NP Adult-Gerontology Acute Care Nurse Practitioner 4 — Questions and Answers
Question 1: A 65-year-old with heart failure presents with acute pulmonary edema. On exam: BP 160/100, HR 110, diffuse crackles, SpO2 84%. Which is the most appropriate initial pharmacological intervention?
- IV furosemide and IV nitroglycerin (Correct answer)
- Oral carvedilol and digoxin
- IV dobutamine infusion
- IV metoprolol and morphine
Correct answer: IV furosemide and IV nitroglycerin
IV furosemide reduces preload through diuresis and venodilation, while IV nitroglycerin reduces preload and afterload, together providing rapid relief in hypertensive acute pulmonary edema.
Question 2: An AG-ACNP is managing a patient with status epilepticus refractory to benzodiazepines. What is the next recommended pharmacological agent?
- Phenobarbital
- IV levetiracetam, fosphenytoin, or valproate (Correct answer)
- Oral carbamazepine
- Propofol infusion immediately
Correct answer: IV levetiracetam, fosphenytoin, or valproate
After benzodiazepine failure, second-line agents including IV levetiracetam, fosphenytoin, or valproate are recommended per Neurocritical Care Society guidelines for established status epilepticus.
Question 3: Which clinical finding best differentiates cardiogenic shock from distributive (septic) shock?
- Elevated lactate
- Warm extremities with bounding pulses
- Cool clammy skin with elevated SVR and low CO (Correct answer)
- Fever and leukocytosis
Correct answer: Cool clammy skin with elevated SVR and low CO
Cardiogenic shock is characterized by cool, clammy skin with elevated systemic vascular resistance and low cardiac output, unlike septic shock which presents with warm skin and low SVR.
Question 4: A 74-year-old patient on warfarin for atrial fibrillation presents with INR of 9.2 and active GI bleeding. What is the most appropriate reversal strategy?
- Vitamin K 10 mg IV alone
- Hold warfarin and transfuse PRBCs
- 4-factor prothrombin complex concentrate (PCC) plus vitamin K (Correct answer)
- Fresh frozen plasma (FFP) alone
Correct answer: 4-factor prothrombin complex concentrate (PCC) plus vitamin K
4-factor PCC combined with vitamin K provides the fastest, most complete reversal of warfarin in life-threatening bleeding, with PCC acting immediately and vitamin K maintaining reversal.
Question 5: A post-operative 70-year-old develops fever, hypotension, and purulent drainage from a central line site on day 7. Blood cultures are drawn. What is the immediate next action?
- Remove the central line and start empiric vancomycin (Correct answer)
- Continue monitoring without antibiotics until cultures result
- Change catheter over a guidewire
- Remove the line only after cultures confirm CLABSI
Correct answer: Remove the central line and start empiric vancomycin
Suspected CLABSI requires immediate central line removal and initiation of empiric broad-spectrum antibiotics (vancomycin for gram-positives), not waiting for culture results in a hemodynamically unstable patient.
Question 6: When assessing a geriatric patient for frailty in the acute care setting, which tool is most validated and widely used?
- Barthel Index
- Clinical Frailty Scale (CFS) (Correct answer)
- Mini-Mental State Examination (MMSE)
- Braden Scale
Correct answer: Clinical Frailty Scale (CFS)
The Clinical Frailty Scale is a 9-point scale validated for use in acute care settings to predict adverse outcomes including mortality, institutionalization, and prolonged hospital stay.
Question 7: A 68-year-old with known liver cirrhosis presents with confusion, asterixis, and abdominal distension. Ammonia level is elevated. Which treatment is most effective?
- IV neomycin and restrict protein intake to 20g/day
- Lactulose titrated to 2-3 soft bowel movements per day (Correct answer)
- Rifaximin alone without lactulose
- Benzodiazepines for agitation management
Correct answer: Lactulose titrated to 2-3 soft bowel movements per day
Lactulose reduces ammonia absorption by acidifying the colon, promoting its conversion to ammonium ion and enhancing fecal elimination, targeting 2-3 soft stools per day.
NP Adult-Gerontology Acute Care Nurse Practitioner 4
A 65-year-old with heart failure presents with acute pulmonary edema.
On exam: BP 160/100, HR 110, diffuse crackles, SpO2 84%.
Which is the most appropriate initial pharmacological intervention?