Acute Care Nurse Practitioner Acute Care Nurse Practitioner 4 — Questions and Answers
Question 1: A patient admitted for septic shock is on norepinephrine 0.3 mcg/kg/min and vasopressin 0.03 units/min. Despite adequate fluid resuscitation (CVP 12, ScvO2 68%), MAP remains 58 mmHg. The next pharmacological intervention should be:
- Add phenylephrine
- Add low-dose corticosteroids (hydrocortisone 200 mg/day) (Correct answer)
- Increase vasopressin to 0.06 units/min
- Start dopamine infusion
Correct answer: Add low-dose corticosteroids (hydrocortisone 200 mg/day)
Refractory septic shock despite two vasopressors warrants evaluation for relative adrenal insufficiency and empiric corticosteroid therapy per Surviving Sepsis guidelines.
Question 2: A patient with a known history of heparin-induced thrombocytopenia (HIT) requires anticoagulation for a new DVT. The preferred agent is:
- Low molecular weight heparin (enoxaparin)
- Unfractionated heparin
- Argatroban (Correct answer)
- Warfarin alone
Correct answer: Argatroban
Argatroban is a direct thrombin inhibitor that does not cross-react with HIT antibodies and is the preferred anticoagulant for patients with confirmed HIT.
Question 3: A patient with acute liver failure has an INR of 4.2. The ACNP orders fresh frozen plasma (FFP) before a central line placement. What is the primary concern with this approach?
- FFP will correct the INR long enough to prevent bleeding
- FFP does not reliably correct the bleeding risk in acute liver failure and exposes the patient to volume overload (Correct answer)
- FFP is contraindicated in acute liver failure
- FFP will worsen encephalopathy
Correct answer: FFP does not reliably correct the bleeding risk in acute liver failure and exposes the patient to volume overload
INR in liver failure reflects both pro- and anti-coagulant factor deficits and does not accurately predict bleeding risk; FFP provides marginal, transient correction with volume and transfusion risks.
Question 4: Which intervention has been shown to reduce 90-day mortality in patients with moderate-to-severe ARDS?
- Prone positioning for ≥16 hours per day (Correct answer)
- High-frequency oscillatory ventilation
- Inhaled nitric oxide
- Prophylactic corticosteroids within 24 hours
Correct answer: Prone positioning for ≥16 hours per day
The PROSEVA trial demonstrated a 28% absolute reduction in 90-day mortality with prone positioning for ≥16 hours/day in moderate-to-severe ARDS.
Question 5: A patient on warfarin for atrial fibrillation has an INR of 9.2 and active intracranial hemorrhage on CT. The ACNP should immediately administer:
- Vitamin K 10 mg IV alone
- Fresh frozen plasma 2 units
- 4-factor prothrombin complex concentrate (4F-PCC) plus vitamin K (Correct answer)
- Protamine sulfate IV
Correct answer: 4-factor prothrombin complex concentrate (4F-PCC) plus vitamin K
4F-PCC provides rapid, complete INR reversal for life-threatening warfarin-associated bleeding; vitamin K is added for sustained reversal.
Question 6: A 72-year-old post-cardiac surgery patient develops atrial fibrillation with rapid ventricular response (HR 145) and hemodynamic instability (BP 80/50 mmHg). The immediate treatment is:
- IV metoprolol
- IV amiodarone
- Synchronized cardioversion (Correct answer)
- IV digoxin
Correct answer: Synchronized cardioversion
Hemodynamically unstable atrial fibrillation requires immediate synchronized cardioversion per ACLS guidelines.
Question 7: A patient with acute pancreatitis has worsening respiratory status. CT shows bilateral infiltrates and a PaO2/FiO2 ratio of 180 mmHg. This is consistent with:
- Cardiogenic pulmonary edema
- Moderate ARDS per Berlin criteria (Correct answer)
- Aspiration pneumonia
- Pleural effusion requiring drainage
Correct answer: Moderate ARDS per Berlin criteria
The Berlin definition classifies ARDS as moderate when PaO2/FiO2 is 100-200 mmHg with bilateral opacities on imaging.
Acute Care Nurse Practitioner Acute Care Nurse Practitioner 4
A patient admitted for septic shock is on norepinephrine 0.3 mcg/kg/min and vasopressin 0.03 units/min.
Despite adequate fluid resuscitation (CVP 12, ScvO2 68%), MAP remains 58 mmHg.
The next pharmacological intervention should be: