NRNP 6566/6566 FINAL EXAM 2026 |
Advanced Care of Adults in Acute
Settings I | Walden University Verified
Q&A 2025/2026 | 100% Correct | A+
Graded | Pass Guaranteed
## **PART A: MULTIPLE CHOICE (Q1–80)**
* *Q1 (Respiratory – ARDS):** A 58-year-old male with ARDS secondary to severe pneumonia is
on mechanical ventilation. His current settings are: Vt 450 mL (6 mL/kg IBW), PEEP 12 cmH₂O,
FiO₂ 0.60. His plateau pressure is 32 cmH₂O. Which ventilator adjustment is most appropriate?
. Increase Vt to 550 mL to improve oxygenation
A
B. Decrease PEEP to 8 cmH₂O to reduce plateau pressure
C. Decrease Vt to 350 mL and increase respiratory rate
D. Maintain current settings; plateau pressure is acceptable
* *[CORRECT]** C
*Rationale: The Surviving Sepsis Campaign 2021 and ARDSNet protocols recommend
maintaining plateau pressure ≤30 cmH₂O to prevent ventilator-induced lung injury. A plateau
pressure of 32 cmH₂O exceeds this threshold, requiring reduction of tidal volume to 4-6 mL/kg
IBW with increased respiratory rate to maintain minute ventilation. Option A would worsen
barotrauma; Option B would compromise oxygenation; Option D ignores the critical plateau
pressure threshold.*
---
* *Q2 (Respiratory – ARDS):** A patient with moderate ARDS (PaO₂/FiO₂ 150) remains
hypoxemic despite PEEP 10 cmH₂O and FiO₂ 0.80. Which intervention is most appropriate next
step?
. Increase PEEP to 18 cmH₂O
A
B. Initiate prone positioning for ≥12 hours daily
C. Switch to pressure control ventilation
D. Administer inhaled nitric oxide
,* *[CORRECT]** B
*Rationale: The PROSEVA trial demonstrated that prone positioning for ≥12 hours daily
significantly reduces mortality in moderate-to-severe ARDS (PaO₂/FiO₂ <150). While high PEEP
strategies may help, prone positioning is the evidence-based next step when hypoxemia
persists despite moderate PEEP and high FiO₂. Inhaled nitric oxide is reserved as rescue
therapy; pressure control alone does not address the fundamental V/Q mismatch.*
---
* *Q3 (Respiratory – COPD Exacerbation):** A 72-year-old with COPD (FEV₁ 35% predicted)
presents with acute exacerbation. SpO₂ is 82% on room air, RR 28, using accessory muscles.
Which oxygen titration target is most appropriate?
. SpO₂ 94-98%
A
B. SpO₂ 88-92%
C. SpO₂ >95%
D. PaO₂ >80 mmHg
* *[CORRECT]** B
*Rationale: The British Thoracic Society and GOLD guidelines recommend maintaining SpO₂
88-92% in COPD patients with chronic hypercapnia to avoid suppressing hypoxic respiratory
drive. Higher oxygen targets (Options A, C, D) risk causing CO₂ retention, respiratory acidosis,
and possible need for emergent intubation. This "controlled oxygen" strategy prevents hypoxic
drive suppression while maintaining adequate tissue oxygenation.*
---
* *Q4 (Respiratory – COPD Exacerbation):** A patient with acute COPD exacerbation has pH
7.32, PaCO₂ 62 mmHg, PaO₂ 58 mmHg on 2L NC. They are alert but dyspneic. Which
intervention is most appropriate?
. Immediate intubation and mechanical ventilation
A
B. Trial of non-invasive ventilation (BiPAP)
C. High-flow nasal cannula at 40 L/min
D. Increase NC to 6L and reassess in 30 minutes
* *[CORRECT]** B
*Rationale: The GOLD 2023 update and NICE guidelines recommend NIV (BiPAP) as first-line
therapy for acute COPD exacerbation with respiratory acidosis (pH <7.35) and dyspnea,
provided the patient is alert and hemodynamically stable. NIV reduces intubation rates, hospital
length of stay, and mortality. Immediate intubation (A) is unnecessary in an alert patient; HFNC
(C) is less effective for hypercapnia; increasing NC (D) risks CO₂ retention without addressing
the acidosis.*
,---
* *Q5 (Respiratory – Asthma Exacerbation):** A 24-year-old with severe asthma exacerbation
has received continuous albuterol, ipratropium bromide, and methylprednisolone 125 mg IV.
Peak flow remains <50% predicted, RR 32, silent chest on auscultation. Which medication
should be added next?
. Magnesium sulfate 2 g IV over 20 minutes
A
B. Levalbuterol nebulizer
C. Terbutaline subcutaneous
D. Montelukast 10 mg orally
* *[CORRECT]** A
*Rationale: The 2020 GINA guidelines and NAEPP recommendations support IV magnesium
sulfate (2 g over 20 minutes) for severe asthma exacerbations unresponsive to initial
bronchodilator and corticosteroid therapy, particularly when FEV₁/peak flow remains <25-30%
predicted or with impending respiratory failure. Magnesium promotes bronchial smooth muscle
relaxation via calcium channel blockade. Levalbuterol (B) offers no advantage over albuterol;
terbutaline (C) is reserved for refractory cases; montelukast (D) has no role in acute
management.*
---
* *Q6 (Respiratory – Pulmonary Embolism):** A 45-year-old postoperative patient develops
sudden dyspnea, tachycardia, and hypoxia. Wells score is 6 (moderate probability). D-dimer is
1200 ng/mL. What is the next best step?
. Begin therapeutic heparin and obtain CTPA
A
B. Obtain CTPA before initiating anticoagulation
C. Begin heparin and obtain V/Q scan
D. Obtain lower extremity Doppler ultrasound
* *[CORRECT]** A
*Rationale: The 2019 ESC/ERS guidelines and CHEST guidelines recommend initiating
therapeutic anticoagulation while awaiting definitive imaging in patients with intermediate-to-high
clinical probability of PE, provided there are no contraindications. Delaying anticoagulation
increases mortality risk. CTPA is the preferred imaging modality; V/Q scan (C) is used when
CTPA is contraindicated; Doppler ultrasound (D) evaluates DVT but does not confirm PE.*
---
, * *Q7 (Respiratory – PE Treatment):** A patient with massive PE presents with sustained
hypotension (SBP 78 mmHg), altered mental status, and RV strain on echocardiogram. Which
management is most appropriate?
. Systemic thrombolysis with alteplase 100 mg IV over 2 hours
A
B. Therapeutic heparin infusion alone
C. Surgical embolectomy as first-line
D. Inferior vena cava filter placement
* *[CORRECT]** A
*Rationale: The 2019 ESC guidelines and AHA scientific statement recommend systemic
thrombolysis as first-line therapy for massive (high-risk) PE with hemodynamic compromise,
unless contraindicated. Alteplase 100 mg IV over 2 hours is the standard regimen. Heparin
alone (B) is insufficient for massive PE; surgical embolectomy (C) is reserved for thrombolysis
failure or contraindications; IVC filter (D) is adjunctive, not primary therapy.*
---
* *Q8 (Respiratory – Mechanical Ventilation):** A patient is intubated for acute hypoxemic
respiratory failure. Which initial ventilator mode and settings are most appropriate?
. Assist-control (AC) volume, Vt 6 mL/kg IBW, RR 20, PEEP 5, FiO₂ 1.0
A
B. SIMV volume, Vt 10 mL/kg IBW, RR 12, PEEP 5, FiO₂ 0.40
C. Pressure support, PS 15, PEEP 5, FiO₂ 0.40
D. AC pressure, Pinsp 20 cmH₂O, RR 16, PEEP 5, FiO₂ 0.60
* *[CORRECT]** A
*Rationale: For acute hypoxemic respiratory failure, AC-volume control with lung-protective
ventilation (Vt 6 mL/kg IBW, appropriate PEEP, initial FiO₂ 1.0) is the standard approach per
ARDSNet protocols. SIMV (B) with high tidal volumes violates lung protection; pressure support
(C) is a weaning mode, not for initial stabilization; AC-pressure (D) may deliver variable tidal
volumes in unstable patients.*
---
* *Q9 (Respiratory – Ventilator Weaning):** A patient recovering from ARDS has been stable on
PS 8/PEEP 5/FiO₂ 0.40 for 24 hours. Which parameter best predicts successful extubation?
. Minute ventilation >10 L/min
A
B. Rapid Shallow Breathing Index (RSBI) <105
C. Negative inspiratory force (NIF) >-15 cmH₂O
D. Tidal volume >3 mL/kg IBW
**[CORRECT]** B
Advanced Care of Adults in Acute
Settings I | Walden University Verified
Q&A 2025/2026 | 100% Correct | A+
Graded | Pass Guaranteed
## **PART A: MULTIPLE CHOICE (Q1–80)**
* *Q1 (Respiratory – ARDS):** A 58-year-old male with ARDS secondary to severe pneumonia is
on mechanical ventilation. His current settings are: Vt 450 mL (6 mL/kg IBW), PEEP 12 cmH₂O,
FiO₂ 0.60. His plateau pressure is 32 cmH₂O. Which ventilator adjustment is most appropriate?
. Increase Vt to 550 mL to improve oxygenation
A
B. Decrease PEEP to 8 cmH₂O to reduce plateau pressure
C. Decrease Vt to 350 mL and increase respiratory rate
D. Maintain current settings; plateau pressure is acceptable
* *[CORRECT]** C
*Rationale: The Surviving Sepsis Campaign 2021 and ARDSNet protocols recommend
maintaining plateau pressure ≤30 cmH₂O to prevent ventilator-induced lung injury. A plateau
pressure of 32 cmH₂O exceeds this threshold, requiring reduction of tidal volume to 4-6 mL/kg
IBW with increased respiratory rate to maintain minute ventilation. Option A would worsen
barotrauma; Option B would compromise oxygenation; Option D ignores the critical plateau
pressure threshold.*
---
* *Q2 (Respiratory – ARDS):** A patient with moderate ARDS (PaO₂/FiO₂ 150) remains
hypoxemic despite PEEP 10 cmH₂O and FiO₂ 0.80. Which intervention is most appropriate next
step?
. Increase PEEP to 18 cmH₂O
A
B. Initiate prone positioning for ≥12 hours daily
C. Switch to pressure control ventilation
D. Administer inhaled nitric oxide
,* *[CORRECT]** B
*Rationale: The PROSEVA trial demonstrated that prone positioning for ≥12 hours daily
significantly reduces mortality in moderate-to-severe ARDS (PaO₂/FiO₂ <150). While high PEEP
strategies may help, prone positioning is the evidence-based next step when hypoxemia
persists despite moderate PEEP and high FiO₂. Inhaled nitric oxide is reserved as rescue
therapy; pressure control alone does not address the fundamental V/Q mismatch.*
---
* *Q3 (Respiratory – COPD Exacerbation):** A 72-year-old with COPD (FEV₁ 35% predicted)
presents with acute exacerbation. SpO₂ is 82% on room air, RR 28, using accessory muscles.
Which oxygen titration target is most appropriate?
. SpO₂ 94-98%
A
B. SpO₂ 88-92%
C. SpO₂ >95%
D. PaO₂ >80 mmHg
* *[CORRECT]** B
*Rationale: The British Thoracic Society and GOLD guidelines recommend maintaining SpO₂
88-92% in COPD patients with chronic hypercapnia to avoid suppressing hypoxic respiratory
drive. Higher oxygen targets (Options A, C, D) risk causing CO₂ retention, respiratory acidosis,
and possible need for emergent intubation. This "controlled oxygen" strategy prevents hypoxic
drive suppression while maintaining adequate tissue oxygenation.*
---
* *Q4 (Respiratory – COPD Exacerbation):** A patient with acute COPD exacerbation has pH
7.32, PaCO₂ 62 mmHg, PaO₂ 58 mmHg on 2L NC. They are alert but dyspneic. Which
intervention is most appropriate?
. Immediate intubation and mechanical ventilation
A
B. Trial of non-invasive ventilation (BiPAP)
C. High-flow nasal cannula at 40 L/min
D. Increase NC to 6L and reassess in 30 minutes
* *[CORRECT]** B
*Rationale: The GOLD 2023 update and NICE guidelines recommend NIV (BiPAP) as first-line
therapy for acute COPD exacerbation with respiratory acidosis (pH <7.35) and dyspnea,
provided the patient is alert and hemodynamically stable. NIV reduces intubation rates, hospital
length of stay, and mortality. Immediate intubation (A) is unnecessary in an alert patient; HFNC
(C) is less effective for hypercapnia; increasing NC (D) risks CO₂ retention without addressing
the acidosis.*
,---
* *Q5 (Respiratory – Asthma Exacerbation):** A 24-year-old with severe asthma exacerbation
has received continuous albuterol, ipratropium bromide, and methylprednisolone 125 mg IV.
Peak flow remains <50% predicted, RR 32, silent chest on auscultation. Which medication
should be added next?
. Magnesium sulfate 2 g IV over 20 minutes
A
B. Levalbuterol nebulizer
C. Terbutaline subcutaneous
D. Montelukast 10 mg orally
* *[CORRECT]** A
*Rationale: The 2020 GINA guidelines and NAEPP recommendations support IV magnesium
sulfate (2 g over 20 minutes) for severe asthma exacerbations unresponsive to initial
bronchodilator and corticosteroid therapy, particularly when FEV₁/peak flow remains <25-30%
predicted or with impending respiratory failure. Magnesium promotes bronchial smooth muscle
relaxation via calcium channel blockade. Levalbuterol (B) offers no advantage over albuterol;
terbutaline (C) is reserved for refractory cases; montelukast (D) has no role in acute
management.*
---
* *Q6 (Respiratory – Pulmonary Embolism):** A 45-year-old postoperative patient develops
sudden dyspnea, tachycardia, and hypoxia. Wells score is 6 (moderate probability). D-dimer is
1200 ng/mL. What is the next best step?
. Begin therapeutic heparin and obtain CTPA
A
B. Obtain CTPA before initiating anticoagulation
C. Begin heparin and obtain V/Q scan
D. Obtain lower extremity Doppler ultrasound
* *[CORRECT]** A
*Rationale: The 2019 ESC/ERS guidelines and CHEST guidelines recommend initiating
therapeutic anticoagulation while awaiting definitive imaging in patients with intermediate-to-high
clinical probability of PE, provided there are no contraindications. Delaying anticoagulation
increases mortality risk. CTPA is the preferred imaging modality; V/Q scan (C) is used when
CTPA is contraindicated; Doppler ultrasound (D) evaluates DVT but does not confirm PE.*
---
, * *Q7 (Respiratory – PE Treatment):** A patient with massive PE presents with sustained
hypotension (SBP 78 mmHg), altered mental status, and RV strain on echocardiogram. Which
management is most appropriate?
. Systemic thrombolysis with alteplase 100 mg IV over 2 hours
A
B. Therapeutic heparin infusion alone
C. Surgical embolectomy as first-line
D. Inferior vena cava filter placement
* *[CORRECT]** A
*Rationale: The 2019 ESC guidelines and AHA scientific statement recommend systemic
thrombolysis as first-line therapy for massive (high-risk) PE with hemodynamic compromise,
unless contraindicated. Alteplase 100 mg IV over 2 hours is the standard regimen. Heparin
alone (B) is insufficient for massive PE; surgical embolectomy (C) is reserved for thrombolysis
failure or contraindications; IVC filter (D) is adjunctive, not primary therapy.*
---
* *Q8 (Respiratory – Mechanical Ventilation):** A patient is intubated for acute hypoxemic
respiratory failure. Which initial ventilator mode and settings are most appropriate?
. Assist-control (AC) volume, Vt 6 mL/kg IBW, RR 20, PEEP 5, FiO₂ 1.0
A
B. SIMV volume, Vt 10 mL/kg IBW, RR 12, PEEP 5, FiO₂ 0.40
C. Pressure support, PS 15, PEEP 5, FiO₂ 0.40
D. AC pressure, Pinsp 20 cmH₂O, RR 16, PEEP 5, FiO₂ 0.60
* *[CORRECT]** A
*Rationale: For acute hypoxemic respiratory failure, AC-volume control with lung-protective
ventilation (Vt 6 mL/kg IBW, appropriate PEEP, initial FiO₂ 1.0) is the standard approach per
ARDSNet protocols. SIMV (B) with high tidal volumes violates lung protection; pressure support
(C) is a weaning mode, not for initial stabilization; AC-pressure (D) may deliver variable tidal
volumes in unstable patients.*
---
* *Q9 (Respiratory – Ventilator Weaning):** A patient recovering from ARDS has been stable on
PS 8/PEEP 5/FiO₂ 0.40 for 24 hours. Which parameter best predicts successful extubation?
. Minute ventilation >10 L/min
A
B. Rapid Shallow Breathing Index (RSBI) <105
C. Negative inspiratory force (NIF) >-15 cmH₂O
D. Tidal volume >3 mL/kg IBW
**[CORRECT]** B
