Acute Care Nurse Practitioner Acute Care Nurse Practitioner 3 — Questions and Answers
Question 1: A patient in the ICU has a serum sodium of 118 mEq/L and is symptomatic with seizures. The ACNP should correct sodium at a rate no faster than:
- 1-2 mEq/L per hour until seizures stop, then 6-8 mEq/L per day total (Correct answer)
- 20 mEq/L in the first hour
- 0.5 mEq/L per hour regardless of symptoms
- 10 mEq/L per hour for the first 4 hours
Correct answer: 1-2 mEq/L per hour until seizures stop, then 6-8 mEq/L per day total
Rapid correction beyond 10-12 mEq/L in 24 hours risks osmotic demyelination syndrome, even when initial correction for seizures is done faster.
Question 2: Which finding is most consistent with hepatorenal syndrome type 1?
- Urinary sodium >40 mEq/L with fractional excretion of sodium >2%
- Serum creatinine doubling to >2.5 mg/dL within 2 weeks in a patient with cirrhosis (Correct answer)
- Oliguria with muddy brown casts on urinalysis
- Proteinuria >3.5 g/day with peripheral edema
Correct answer: Serum creatinine doubling to >2.5 mg/dL within 2 weeks in a patient with cirrhosis
Hepatorenal syndrome type 1 is defined by a rapid doubling of creatinine to >2.5 mg/dL within 2 weeks in a patient with end-stage liver disease.
Question 3: A patient with suspected pulmonary embolism has a Wells score of 6 and a positive D-dimer. The most appropriate next step is:
- Empiric anticoagulation without further imaging
- CT pulmonary angiography (CTPA) (Correct answer)
- Ventilation-perfusion (V/Q) scan only
- Lower extremity Doppler ultrasound
Correct answer: CT pulmonary angiography (CTPA)
A high pre-test probability score with elevated D-dimer warrants definitive imaging with CTPA to confirm PE before or concurrent with anticoagulation decisions.
Question 4: The ACNP orders continuous renal replacement therapy (CRRT) for a critically ill patient. Which electrolyte requires close monitoring and frequent supplementation during CRRT?
- Sodium
- Phosphorus (Correct answer)
- Bicarbonate
- Chloride
Correct answer: Phosphorus
Phosphorus is significantly cleared by CRRT filters and requires frequent monitoring and replacement to prevent hypophosphatemia.
Question 5: A mechanically ventilated patient's peak airway pressure suddenly increases from 25 to 45 cmH2O, but plateau pressure remains unchanged. The most likely cause is:
- Worsening ARDS with decreased lung compliance
- Endotracheal tube obstruction or bronchospasm (Correct answer)
- Right mainstem intubation
- Development of pneumothorax
Correct answer: Endotracheal tube obstruction or bronchospasm
Increased peak pressure with unchanged plateau pressure indicates increased airway resistance (not compliance), pointing to ETT secretion plugging or bronchospasm.
Question 6: A patient with ST-elevation MI undergoes primary PCI and is now on dual antiplatelet therapy. On day 2, the patient develops melena and hemoglobin drops from 12 to 9 g/dL. The ACNP should:
- Immediately discontinue both antiplatelet agents
- Hold aspirin only and proceed with urgent endoscopy
- Consult cardiology before discontinuing any antiplatelet agent and proceed with endoscopy (Correct answer)
- Administer fresh frozen plasma and continue both agents
Correct answer: Consult cardiology before discontinuing any antiplatelet agent and proceed with endoscopy
The risk of stent thrombosis if antiplatelet therapy is discontinued in the early post-PCI period is high, so cardiology must be involved before altering therapy.
Question 7: Which finding on a 12-lead ECG is most specific for right ventricular strain in massive pulmonary embolism?
- ST depression in V1-V3
- S1Q3T3 pattern (Correct answer)
- Atrial fibrillation with rapid ventricular response
- Left bundle branch block
Correct answer: S1Q3T3 pattern
The S1Q3T3 pattern (S wave in lead I, Q wave and inverted T wave in lead III) is the classic ECG finding of acute right heart strain from PE.
Acute Care Nurse Practitioner Acute Care Nurse Practitioner 3
A patient in the ICU has a serum sodium of 118 mEq/L and is symptomatic with seizures.
The ACNP should correct sodium at a rate no faster than: