Acute Care Nurse Practitioner Acute Care Nurse Practitioner 5 — Questions and Answers
Question 1: A critically ill patient is receiving propofol infusion for sedation at 70 mcg/kg/min for 48 hours. The nurse reports increasing lactic acidosis, new ECG changes, and lipemic plasma. The ACNP should suspect:
- Septic shock progression
- Propofol infusion syndrome (Correct answer)
- Hypertriglyceridemia from TPN
- Acute mesenteric ischemia
Correct answer: Propofol infusion syndrome
Propofol infusion syndrome (PRIS) presents with metabolic acidosis, rhabdomyolysis, cardiac dysfunction, and lipemia, especially with doses >4 mg/kg/hr for >48 hours.
Question 2: A patient with severe traumatic brain injury has a Glasgow Coma Scale of 7 and ICP of 28 mmHg. After elevating the head of bed to 30° and ensuring normocapnia, the next intervention is:
- Hyperventilate to PaCO2 of 25 mmHg
- Administer 23.4% hypertonic saline or mannitol (Correct answer)
- Immediate decompressive craniectomy
- Administer dexamethasone 10 mg IV
Correct answer: Administer 23.4% hypertonic saline or mannitol
Hyperosmolar therapy with hypertonic saline or mannitol is the next step to reduce ICP after basic positioning and ventilation optimization.
Question 3: Which glucose target is recommended by current evidence for critically ill adult patients in the ICU?
- 80-110 mg/dL (tight glycemic control)
- 140-180 mg/dL (Correct answer)
- 180-220 mg/dL
- <140 mg/dL at all times
Correct answer: 140-180 mg/dL
The NICE-SUGAR trial showed that tight glycemic control (80-110) increased mortality; current guidelines target 140-180 mg/dL in most ICU patients.
Question 4: A patient with end-stage renal disease on hemodialysis develops acute chest pain and shortness of breath. ECG shows diffuse ST elevation in all leads with PR depression. The ACNP's initial management should include:
- Emergent cardiac catheterization
- NSAIDs and colchicine for pericarditis, with urgent dialysis to remove fluid (Correct answer)
- Aspirin, heparin, and cardiology consult for STEMI protocol
- Pericardiocentesis immediately
Correct answer: NSAIDs and colchicine for pericarditis, with urgent dialysis to remove fluid
Diffuse ST elevation with PR depression in a dialysis patient indicates uremic pericarditis; NSAIDs, colchicine, and urgent dialysis are first-line treatment.
Question 5: A 45-year-old woman is admitted with thyroid storm (Burch-Wartofsky score 65). Which medication must be given BEFORE radioactive iodine or inorganic iodide?
- Propranolol
- Propylthiouracil (PTU) or methimazole (Correct answer)
- Dexamethasone
- Cholestyramine
Correct answer: Propylthiouracil (PTU) or methimazole
Thionamides (PTU or methimazole) must be given before iodine to block new thyroid hormone synthesis and prevent iodine from being used as substrate.
Question 6: A patient has a pulmonary artery catheter showing: CI 1.8 L/min/m², PCWP 8 mmHg, SVR 1800 dynes/sec/cm⁵. This pattern is most consistent with:
- Cardiogenic shock
- Distributive (septic) shock
- Obstructive shock from tension pneumothorax
- Hypovolemic shock (Correct answer)
Correct answer: Hypovolemic shock
Hypovolemic shock presents with low cardiac index, low PCWP (low filling pressures), and elevated SVR as compensatory vasoconstriction occurs.
Question 7: The ACNP is performing a capacity assessment for a patient who refuses a below-knee amputation for wet gangrene. Which element is NOT required for decision-making capacity?
- Ability to understand the information provided
- Ability to reason and weigh options
- Agreement with the recommended treatment plan (Correct answer)
- Ability to communicate a consistent choice
Correct answer: Agreement with the recommended treatment plan
Capacity does not require agreement with the medical team; a competent patient has the right to refuse treatment as long as they understand and can reason about their decision.
Acute Care Nurse Practitioner Acute Care Nurse Practitioner 5
A critically ill patient is receiving propofol infusion for sedation at 70 mcg/kg/min for 48 hours.
The nurse reports increasing lactic acidosis, new ECG changes, and lipemic plasma.
The ACNP should suspect: