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ANCC AGCNS-BC study materials
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ANCC AGCNS-BC practice questions

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Question 1Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A 68-year-old adult is admitted with pneumonia and becomes hypotensive (82/48 mm Hg) with a lactate of 3.4 mmol/L. After 30 mL/kg of crystalloid, norepinephrine is started. Which initial crystalloid volume is recommended for sepsis-induced hypoperfusion?

  1. 10 mL/kg
  2. 30 mL/kg Correct answer.
  3. 20 mL/kg
  4. 50 mL/kg

Explanation

Surviving Sepsis guidance recommends 30 mL/kg of IV crystalloid within the first 3 hours for sepsis-induced hypoperfusion or septic shock. Reassessment of volume status and perfusion follows each bolus. Smaller volumes are used only when fluid overload risk predominates.

Question 2Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with ARDS has a PaO2/FiO2 ratio of 140 on volume-control ventilation. Which tidal volume target should be used?

  1. 10 mL/kg predicted body weight
  2. 12 mL/kg actual body weight
  3. 8 mL/kg actual body weight
  4. 6 mL/kg predicted body weight Correct answer.

Explanation

Lung-protective ventilation in ARDS targets 4 to 6 mL/kg of predicted body weight to limit ventilator-induced lung injury. Actual body weight is not used because it overestimates lung size. Plateau pressure is kept at or below 30 cm H2O.

Question 3Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A 24-year-old with diabetic ketoacidosis has a glucose of 480 mg/dL and a blood pressure of 88/54 mm Hg. After airway assessment, which fluid should be given first?

  1. 0.9% sodium chloride Correct answer.
  2. 5% dextrose with 0.45% saline
  3. 0.45% sodium chloride
  4. Sodium bicarbonate

Explanation

Initial DKA resuscitation uses isotonic 0.9% sodium chloride to restore intravascular volume and perfusion. Hypotonic fluids and dextrose-containing fluids are added later once glucose falls and volume status improves. Bicarbonate is reserved for severe acidemia.

Question 4Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A hemodynamically stable patient has high pretest probability for pulmonary embolism and no contraindication to iodinated contrast. Which test is the most appropriate confirmatory study?

  1. Ventilation-perfusion scan
  2. Bedside echocardiography
  3. D-dimer
  4. CT pulmonary angiography Correct answer.

Explanation

CT pulmonary angiography is the preferred confirmatory test for a stable patient with high pretest probability and adequate renal function without contrast allergy. D-dimer is used to exclude PE in low- or intermediate-risk patients. Echocardiography supports bedside assessment in unstable patients but does not confirm PE in stable patients.

Question 5Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with an ST-elevation myocardial infarction arrives at a hospital with an available catheterization laboratory. Which door-to-balloon time is recommended?

  1. 30 minutes
  2. 180 minutes
  3. 90 minutes Correct answer.
  4. 120 minutes

Explanation

Primary percutaneous coronary intervention should be performed within 90 minutes of first medical contact at a PCI-capable facility. If transfer is required, the target is 120 minutes. Fibrinolysis is considered when timely PCI is unavailable.

Question 6Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with acute myocardial infarction has a blood pressure of 78/50 mm Hg, cool extremities, cardiac index 1.6 L/min/m2, and PCWP 24 mm Hg despite fluids. Which vasoactive agent is the best initial choice?

  1. Nitroglycerin
  2. Dopamine
  3. Norepinephrine Correct answer.
  4. Dobutamine

Explanation

Norepinephrine is first-line to restore mean arterial pressure in cardiogenic shock. An inotrope such as dobutamine may be added for persistent hypoperfusion after pressure is supported. Nitroglycerin and dopamine are not preferred initial agents in hypotensive cardiogenic shock.

Question 7Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with an ischemic stroke has a last known well time 3 hours ago and no hemorrhage on imaging. Within what window can IV alteplase be given?

  1. 12 hours
  2. 4.5 hours Correct answer.
  3. 24 hours
  4. 6 hours

Explanation

IV alteplase is approved for selected patients within 4.5 hours of symptom onset or last known well. Beyond that window, treatment decisions depend on advanced imaging and thrombectomy eligibility. Hemorrhage must be excluded before administration.

Question 8Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with acute ischemic stroke has a blood pressure of 192/108 mm Hg before planned IV alteplase. What blood pressure target must be achieved before thrombolysis?

  1. <185/110 mm Hg Correct answer.
  2. <160/90 mm Hg
  3. <140/90 mm Hg
  4. <220/120 mm Hg

Explanation

Blood pressure must be lowered to below 185/110 mm Hg before IV thrombolysis to reduce hemorrhagic transformation risk. Labetalol or nicardipine is commonly used. After treatment, pressure is maintained below 180/105 mm Hg.

Question 9Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with elevated intracranial pressure is being positioned in bed. Which head-of-bed angle is recommended?

  1. 10 degrees
  2. 45 degrees
  3. 30 degrees Correct answer.
  4. Flat

Explanation

Elevating the head of the bed about 30 degrees promotes cerebral venous drainage and can lower intracranial pressure. The head should remain midline to avoid jugular venous compression. Flat positioning may raise intracranial pressure.

Question 10Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A ventilated patient with COPD becomes hypotensive with high peak pressures and suspected auto-PEEP. Which action is most appropriate?

  1. Decrease the respiratory rate and treat bronchospasm Correct answer.
  2. Increase the respiratory rate
  3. Add PEEP without other changes
  4. Increase the tidal volume

Explanation

Auto-PEEP is reduced by lengthening expiratory time, often by decreasing respiratory rate, and by treating airflow obstruction. Increasing rate or tidal volume worsens air trapping. PEEP adjustment alone does not correct the underlying expiratory flow limitation.

Question 11Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient has a potassium level of 6.8 mEq/L. Which ECG finding is an early sign of hyperkalemia?

  1. Peaked T waves Correct answer.
  2. Delta waves
  3. U waves
  4. Prolonged QT interval

Explanation

Peaked, narrow T waves are an early ECG manifestation of hyperkalemia. As potassium rises, the QRS widens and the P wave may flatten, progressing to sine wave and arrest. Calcium is given when ECG changes are present.

Question 12Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with a sodium level of 108 mEq/L has seizures. What is the recommended maximum sodium correction to avoid osmotic demyelination?

  1. 12 mEq/L in 24 hours
  2. 8 mEq/L in 24 hours Correct answer.
  3. 18 mEq/L in 24 hours
  4. 20 mEq/L in 24 hours

Explanation

Correction of chronic hyponatremia should not exceed about 8 mEq/L in 24 hours in patients at high risk for osmotic demyelination. Symptomatic severe hyponatremia is treated with hypertonic saline to raise sodium modestly and stop seizures. Frequent monitoring guides further correction.

Question 13Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient has oliguria, a BUN-to-creatinine ratio of 30, a fractional excretion of sodium of 0.6%, and improves after fluid administration. Which condition is most likely?

  1. Interstitial nephritis
  2. Acute tubular necrosis
  3. Prerenal azotemia Correct answer.
  4. Postrenal obstruction

Explanation

A low fractional excretion of sodium with an elevated BUN-to-creatinine ratio and response to fluids indicates prerenal azotemia from hypoperfusion. Intrinsic renal injury typically has a higher fractional excretion of sodium. Obstruction is evaluated with bladder scanning and imaging.

Question 14Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A stable ICU patient has a hemoglobin of 7.4 g/dL and no active bleeding. What hemoglobin threshold generally triggers transfusion?

  1. 7 g/dL Correct answer.
  2. 8 g/dL
  3. 9 g/dL
  4. 10 g/dL

Explanation

Restrictive transfusion strategies use a hemoglobin threshold of 7 g/dL for most stable critically ill adults. Higher thresholds are reserved for active ischemia or ongoing bleeding. Transfusion decisions also incorporate clinical status.

Question 15Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient develops bilateral infiltrates and hypoxemia within 6 hours of a fresh frozen plasma transfusion. Blood pressure is 110/70 mm Hg, BNP is normal, and there is no evidence of volume overload. Which complication is most likely?

  1. Ventilator-associated pneumonia
  2. Transfusion-related acute lung injury Correct answer.
  3. Transfusion-associated circulatory overload
  4. Anaphylaxis

Explanation

Transfusion-related acute lung injury presents with acute hypoxemia and bilateral infiltrates within 6 hours of transfusion without evidence of volume overload. It is a noncardiogenic pulmonary edema associated with donor antibodies. Management is supportive.

Question 16Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

Which strategy is most effective for preventing delirium in hospitalized older adults?

  1. Multicomponent nonpharmacologic interventions Correct answer.
  2. Prophylactic antipsychotics
  3. Physical restraints
  4. Scheduled benzodiazepines at night

Explanation

Multicomponent nonpharmacologic programs targeting orientation, sleep, mobility, hydration, and sensory aids reduce delirium incidence. Antipsychotics are not recommended for prophylaxis. Benzodiazepines and restraints can worsen delirium.

Question 17Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

An older adult has a shallow open ulcer with a pink wound bed and partial-thickness loss of the dermis. How should this pressure injury be staged?

  1. Stage 2 Correct answer.
  2. Stage 1
  3. Stage 4
  4. Stage 3

Explanation

Stage 2 pressure injuries involve partial-thickness skin loss with a shallow open ulcer or intact blister. Stage 1 is nonblanchable erythema of intact skin. Stage 3 and 4 involve full-thickness tissue loss.

Question 18Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A hemodynamically stable, mechanically ventilated critically ill adult cannot eat orally. What is the preferred nutrition approach?

  1. Clear liquids only for 5 days
  2. Parenteral lipids alone
  3. Total parenteral nutrition within 24 hours
  4. Early enteral nutrition within 24 to 48 hours Correct answer.

Explanation

Early enteral nutrition within 24 to 48 hours is preferred in stable critically ill patients to maintain gut integrity and reduce infection risk. Parenteral nutrition is reserved for enteral nutrition failure or contraindications. Clear liquids alone do not meet nutritional needs.

Question 19Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A mechanically ventilated patient cannot self-report pain. Which tool is most appropriate for assessing pain?

  1. Wong-Baker FACES scale
  2. Numeric rating scale
  3. Behavioral Pain Scale Correct answer.
  4. Visual analog scale

Explanation

The Behavioral Pain Scale and Critical-Care Pain Observation Tool are validated for patients who cannot self-report. They use facial expression, body movement, and ventilator compliance. Self-report scales require intact communication.

Question 20Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A postoperative patient on opioid patient-controlled analgesia has a respiratory rate of 6 breaths/min and is difficult to arouse. What is the priority intervention?

  1. Administer flumazenil
  2. Give an additional opioid dose
  3. Increase oxygen flow
  4. Administer naloxone Correct answer.

Explanation

Opioid-induced respiratory depression is treated with naloxone while supporting airway and ventilation. Flumazenil reverses benzodiazepines, not opioids. Oxygen alone does not correct opioid-induced hypoventilation.

Question 21Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with cirrhosis presents with hematemesis and suspected variceal bleeding. Which initial pharmacologic therapy is indicated?

  1. Octreotide and ceftriaxone Correct answer.
  2. Propranolol
  3. Vitamin K only
  4. Omeprazole infusion alone

Explanation

Suspected variceal hemorrhage is treated with a vasoactive agent such as octreotide plus prophylactic antibiotics, commonly ceftriaxone. Antibiotics reduce bacterial infection and rebleeding risk. Endoscopic therapy follows resuscitation.

Question 22Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with mild acute pancreatitis is hemodynamically stable. When should enteral feeding be started?

  1. After 2 weeks of total parenteral nutrition
  2. After 7 days of bowel rest
  3. Within 24 to 48 hours as tolerated Correct answer.
  4. Only after lipase normalizes

Explanation

Early enteral feeding within 24 to 48 hours is recommended in mild acute pancreatitis once the patient is stable and tolerating it. Bowel rest does not shorten recovery and increases complications. Lipase normalization is not required before feeding.

Question 23Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

Which finding is a reason to withhold pharmacologic venous thromboembolism prophylaxis?

  1. Active major bleeding Correct answer.
  2. Platelet count of 180,000/mcL
  3. History of deep vein thrombosis
  4. Age of 75 years

Explanation

Active major bleeding is a contraindication to anticoagulant prophylaxis until bleeding is controlled. Prior DVT and older age increase thrombotic risk and support prophylaxis. A normal platelet count does not preclude prophylaxis.

Question 24Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with suspected adrenal crisis has hypotension refractory to fluids. After drawing a cortisol level, which treatment should be given next?

  1. Wait for ACTH stimulation results
  2. IV hydrocortisone 100 mg Correct answer.
  3. IV dexamethasone 4 mg
  4. Oral fludrocortisone

Explanation

Immediate IV hydrocortisone provides both glucocorticoid and mineralocorticoid activity and should not be delayed for confirmatory testing. Dexamethasone lacks mineralocorticoid effect and is used when ACTH stimulation testing is planned. Fluids and vasopressors are given concurrently.

Question 25Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with metastatic cancer is being evaluated for hospice eligibility. What prognosis generally supports hospice enrollment?

  1. 3 months
  2. 6 months or less Correct answer.
  3. 12 months
  4. 24 months

Explanation

Hospice eligibility generally requires a prognosis of 6 months or less if the terminal illness follows its expected course. The focus is comfort and quality of life rather than curative treatment. Recertification occurs at benefit periods.

Question 26Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

An adult with sepsis and a lactate of 4.2 mmol/L remains hypotensive after cultures are drawn and antibiotics are started. How much initial intravenous crystalloid is recommended?

  1. 20 mL/kg
  2. 30 mL/kg Correct answer.
  3. 10 mL/kg
  4. 40 mL/kg

Explanation

Sepsis with hypoperfusion (elevated lactate or hypotension) warrants at least 30 mL/kg of IV crystalloid started within the first 3 hours. Fluid should be given as boluses with reassessment of perfusion between boluses rather than as an unmonitored total.

Question 27Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with early acute respiratory distress syndrome is being placed on volume-control ventilation. Which tidal volume target is recommended?

  1. 2 mL/kg predicted body weight
  2. 10 mL/kg predicted body weight
  3. 12 mL/kg predicted body weight
  4. 6 mL/kg predicted body weight Correct answer.

Explanation

Lung-protective ventilation in ARDS uses 6 mL/kg of predicted body weight, titrated down to as low as 4 mL/kg if plateau pressure exceeds 30 cm H2O. Predicted body weight based on height and sex is used, not actual body weight.

Question 28Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with moderate-to-severe ARDS (PaO2/FiO2 ratio 110) remains hypoxemic despite optimized ventilation. How should prone positioning be applied?

  1. For at least 12 hours per day Correct answer.
  2. Only during daytime waking hours
  3. Only when the PaO2/FiO2 ratio falls below 60
  4. For at least 2 hours per day

Explanation

Prone positioning improves oxygenation and mortality in moderate-to-severe ARDS when sessions last at least 12 hours per day, often longer. Shorter sessions do not produce the same survival benefit.

Question 29Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient presents with diabetic ketoacidosis, glucose 480 mg/dL, pH 7.12, and blood pressure 92/58 mm Hg. Which action should come first?

  1. Give sodium bicarbonate for a pH below 7.1
  2. Start an insulin infusion at 0.1 units/kg/hr
  3. Give intravenous potassium before any fluid
  4. Begin isotonic crystalloid resuscitation Correct answer.

Explanation

Volume depletion is the immediate threat in DKA, so isotonic saline is started before insulin. Insulin given before fluid repletion can worsen hypotension by shifting glucose and water intracellularly. Potassium is replaced once the level is known and is not given before volume resuscitation.

Question 30Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient in septic shock remains hypotensive after adequate crystalloid resuscitation. Which vasopressor is first-line?

  1. Phenylephrine
  2. Norepinephrine Correct answer.
  3. Vasopressin
  4. Dopamine

Explanation

Norepinephrine is the first-line vasopressor for septic shock because it raises mean arterial pressure with less tachyarrhythmia than dopamine. Vasopressin is typically added as a second agent to reduce norepinephrine requirements.

Question 31Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient arrives in convulsive status epilepticus with ongoing motor seizure activity. Which medication is the appropriate first-line therapy?

  1. IV levetiracetam 60 mg/kg
  2. IV phenytoin 20 mg/kg
  3. IV lorazepam 0.1 mg/kg Correct answer.
  4. IV propofol bolus

Explanation

Benzodiazepines are first-line for terminating convulsive status epilepticus, with lorazepam, midazolam, or diazepam all acceptable. A second-line antiseizure medication such as levetiracetam, fosphenytoin, or valproate follows if seizures continue.

Question 32Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient in thyroid storm is to receive both a thionamide and a saturated solution of potassium iodide. Which sequence is correct?

  1. Give iodine at least one hour before the thionamide is started
  2. Withhold iodine until the TSH level normalizes
  3. Give both agents simultaneously at the same time
  4. Give the thionamide first, with iodine added an hour later Correct answer.

Explanation

A thionamide must be given first to block new hormone synthesis, because iodine is a substrate for organification and can transiently worsen hyperthyroidism. Iodine is added at least one hour later to inhibit hormone release.

Question 33Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with acute decompensated heart failure is dyspneic with bibasilar rales, SpO2 88% on 6 L nasal cannula, and blood pressure 178/96 mm Hg. Which initial intravenous therapy is most appropriate?

  1. IV nitroglycerin plus IV furosemide Correct answer.
  2. Rapid IV bolus of 1 L of 0.9% saline
  3. A loading dose of digoxin
  4. Oral metoprolol tartrate 100 mg

Explanation

Hypertensive acute pulmonary edema is treated by reducing preload and afterload with intravenous nitrates together with a loop diuretic in patients who are volume overloaded. Vasodilators act faster than diuretics on filling pressures and congestion.

Question 34Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

Endoscopy confirms a bleeding duodenal ulcer and achieves hemostasis in a hemodynamically stable patient. Which therapy reduces the risk of recurrent bleeding?

  1. Prophylactic broad-spectrum antibiotics
  2. Intravenous octreotide infusion
  3. High-dose proton pump inhibitor infusion Correct answer.
  4. Oral sucralfate suspension given four times daily

Explanation

High-dose proton pump inhibitor therapy raises intragastric pH, stabilizing the clot over a nonvariceal ulcer and lowering rebleeding risk. Octreotide and antibiotics target variceal hemorrhage, not ulcer bleeding.

Question 35Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with cirrhosis and hepatic encephalopathy is started on lactulose. Which endpoint is used to titrate the dose?

  1. Two soft stools per week
  2. A serum ammonia level below 40 mcg/dL
  3. Complete resolution of asterixis
  4. Two to three soft stools per day Correct answer.

Explanation

Lactulose is titrated to produce two to three soft bowel movements daily, which reflects adequate acidification and clearance of ammonia in the colon. Serum ammonia levels correlate poorly with mental status and are not used to guide therapy.

Question 36Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient admitted for cellulitis with a history of heavy alcohol use develops tremor, diaphoresis, and tachycardia on hospital day two. Which management approach is recommended?

  1. Clonidine monotherapy titrated to the heart rate response
  2. Standing lorazepam given around the clock regardless of symptoms
  3. Fixed-dose haloperidol given every six hours with vital sign checks
  4. Symptom-triggered benzodiazepines guided by a validated withdrawal scale Correct answer.

Explanation

Symptom-triggered benzodiazepine dosing using a validated scale such as CIWA-Ar treats withdrawal adequately while reducing total drug exposure and sedation. Fixed dosing is reserved for patients who cannot be reliably assessed or who have a history of withdrawal seizures.

Question 37Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A comatose patient achieves return of spontaneous circulation after cardiac arrest. Which temperature management strategy is recommended?

  1. Maintain 37.5 to 38.0°C with active warming
  2. No temperature control is required
  3. Target 32 to 36°C for at least 24 hours Correct answer.
  4. Cool to 30 to 32°C for 72 hours

Explanation

Post-arrest care includes preventing fever and maintaining a constant target temperature between 32 and 36°C for at least 24 hours in patients who remain comatose. Avoiding hyperthermia is important regardless of which temperature within that range is chosen.

Question 38Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A severely malnourished patient with anorexia nervosa begins enteral feeding and on day two develops weakness, confusion, and new arrhythmia. Which laboratory abnormality best explains this presentation?

  1. Hypernatremia
  2. Hyperphosphatemia
  3. Hypophosphatemia Correct answer.
  4. Hyperkalemia

Explanation

Refeeding syndrome is driven by an insulin surge that drives phosphate, potassium, and magnesium into cells, producing hypophosphatemia with weakness, confusion, and arrhythmias. Feeding is started slowly in high-risk patients with electrolyte repletion before and during initiation.

Question 39Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with confirmed pulmonary embolism is hypotensive at 82/54 mm Hg with elevated troponin and right ventricular strain on echocardiography. Which treatment is indicated?

  1. Unfractionated heparin infusion alone
  2. Inferior vena cava filter placement
  3. Catheter-directed thrombectomy as first-line therapy for every patient
  4. Systemic thrombolysis with alteplase Correct answer.

Explanation

High-risk (massive) pulmonary embolism with hemodynamic instability warrants systemic thrombolysis unless contraindicated, because it rapidly reduces clot burden and right ventricular afterload. Anticoagulation alone is insufficient once shock is present.

Question 40Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient presents with sudden tearing chest pain and a blood pressure of 190/100 mm Hg; CT angiography shows a dissection involving the ascending aorta. What is the immediate priority?

  1. Give thrombolytics for presumed acute coronary syndrome
  2. IV beta-blockade and urgent cardiothoracic surgery Correct answer.
  3. Start dual antiplatelet therapy
  4. Discharge home with oral antihypertensives and close follow-up

Explanation

Type A dissection is a surgical emergency, and heart rate and blood pressure are controlled with intravenous beta-blockade before and during transfer to the operating room. Reducing dP/dt limits propagation of the intimal tear.

Question 41Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with acute severe asthma has diffuse wheezing, accessory muscle use, and a PaCO2 of 48 mm Hg. Which combination of therapies is most appropriate?

  1. Prophylactic broad-spectrum antibiotics with chest physiotherapy twice daily
  2. Oral prednisone alone with observation for six hours
  3. Inhaled albuterol-ipratropium, systemic steroids, and IV magnesium Correct answer.
  4. Nebulized albuterol alone every four hours

Explanation

Severe asthma is treated with repeated short-acting beta-agonist and ipratropium nebulization, early systemic corticosteroids, and intravenous magnesium for patients who respond poorly. A normal or rising PaCO2 signals impending respiratory failure and demands aggressive therapy.

Question 42Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

An alert older adult with diabetes has a point-of-care glucose of 52 mg/dL and is able to swallow safely. What is the first action?

  1. Start an infusion of 10% dextrose at 100 mL/hr
  2. Give 15 to 20 g of oral carbohydrate and recheck in 15 minutes Correct answer.
  3. Give 25 g of dextrose as a 50% solution intravenously
  4. Give 1 mg of glucagon intramuscularly

Explanation

A conscious patient who can swallow should receive fast-acting oral carbohydrate, with glucose rechecked in about 15 minutes and repeated if still low. Glucagon and intravenous dextrose are reserved for patients who cannot take oral intake or have no IV access.

Question 43Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

An 84-year-old with diabetes is evaluated for possible acute coronary syndrome. Which statement about presentation in older adults is accurate?

  1. Troponin levels are unreliable in older adults
  2. Dyspnea may be the only presenting symptom Correct answer.
  3. Chest pain is present in nearly all cases
  4. A normal ECG excludes acute coronary syndrome

Explanation

Older adults, especially those with diabetes, often present with dyspnea, fatigue, syncope, or confusion rather than classic chest pain. Atypical presentation contributes to delayed recognition and treatment.

Question 44Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

An older adult hospitalized for pneumonia asks for a sleep aid. Which medication class should generally be avoided because of fall and delirium risk?

  1. Benzodiazepines Correct answer.
  2. Melatonin receptor agonists
  3. Low-dose doxepin
  4. Cognitive behavioral therapy for insomnia

Explanation

Benzodiazepines and other sedative-hypnotics are potentially inappropriate in older adults because they increase falls, fractures, delirium, and motor vehicle crashes. Nonpharmacologic sleep measures are preferred in hospitalized older adults.

Question 45Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

Which strategy most effectively reduces catheter-associated urinary tract infections on an inpatient unit?

  1. Routine urine cultures every 48 hours
  2. Irrigating the catheter every shift
  3. Nurse-driven removal protocols reviewed daily Correct answer.
  4. Prophylactic antibiotics during catheterization

Explanation

The strongest preventive measure is avoiding unnecessary catheter days through daily review of indications with nurse-driven removal protocols. Aseptic insertion and a closed drainage system further reduce risk.

Question 46Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A critically ill patient with acute kidney injury, lactate 6 mmol/L, and rising norepinephrine requirements needs renal replacement therapy. Which modality is preferred?

  1. Twice-weekly isolated ultrafiltration
  2. Continuous renal replacement therapy Correct answer.
  3. Intermittent hemodialysis three times weekly
  4. Peritoneal dialysis

Explanation

Continuous renal replacement therapy removes solute and volume slowly, avoiding the hypotension and fluid shifts that intermittent dialysis can cause in hemodynamically unstable patients. Intermittent therapy remains appropriate for stable patients.

Question 47Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient taking an SSRI who was given tramadol develops agitation, diaphoresis, tremor, and lower-extremity clonus. Which finding most helps distinguish this from neuroleptic malignant syndrome?

  1. Elevated creatine kinase
  2. Hyperreflexia with clonus Correct answer.
  3. Lead-pipe rigidity
  4. Temperature above 38.5°C

Explanation

Serotonin syndrome characteristically produces neuromuscular hyperactivity with hyperreflexia and clonus, particularly in the lower extremities. Neuroleptic malignant syndrome presents with lead-pipe rigidity, bradyreflexia, and a slower onset over days.

Question 48Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with a C6 spinal cord injury has a blood pressure of 78/46 mm Hg and a heart rate of 48 beats/min. Which intervention is most appropriate?

  1. IV fluids with a vasopressor such as norepinephrine Correct answer.
  2. Nitroglycerin infusion for suspected autonomic dysreflexia
  3. Atropine 1 mg for bradycardia with no additional treatment
  4. A single 2 L crystalloid bolus without further therapy

Explanation

Neurogenic shock reflects loss of sympathetic vascular tone and produces hypotension with bradycardia, treated with volume resuscitation plus a vasopressor when fluids are insufficient. Atropine may be added for symptomatic bradycardia but does not correct the hypotension alone.

Question 49Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A hemodynamically stable patient who is mechanically ventilated has been immobile for three days. Which intervention most reduces intensive care unit-acquired weakness?

  1. Neuromuscular electrical stimulation used as the sole therapy
  2. Early progressive mobilization and physical therapy Correct answer.
  3. Strict bed rest until the patient is extubated
  4. Continuous deep sedation to reduce oxygen consumption

Explanation

Early progressive mobilization, beginning with in-bed activity and advancing as tolerated, preserves muscle mass and function and shortens ventilator and ICU days. Minimizing sedation is a key facilitator of early mobility.

Question 50Clinical Practice and Care Management of the Acutely Ill Adult-Gerontology Population

A patient with a COPD exacerbation has a pH of 7.28 and PaCO2 of 62 mm Hg while receiving 2 L/min nasal cannula, and is alert and cooperative. Which intervention is most appropriate?

  1. Noninvasive ventilation with bilevel positive airway pressure Correct answer.
  2. High-flow nasal cannula at 60 L/min
  3. Immediate endotracheal intubation
  4. Nebulized albuterol as the sole therapy

Explanation

Hypercapnic respiratory acidosis with an acidic pH in an alert, cooperative COPD patient is the classic indication for bilevel noninvasive ventilation, which reduces intubation and mortality. Intubation is reserved for failure of noninvasive support or inability to protect the airway.