevation in leads II, III, and aVF indicates inferior wall myocardial infarction,
most commonly caused by occlusion of the right coronary artery (in ~80-90% of cases). The left
circumflex may also supply the inferior wall in some anatomical variants, but the RCA is the
most frequent culprit.
Question 10: Which of the following is a reversible cause of cardiac arrest represented by the
letter "H" in the H's and T's mnemonic?
A. Hypertension
B. Hypovolemia
C. Hyperglycemia
D. Hyperlipidemia
CORRECT ANSWER: B. Hypovolemia
RATIONALE: The H's and T's mnemonic helps identify reversible causes of cardiac arrest. The
"H's" include Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia,
Hypothermia. Hypertension, hyperglycemia, and hyperlipidemia are not part of this mnemonic
and are not immediate reversible causes of arrest.
Question 11: During synchronized cardioversion for unstable atrial fibrillation, what is the
recommended initial energy dose for a biphasic defibrillator?
A. 50 J
B. 100 J
C. 120-200 J
D. 360 J
CORRECT ANSWER: C. 120-200 J
RATIONALE: For synchronized cardioversion of atrial fibrillation using a biphasic defibrillator,
the recommended initial energy dose is 120-200 J. If the first shock fails, escalate the energy for
subsequent shocks. Monophasic defibrillators (less common) start at 200 J.
Question 12: A patient in pulseless electrical activity (PEA) has a heart rate of 45 bpm on the
monitor but no palpable pulse. What is the priority intervention?
A. Administer atropine 1 mg IV
B. Perform immediate defibrillation
Study Guide 2025, Covering Cardiac Arrest Algorithms, BLS and ACLS
Integration, Airway Management Techniques, ECG Rhythm Interpretation,
Pharmacology for ACLS, Megacode Scenarios, Team Dynamics and
Communication, Post-Cardiac Arrest Care, Stroke and Acute Coronary
Syndrome Management, Defibrillation and Cardioversion Procedures,
Practice Questions with Detailed Rationales, Real-Life Emergency Scenarios,
Step-by-Step Algorithms, and Proven Strategies to Successfully Pass the
ACLS Certification Exam on the First Attempt
Question 1: During a cardiac arrest, the rhythm check reveals ventricular fibrillation. After
initiating high-quality CPR and delivering the first defibrillation shock, what is the immediate
next action according to ACLS guidelines?
A. Administer epinephrine 1 mg IV/IO
B. Check for a pulse and rhythm
C. Resume CPR immediately for 2 minutes
D. Administer amiodarone 300 mg IV/IO
CORRECT ANSWER: C. Resume CPR immediately for 2 minutes
RATIONALE: According to the 2020 AHA ACLS guidelines, after a defibrillation shock is delivered
for VF/pVT, CPR should be resumed immediately without delay for rhythm or pulse check. This
minimizes interruptions in chest compressions and supports coronary and cerebral perfusion.
Epinephrine and antiarrhythmics are administered after the second rhythm check following 2
minutes of CPR.
Question 2: Which of the following is the recommended initial dose of epinephrine for adult
cardiac arrest?
A. 0.5 mg IV/IO
B. 1 mg IV/IO
C. 2 mg IV/IO
D. 0.1 mg/kg IV/IO
CORRECT ANSWER: B. 1 mg IV/IO
RATIONALE: The standard initial and subsequent dose of epinephrine in adult cardiac arrest is 1
mg IV/IO every 3-5 minutes. This dose is supported by AHA ACLS guidelines to enhance
coronary and cerebral perfusion pressure during CPR without excessive adverse effects.
Question 3: A patient presents with symptomatic bradycardia, heart rate 38 bpm, blood
pressure 80/50 mmHg, and altered mental status. After establishing IV access and
administering oxygen, what is the first-line pharmacologic intervention?
,A. Atropine 0.5 mg IV
B. Epinephrine infusion 2-10 mcg/min
C. Dopamine infusion 5-20 mcg/kg/min
D. Transcutaneous pacing
CORRECT ANSWER: A. Atropine 0.5 mg IV
RATIONALE: For symptomatic bradycardia with adequate IV access, atropine 0.5 mg IV is the
first-line medication per ACLS algorithms. It may be repeated every 3-5 minutes to a maximum
of 3 mg. If ineffective, transcutaneous pacing or catecholamine infusions (epinephrine or
dopamine) are indicated.
Question 4: Which rhythm is characterized by a regular narrow-complex tachycardia with a
rate of 180 bpm and no visible P waves?
A. Atrial fibrillation
B. Atrial flutter
C. Supraventricular tachycardia (SVT)
D. Ventricular tachycardia
CORRECT ANSWER: C. Supraventricular tachycardia (SVT)
RATIONALE: SVT typically presents as a regular narrow-complex tachycardia with rates between
150-250 bpm. P waves are often buried in the QRS complex or not visible. Atrial fibrillation is
irregularly irregular; atrial flutter shows sawtooth flutter waves; ventricular tachycardia is
usually wide-complex.
Question 5: During post-cardiac arrest care, a patient remains comatose after ROSC. What is
the recommended target temperature range for targeted temperature management (TTM)?
A. 32°C to 34°C
B. 32°C to 36°C
C. 35°C to 37°C
D. 36°C to 38°C
CORRECT ANSWER: B. 32°C to 36°C
RATIONALE: The 2020 AHA guidelines recommend TTM for comatose adult patients after ROSC,
maintaining a constant target temperature between 32°C and 36°C for at least 24 hours. This
range is associated with improved neurologic outcomes and is more flexible than prior
narrower recommendations.
Question 6: A patient in cardiac arrest has a rhythm of asystole confirmed on two leads. What
is the appropriate next step after starting high-quality CPR?
,A. Defibrillate at 200 J
B. Administer epinephrine 1 mg IV/IO
C. Administer atropine 1 mg IV
D. Perform transcutaneous pacing
CORRECT ANSWER: B. Administer epinephrine 1 mg IV/IO
RATIONALE: Asystole is a non-shockable rhythm. After confirming asystole and initiating CPR,
epinephrine 1 mg IV/IO should be administered as soon as feasible, repeated every 3-5
minutes. Atropine is no longer recommended for asystole in current ACLS guidelines.
Defibrillation and pacing are not indicated for asystole.
Question 7: Which medication is preferred for stable monomorphic ventricular tachycardia
with a pulse when pharmacologic conversion is indicated?
A. Lidocaine 1-1.5 mg/kg IV
B. Amiodarone 150 mg IV over 10 minutes
C. Procainamide 20-50 mg/min IV
D. Adenosine 6 mg IV rapid push
CORRECT ANSWER: B. Amiodarone 150 mg IV over 10 minutes
RATIONALE: For stable monomorphic VT with a pulse, amiodarone 150 mg IV infused over 10
minutes is the preferred antiarrhythmic per ACLS. Procainamide is an alternative if amiodarone
is unavailable and the patient has preserved LV function. Lidocaine is less effective; adenosine is
only for stable wide-complex tachycardia of uncertain origin when SVT with aberrancy is
suspected.
Question 8: What is the recommended compression-to-ventilation ratio for adult CPR with an
advanced airway in place during cardiac arrest?
A. 15:2
B. 30:2
C. Continuous compressions with asynchronous ventilations
D. 10:1
CORRECT ANSWER: C. Continuous compressions with asynchronous ventilations
RATIONALE: When an advanced airway (endotracheal tube or supraglottic device) is in place
during adult cardiac arrest, rescuers should perform continuous chest compressions without
pausing for ventilations. Ventilations are delivered asynchronously at a rate of 1 breath every 6
seconds (10 breaths per minute).
Question 9: A patient with acute coronary syndrome presents with chest pain, ST-segment
elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?
, A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
CORRECT ANSWER: C. Right coronary artery
RATIONALE: ST-elevation in leads II, III, and aVF indicates inferior wall myocardial infarction,
most commonly caused by occlusion of the right coronary artery (in ~80-90% of cases). The left
circumflex may also supply the inferior wall in some anatomical variants, but the RCA is the
most frequent culprit.
Question 10: Which of the following is a reversible cause of cardiac arrest represented by the
letter "H" in the H's and T's mnemonic?
A. Hypertension
B. Hypovolemia
C. Hyperglycemia
D. Hyperlipidemia
CORRECT ANSWER: B. Hypovolemia
RATIONALE: The H's and T's mnemonic helps identify reversible causes of cardiac arrest. The
"H's" include Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia,
Hypothermia. Hypertension, hyperglycemia, and hyperlipidemia are not part of this mnemonic
and are not immediate reversible causes of arrest.
Question 11: During synchronized cardioversion for unstable atrial fibrillation, what is the
recommended initial energy dose for a biphasic defibrillator?
A. 50 J
B. 100 J
C. 120-200 J
D. 360 J
CORRECT ANSWER: C. 120-200 J
RATIONALE: For synchronized cardioversion of atrial fibrillation using a biphasic defibrillator,
the recommended initial energy dose is 120-200 J. If the first shock fails, escalate the energy for
subsequent shocks. Monophasic defibrillators (less common) start at 200 J.
Question 12: A patient in pulseless electrical activity (PEA) has a heart rate of 45 bpm on the
monitor but no palpable pulse. What is the priority intervention?
A. Administer atropine 1 mg IV
B. Perform immediate defibrillation
