An ACNP is evaluating a 64-year-old man in the ED with substernal chest pressure that began 90 minutes ago. The 12-lead ECG shows 2 mm ST elevation in leads II, III, and aVF with reciprocal ST depression in I and aVL. Vital signs: BP 92/58, HR 48, RR 18, SpO2 96% on room air. Which additional ECG lead set is most important to obtain before administering nitroglycerin?
Cardiovascular
Question · Medium
A 58-year-old patient with ARDS is on volume-control ventilation. Weight is 80 kg, height 178 cm (predicted body weight 73 kg). The current tidal volume is 600 mL with plateau pressure 34 cmH2O, PEEP 12, FiO2 0.7, PaO2 62. Per ARDSnet protocol, what is the most appropriate next adjustment?
Pulmonary
Chapter 1: Acute Coronary Syndromes & Hemodynamics
1.1 Acute Coronary Syndromes & Myocardial Infarction Management
Study guide
A 72-year-old septic patient remains hypotensive (MAP 58) after 30 mL/kg of balanced crystalloid. Lactate is 4.2 mmol/L. Per the Surviving Sepsis 1-hour bundle, which intervention should be initiated next?
Infectious Disease
Question · Easy
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An ACNP is interpreting an ABG on a patient with COPD exacerbation: pH 7.28, PaCO2 72, PaO2 58, HCO3 33, on 2 L NC. The patient is somnolent but arousable, with accessory muscle use. What is the most appropriate intervention?
A 45-year-old presents with sudden severe headache ("worst of my life"). Non-contrast head CT performed 4 hours after onset is read as normal. What is the most appropriate next step?
Neurologic
A patient in cardiogenic shock from acute decompensated heart failure has BP 78/50, HR 118, lactate 5.1, cool extremities, and mottling. PAC shows CI 1.6 L/min/m2, SVR 1900 dynes·s·cm-5, PCWP 28. Which initial inotrope/vasoactive strategy is most appropriate?
Question · Hard
1.2 Invasive Hemodynamic Monitoring & Waveform Interpretation
A 28-year-old presents with DKA: glucose 612, pH 7.10, HCO3 8, anion gap 28, K+ 5.8, Na+ 132. The patient is alert. What is the most appropriate initial fluid management?
Endocrine
An ACNP is preparing to perform an internal jugular central venous catheter insertion. According to the CDC and SHEA guidelines for prevention of CLABSI, which step has the strongest evidence for reducing infection risk?
Clinical Judgment
A 70-year-old post-CABG patient develops new-onset atrial fibrillation with RVR (HR 145), BP 110/70, and is asymptomatic. Which initial rate-control strategy is most appropriate?
A 55-year-old with severe sepsis from pneumonia has an indwelling arterial line for hemodynamic monitoring. Which waveform abnormality most strongly suggests an underdamped (whip) tracing requiring correction?
1.3 Cardiogenic Shock, Acute Heart Failure & Mechanical Circulatory Support
A 67-year-old presents with massive hematemesis and hemodynamic instability (BP 82/48, HR 132). Hemoglobin is 6.8. What is the most appropriate transfusion strategy until bleeding is controlled?
Trauma Surgical
An 82-year-old admitted for hip fracture develops acute confusion on hospital day 2. She is alert but inattentive, oriented x1, with fluctuating mentation. Vital signs are stable. Which assessment is most appropriate to confirm delirium?
Geriatric
A patient on mechanical ventilation has these settings: AC/VC, Vt 450 mL, RR 16, PEEP 8, FiO2 0.5. ABG: pH 7.32, PaCO2 52, PaO2 92, HCO3 26. The patient is triggering 22 breaths/min. What ventilator change best addresses the acidosis?
A 60-year-old is admitted with NSTEMI. Troponin I is 4.2 ng/mL (normal <0.04). The patient is hemodynamically stable, pain-free, and has TIMI score of 5. Which strategy is most appropriate per ACC/AHA 2022 guidelines?
Chapter 2: Cardiac Dysrhythmias, Valvular & Pericardial Emergencies
2.1 Cardiac Dysrhythmias, Conduction Blocks & Device Management
A 50-year-old with cirrhosis presents with hematemesis from suspected variceal bleeding. After fluid resuscitation and transfusion, which medication should be initiated?
Gastrointestinal
An ACNP performing a Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT) per the ABCDEF bundle should ensure which SBT criteria are met before extubation?
A patient develops sudden hypoxemia and hypotension 24 hours after long-bone orthopedic surgery. Heart rate is 130, BP 88/52, SpO2 86% on 100% NRB, RR 32. Bedside echo shows a dilated RV with septal flattening. What is the most appropriate next step?
An 85-year-old admitted with pneumonia has a frailty index suggesting moderate frailty (Clinical Frailty Scale 6). She has expressed wishes to avoid ICU and intubation. Which approach best aligns with patient-centered acute care?
2.2 Valvular Crises, Acute Aortic Syndromes & Pericardial Tamponade
A 45-year-old with severe acute pancreatitis (BISAP 4) is admitted to the ICU. She is hemodynamically stable after resuscitation. Per ACG guidelines, when should enteral nutrition be initiated?
A 70-year-old presents with new ischemic stroke symptoms onset 2 hours ago. NIHSS is 14. CT head shows no hemorrhage. BP is 178/96. Which is the most important contraindication to evaluate before alteplase administration?
A patient on mechanical ventilation receives propofol for sedation. The ACNP notices rising lactate (5.2), metabolic acidosis (pH 7.20, HCO3 14), creatine kinase 8200, and an acute drop in blood pressure. The propofol dose has been 80 mcg/kg/min for 36 hours. What is the most likely diagnosis?
A 65-year-old with metastatic small cell lung cancer presents with confusion, weakness, and serum sodium 118 mEq/L. Urine osmolality is 480, serum osmolality 252, urine sodium 70. The patient is euvolemic. What is the most appropriate initial management?
Chapter 3: Acute Respiratory Failure & Advanced Ventilation
3.1 Acute Respiratory Failure & ARDS Management
A 78-year-old admitted with CHF exacerbation has new diagnoses of HFrEF (LVEF 28%). Admission medications include digoxin 0.25 mg daily, ibuprofen, diphenhydramine, and oxybutynin. Per the Beers Criteria, which medication review priority is most important?
An ACNP is reviewing scope of practice in a state with reduced practice authority. Which APRN Consensus Model element best describes the ACNPC-AG population focus?
Professional Role
A 60-year-old has AKI with KDIGO stage 3, oliguria <0.3 mL/kg/hr for 12 hours, K+ 6.4, pH 7.18, BUN 96, creatinine 5.8, and rising. Urine sediment shows muddy brown casts. Which indication for renal replacement therapy is most pressing?
Renal Gu
A 25-year-old with status epilepticus has had ongoing seizure activity for 8 minutes despite IV lorazepam 4 mg x 2 doses. What is the most appropriate next-line therapy?
3.2 Mechanical Ventilation Modes, Waveforms & Weaning Protocols
A 55-year-old with known hepatic cirrhosis and ascites presents with abdominal pain and fever. Diagnostic paracentesis shows ascitic fluid PMN count 320/mm3, total protein 0.8 g/dL, glucose 80. Which is the most likely diagnosis and treatment?
A 48-year-old presents with acute thyroid storm: temp 40.2°C, HR 168 (atrial fibrillation), BP 158/92, agitation. Which medication regimen is most appropriate?
A 62-year-old neutropenic chemotherapy patient (ANC 280) develops fever 38.6°C. Per IDSA guidelines, which empirical antibiotic regimen is most appropriate while awaiting cultures?
Hematology Oncology
A patient with severe TBI has ICP of 28 mmHg, MAP 84, CPP 56. Per Brain Trauma Foundation guidelines, which intervention should be implemented to maintain CPP target?
3.3 Obstructive Pulmonary Emergencies: Status Asthmaticus & Severe COPD
A 70-year-old with sepsis from a urinary source has been on norepinephrine 0.45 mcg/kg/min and vasopressin 0.04 units/min for 18 hours. MAP remains 58. Cortisol is 10 mcg/dL. Which intervention is most appropriate?
An ACNP is interpreting an ECG showing ST elevation in V2-V3 with concordant ST elevation in lead III. The patient has known LBBB and chest pain. Which finding most strongly supports acute MI per Sgarbossa criteria?
A 60-year-old presents with severe sepsis. Initial lactate was 4.8. After 6 hours of resuscitation, lactate is 3.2. What does this lactate clearance represent?
A 30-year-old presents with acute asthma exacerbation. After three rounds of nebulized albuterol/ipratropium and IV methylprednisolone, the patient is exhausted, with rising PaCO2 from 38 to 52, and falling SpO2 from 94 to 89%. Which is the most appropriate next step?
Chapter 4: Pulmonary Vascular & Thoracic Emergencies
4.1 Massive Pulmonary Embolism & Acute Pulmonary Hypertension Crises
An ACNP is planning a paracentesis on a cirrhotic patient with tense ascites. Platelets are 45,000, INR 1.6. Per AASLD guidelines, what is the most appropriate management before the procedure?
A 75-year-old with HFrEF (LVEF 25%) is admitted with volume overload. Per ACC/AHA/HFSA 2022 HF guideline, which medication should be initiated or continued for guideline-directed medical therapy (GDMT) in addition to a loop diuretic?
A patient develops anaphylaxis after receiving IV vancomycin: hypotension (BP 75/40), wheezing, urticaria, and angioedema. What is the most appropriate first medication?
A 65-year-old with newly diagnosed acute promyelocytic leukemia (APL) develops oozing from IV sites, epistaxis, and ecchymoses. Labs: platelets 22, fibrinogen 80, D-dimer >20, PT 22, INR 1.9. What is the most appropriate management?
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