1
NUR 2459 Critical Care Nursing Final Exam Study Guide \
100 Actual Critical Care Questions with Verified
Answers & Rationales
SECTION 1: CARDIOVASCULAR CRITICAL CARE (1–25)
1. A patient with an acute anterior STEMI is being prepared for emergent PCI.
Which antiplatelet agent should be administered as a loading dose before the
procedure?
A. Aspirin 81 mg
B. Clopidogrel 300 mg
C. Ticagrelor 180 mg or prasugrel 60 mg
D. Warfarin
Answer: C
Rationale: Dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor
(ticagrelor or prasugrel) is essential before PCI to prevent stent thrombosis. The
loading dose of ticagrelor is 180 mg, prasugrel 60 mg. Aspirin should be given as
324 mg chewed, not 81 mg. Clopidogrel is an alternative but less potent.
2. A 68-year-old man presents with tearing chest pain radiating to the back. BP
is 170/90 in the right arm and 130/80 in the left. Chest X-ray shows a widened
mediastinum. What is the priority intervention?
A. Administer aspirin
B. Start aggressive blood pressure control (beta-blocker first, then vasodilator)
and prepare for emergency surgery
C. Administer thrombolytics
D. Obtain a CT abdomen
Answer: B
Rationale: The presentation is classic for aortic dissection (Stanford A). The
priority is to reduce shear stress on the aortic wall by controlling heart rate (target
HR ~60) with a beta-blocker (esmolol, labetalol) and then lowering BP with a
pg. 1
,2
vasodilator (nitroprusside). Emergency surgical consultation is essential.
Thrombolytics are contraindicated.
3. A patient with cardiogenic shock has a cardiac index of 1.6 L/min/m², PCWP
28 mmHg, and MAP 52 mmHg on dobutamine. What is the next appropriate
intervention?
A. Add nitroprusside
B. Add norepinephrine
C. Initiate mechanical circulatory support (IABP or Impella)
D. Start milrinone
Answer: C
Rationale: A cardiac index <2.2 with high filling pressures and inadequate
response to inotropes indicates refractory cardiogenic shock. Mechanical support
(IABP, Impella, VA-ECMO) is indicated as a bridge to recovery or advanced
therapies. Norepinephrine would increase afterload; milrinone causes
vasodilation and may worsen hypotension.
4. A patient with a right ventricular infarction becomes hypotensive after
nitroglycerin administration. What is the most appropriate intervention?
A. Administer more nitroglycerin
B. Administer IV fluid boluses (250-500 mL normal saline)
C. Start dopamine
D. Administer furosemide
Answer: B
Rationale: RV infarction is preload-dependent. Nitrates and diuretics reduce
preload and can cause severe hypotension. Treatment involves IV fluid
resuscitation to maintain RV filling and cardiac output. Avoid nitrates and
diuretics.
5. A patient is 2 days post-MI and develops a new holosystolic murmur at the
left lower sternal border with acute pulmonary edema. What is the most likely
pg. 2
,3
diagnosis?
A. Papillary muscle rupture
B. Ventricular septal rupture
C. Acute mitral regurgitation
D. Pericardial tamponade
Answer: B
Rationale: Ventricular septal rupture (VSR) presents with a new holosystolic
murmur at the LLSB and acute heart failure 3-7 days post-MI. Papillary muscle
rupture causes a murmur at the apex and severe mitral regurgitation. Both are
mechanical complications requiring emergency surgery.
6. Which hemodynamic profile is consistent with hypovolemic shock?
A. Increased CVP, increased PCWP, decreased CO
B. Decreased CVP, decreased PCWP, decreased CO
C. Increased CVP, decreased PCWP, normal CO
D. Normal CVP, increased PCWP, decreased CO
Answer: B
Rationale: Hypovolemic shock: low preload (low CVP, low PCWP), low cardiac
output (CO), and increased systemic vascular resistance (SVR) from compensatory
vasoconstriction.
7. A patient with septic shock remains hypotensive after 30 mL/kg IV crystalloid.
Which vasopressor is first-line per the Surviving Sepsis Campaign?
A. Dopamine
B. Norepinephrine
C. Epinephrine
D. Vasopressin
Answer: B
Rationale: Norepinephrine is the initial vasopressor of choice for septic shock due
to its alpha-1 agonism (vasoconstriction) with some beta-1 effect (maintains
cardiac output). Vasopressin can be added as a second-line agent.
pg. 3
, 4
8. A patient on amiodarone develops pulmonary infiltrates, dyspnea, and a dry
cough. What is the most likely diagnosis?
A. Pulmonary embolism
B. Amiodarone-induced pulmonary toxicity
C. Heart failure exacerbation
D. Pneumonia
Answer: B
Rationale: Amiodarone can cause pulmonary toxicity, including interstitial
pneumonitis and pulmonary fibrosis, which can be fatal. The drug should be
discontinued, and corticosteroids may be used.
9. A patient with atrial fibrillation and rapid ventricular response is
hemodynamically unstable (BP 78/50, altered mental status). What is the
immediate treatment?
A. Administer IV diltiazem
B. Perform synchronized cardioversion
C. Administer IV digoxin
D. Start a heparin infusion
Answer: B
Rationale: Unstable tachyarrhythmias (hypotension, altered mental status, chest
pain, shock) require immediate synchronized cardioversion. Rate control
medications are for stable patients.
10. A patient is receiving IV heparin for a DVT. The aPTT is 90 seconds (control
30 seconds). What is the appropriate action?
A. Continue the infusion at the same rate
B. Decrease the infusion rate per nomogram; the aPTT is supratherapeutic
C. Increase the infusion rate
D. Stop the heparin immediately and administer protamine
pg. 4
NUR 2459 Critical Care Nursing Final Exam Study Guide \
100 Actual Critical Care Questions with Verified
Answers & Rationales
SECTION 1: CARDIOVASCULAR CRITICAL CARE (1–25)
1. A patient with an acute anterior STEMI is being prepared for emergent PCI.
Which antiplatelet agent should be administered as a loading dose before the
procedure?
A. Aspirin 81 mg
B. Clopidogrel 300 mg
C. Ticagrelor 180 mg or prasugrel 60 mg
D. Warfarin
Answer: C
Rationale: Dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor
(ticagrelor or prasugrel) is essential before PCI to prevent stent thrombosis. The
loading dose of ticagrelor is 180 mg, prasugrel 60 mg. Aspirin should be given as
324 mg chewed, not 81 mg. Clopidogrel is an alternative but less potent.
2. A 68-year-old man presents with tearing chest pain radiating to the back. BP
is 170/90 in the right arm and 130/80 in the left. Chest X-ray shows a widened
mediastinum. What is the priority intervention?
A. Administer aspirin
B. Start aggressive blood pressure control (beta-blocker first, then vasodilator)
and prepare for emergency surgery
C. Administer thrombolytics
D. Obtain a CT abdomen
Answer: B
Rationale: The presentation is classic for aortic dissection (Stanford A). The
priority is to reduce shear stress on the aortic wall by controlling heart rate (target
HR ~60) with a beta-blocker (esmolol, labetalol) and then lowering BP with a
pg. 1
,2
vasodilator (nitroprusside). Emergency surgical consultation is essential.
Thrombolytics are contraindicated.
3. A patient with cardiogenic shock has a cardiac index of 1.6 L/min/m², PCWP
28 mmHg, and MAP 52 mmHg on dobutamine. What is the next appropriate
intervention?
A. Add nitroprusside
B. Add norepinephrine
C. Initiate mechanical circulatory support (IABP or Impella)
D. Start milrinone
Answer: C
Rationale: A cardiac index <2.2 with high filling pressures and inadequate
response to inotropes indicates refractory cardiogenic shock. Mechanical support
(IABP, Impella, VA-ECMO) is indicated as a bridge to recovery or advanced
therapies. Norepinephrine would increase afterload; milrinone causes
vasodilation and may worsen hypotension.
4. A patient with a right ventricular infarction becomes hypotensive after
nitroglycerin administration. What is the most appropriate intervention?
A. Administer more nitroglycerin
B. Administer IV fluid boluses (250-500 mL normal saline)
C. Start dopamine
D. Administer furosemide
Answer: B
Rationale: RV infarction is preload-dependent. Nitrates and diuretics reduce
preload and can cause severe hypotension. Treatment involves IV fluid
resuscitation to maintain RV filling and cardiac output. Avoid nitrates and
diuretics.
5. A patient is 2 days post-MI and develops a new holosystolic murmur at the
left lower sternal border with acute pulmonary edema. What is the most likely
pg. 2
,3
diagnosis?
A. Papillary muscle rupture
B. Ventricular septal rupture
C. Acute mitral regurgitation
D. Pericardial tamponade
Answer: B
Rationale: Ventricular septal rupture (VSR) presents with a new holosystolic
murmur at the LLSB and acute heart failure 3-7 days post-MI. Papillary muscle
rupture causes a murmur at the apex and severe mitral regurgitation. Both are
mechanical complications requiring emergency surgery.
6. Which hemodynamic profile is consistent with hypovolemic shock?
A. Increased CVP, increased PCWP, decreased CO
B. Decreased CVP, decreased PCWP, decreased CO
C. Increased CVP, decreased PCWP, normal CO
D. Normal CVP, increased PCWP, decreased CO
Answer: B
Rationale: Hypovolemic shock: low preload (low CVP, low PCWP), low cardiac
output (CO), and increased systemic vascular resistance (SVR) from compensatory
vasoconstriction.
7. A patient with septic shock remains hypotensive after 30 mL/kg IV crystalloid.
Which vasopressor is first-line per the Surviving Sepsis Campaign?
A. Dopamine
B. Norepinephrine
C. Epinephrine
D. Vasopressin
Answer: B
Rationale: Norepinephrine is the initial vasopressor of choice for septic shock due
to its alpha-1 agonism (vasoconstriction) with some beta-1 effect (maintains
cardiac output). Vasopressin can be added as a second-line agent.
pg. 3
, 4
8. A patient on amiodarone develops pulmonary infiltrates, dyspnea, and a dry
cough. What is the most likely diagnosis?
A. Pulmonary embolism
B. Amiodarone-induced pulmonary toxicity
C. Heart failure exacerbation
D. Pneumonia
Answer: B
Rationale: Amiodarone can cause pulmonary toxicity, including interstitial
pneumonitis and pulmonary fibrosis, which can be fatal. The drug should be
discontinued, and corticosteroids may be used.
9. A patient with atrial fibrillation and rapid ventricular response is
hemodynamically unstable (BP 78/50, altered mental status). What is the
immediate treatment?
A. Administer IV diltiazem
B. Perform synchronized cardioversion
C. Administer IV digoxin
D. Start a heparin infusion
Answer: B
Rationale: Unstable tachyarrhythmias (hypotension, altered mental status, chest
pain, shock) require immediate synchronized cardioversion. Rate control
medications are for stable patients.
10. A patient is receiving IV heparin for a DVT. The aPTT is 90 seconds (control
30 seconds). What is the appropriate action?
A. Continue the infusion at the same rate
B. Decrease the infusion rate per nomogram; the aPTT is supratherapeutic
C. Increase the infusion rate
D. Stop the heparin immediately and administer protamine
pg. 4
