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BCCCP practice questions

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Question 1Cardiovascular Disorders

A patient in cardiac arrest with ventricular fibrillation is receiving CPR and has just been defibrillated. Which epinephrine regimen is recommended by current advanced cardiac life support guidelines?

  1. 3 mg IV push every 3 to 5 minutes
  2. 0.1 mg IV push every 3 to 5 minutes
  3. 1 mg IV push every 3 to 5 minutes Correct answer.
  4. 1 mg IV push every 10 minutes

Explanation

Standard-dose epinephrine for cardiac arrest is 1 mg IV/IO repeated every 3 to 5 minutes. High-dose regimens have not improved survival or neurologic outcome and are not recommended. The drug is given as a bolus and repeated at the shorter interval because of its brief vasopressor effect during arrest.

Question 2Cardiovascular Disorders

A patient has symptomatic bradycardia with a heart rate of 42 beats/min and a blood pressure of 82/48 mmHg. Which atropine regimen is correct?

  1. 0.5 mg IV every 5 minutes, with a maximum total of 1 mg
  2. 0.1 mg IV every 2 minutes, maximum 3 mg
  3. 3 mg IV once, then stop
  4. 1 mg IV every 3 to 5 minutes, maximum 3 mg Correct answer.

Explanation

Atropine for symptomatic bradycardia is dosed at 1 mg IV every 3 to 5 minutes, with a total maximum of 3 mg. Doses smaller than 0.5 mg can produce a paradoxical bradycardia and are avoided. If atropine fails, pacing or a chronotropic infusion is required.

Question 3Cardiovascular Disorders

A 70-kg adult with stable narrow-complex supraventricular tachycardia that persists after vagal maneuvers is to receive adenosine. What is the recommended initial dose?

  1. 6 mg rapid IV push Correct answer.
  2. 0.1 mg/kg rapid IV push
  3. 12 mg rapid IV push
  4. 1 mg rapid IV push

Explanation

The initial adult adenosine dose for stable supraventricular tachycardia is 6 mg given as a rapid IV push followed by a flush. If the rhythm does not convert within 1 to 2 minutes, a 12 mg dose may be repeated. Dosing is fixed rather than weight-based in adults.

Question 4Cardiovascular Disorders

During cardiac arrest from pulseless ventricular tachycardia that persists after defibrillation and epinephrine, what amiodarone dose is recommended?

  1. 150 mg IV over 10 minutes
  2. 1 mg/min infusion for 6 hours
  3. 900 mg IV bolus
  4. 300 mg IV bolus Correct answer.

Explanation

The amiodarone bolus for refractory ventricular fibrillation or pulseless ventricular tachycardia is 300 mg IV/IO push. This may be followed by a second 150 mg bolus, and a maintenance infusion follows return of spontaneous circulation. The 150 mg dose and the 1 mg/min infusion belong to post-arrest maintenance, not the arrest bolus.

Question 5Cardiovascular Disorders

Which vasopressor is recommended as the first-line agent for adults with septic shock?

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

Explanation

Norepinephrine is the first-line vasopressor in septic shock because it raises mean arterial pressure with a lower risk of arrhythmia than dopamine. Vasopressin is typically added as a second agent to spare norepinephrine. Dopamine and phenylephrine are reserved for selected situations.

Question 6Cardiovascular Disorders

A patient in septic shock receiving norepinephrine at 0.3 mcg/kg/min has a mean arterial pressure of 58 mmHg. Vasopressin is added to the regimen. What is the appropriate dosing approach?

  1. 0.5 units/min titrated to effect
  2. Bolus 20 units IV, then infuse at 0.1 units/min
  3. Titrate from 0.01 to 0.1 units/min to a MAP of 65 mmHg
  4. Fixed 0.03 units/min without titration Correct answer.

Explanation

Vasopressin is given as a fixed infusion of 0.03 units/min and is not titrated to blood pressure. It is added to norepinephrine, often when norepinephrine requirements are escalating, to reduce catecholamine exposure. Higher fixed doses increase the risk of digital and mesenteric ischemia.

Question 7Cardiovascular Disorders

Which finding most strongly contraindicates intravenous nitroglycerin in a patient presenting with chest pain?

  1. History of migraine
  2. Blood pressure of 148/92 mmHg
  3. Heart rate of 105 beats/min
  4. Sildenafil use 12 hours ago Correct answer.

Explanation

Nitrates are contraindicated with phosphodiesterase-5 inhibitors because the combined increase in cyclic GMP can cause profound, refractory hypotension. Sildenafil and vardenafil require a 24-hour washout, while tadalafil requires 48 hours. Nitrates are also avoided in right ventricular infarction, severe aortic stenosis, and hypotension.

Question 8Cardiovascular Disorders

A patient has received sodium nitroprusside at 10 mcg/kg/min for 48 hours and develops unexplained lactic acidosis, confusion, and seizures. What is the most likely cause?

  1. Methemoglobinemia
  2. Reflex tachycardia
  3. Thiocyanate accumulation
  4. Cyanide toxicity Correct answer.

Explanation

Nitroprusside is metabolized to cyanide, and prolonged high-dose infusions or impaired hepatic or renal clearance allow cyanide to accumulate. Cyanide blocks mitochondrial cytochrome oxidase, producing lactic acidosis and encephalopathy. Hydroxocobalamin or sodium thiosulfate is used for treatment.

Question 9Cardiovascular Disorders

Dobutamine's positive inotropic effect is mediated primarily by which receptor activity?

  1. Alpha-1 adrenergic agonism
  2. Phosphodiesterase-3 inhibition
  3. Beta-2 adrenergic agonism
  4. Beta-1 adrenergic agonism Correct answer.

Explanation

Dobutamine is a synthetic catecholamine whose inotropy comes mainly from beta-1 receptor stimulation, with lesser beta-2 and alpha-1 activity. Beta-1 stimulation increases cyclic AMP and intracellular calcium, enhancing contractility. Beta-2 activity contributes to vasodilation, and the drug can cause tachycardia and arrhythmia.

Question 10Cardiovascular Disorders

Which statement about milrinone is correct?

  1. It has a half-life of approximately 2 minutes.
  2. It is eliminated primarily by hepatic metabolism.
  3. It requires dose reduction in renal impairment. Correct answer.
  4. It causes reflex bradycardia as its principal adverse effect.

Explanation

Milrinone is a phosphodiesterase-3 inhibitor that is cleared largely unchanged by the kidney, so dosing must be reduced in renal impairment to avoid hypotension and arrhythmia. Its half-life is roughly 2 to 4 hours, and it is not rapidly titratable. Thrombocytopenia is a recognized adverse effect.

Question 11Cardiovascular Disorders

A patient taking digoxin 0.25 mg daily presents with nausea, confusion, and a serum potassium of 3.1 mEq/L. Which best explains the increased risk of toxicity?

  1. Hypokalemia increases digoxin binding at the sodium-potassium ATPase. Correct answer.
  2. Hypokalemia increases renal tubular reabsorption of digoxin.
  3. Hypokalemia decreases digoxin protein binding.
  4. Hypokalemia accelerates conversion of digoxin to its active metabolite.

Explanation

Digoxin inhibits the sodium-potassium ATPase, and potassium competes with digoxin at that binding site. When potassium is low, more digoxin binds and toxicity occurs at lower serum concentrations. Correcting the potassium and, in severe cases, giving digoxin immune Fab are key steps.

Question 12Cardiovascular Disorders

A patient has taken amiodarone 200 mg daily for 8 months and reports a new dry cough and progressive dyspnea. Which monitoring test is most appropriate?

  1. Serum thyrotropin only
  2. High-resolution chest CT Correct answer.
  3. Serum amiodarone level
  4. Transthoracic echocardiogram

Explanation

Amiodarone can cause interstitial pneumonitis and pulmonary fibrosis, which may present with cough, dyspnea, and declining diffusing capacity. Chest imaging, particularly high-resolution CT, is used when pulmonary toxicity is suspected. Amiodarone levels correlate poorly with toxicity and are not used for this purpose.

Question 13Cardiovascular Disorders

A hemodynamically stable patient has torsades de pointes with a markedly prolonged QT interval. Which initial pharmacologic therapy is recommended?

  1. Diltiazem 20 mg IV
  2. Amiodarone 150 mg IV
  3. Magnesium sulfate 2 g IV Correct answer.
  4. Procainamide 15 mg/kg IV

Explanation

Intravenous magnesium is the treatment of choice for torsades de pointes, even when the serum magnesium is normal. In an unstable patient, unsynchronized defibrillation is performed first. Offending QT-prolonging drugs and electrolyte deficits should be corrected.

Question 14Cardiovascular Disorders

A patient with a tricyclic antidepressant overdose has a QRS of 130 ms and hypotension. Which therapy is indicated?

  1. Calcium chloride 1 g IV to stabilize the myocardium
  2. Activated charcoal 50 g by mouth if the airway is protected
  3. Flumazenil 0.2 mg IV to reverse sedation
  4. Sodium bicarbonate to a serum pH of 7.45 to 7.55 Correct answer.

Explanation

Sodium bicarbonate is the antidote for tricyclic cardiotoxicity, given for a QRS above 100 ms, ventricular arrhythmia, or hypotension. Sodium loading and alkalinization target a serum pH of 7.45 to 7.55. Serum alkalinization reduces drug binding to the cardiac sodium channel.

Question 15Cardiovascular Disorders

A patient develops seizures and ventricular arrhythmias minutes after a large-volume bupivacaine infiltration. After airway management and benzodiazepines, which specific therapy is indicated?

  1. Glucagon 3 mg IV
  2. Sodium bicarbonate 1 mEq/kg IV
  3. Naloxone 2 mg IV
  4. Lipid emulsion 20% bolus Correct answer.

Explanation

This presentation is local anesthetic systemic toxicity, for which intravenous 20% lipid emulsion is the specific antidote. A bolus of about 1.5 mL/kg is followed by an infusion until circulation is restored. Standard resuscitation should continue concurrently, and epinephrine doses are reduced.

Question 16Cardiovascular Disorders

Norepinephrine extravasation is suspected at a peripheral forearm IV site. Which intervention is appropriate?

  1. Apply warm compresses to the site
  2. Elevate the limb and observe
  3. Infiltrate the area with epinephrine
  4. Infiltrate with phentolamine Correct answer.

Explanation

Phentolamine, an alpha-adrenergic antagonist, is infiltrated into the affected area to reverse vasoconstriction and prevent tissue necrosis. Around 5 to 10 mg diluted in saline is injected within 12 hours of extravasation. The infusion should be stopped and moved to another site.

Question 17Cardiovascular Disorders

A patient stabilized on digoxin 0.25 mg daily for atrial fibrillation is started on amiodarone. What adjustment is recommended?

  1. No change is needed because the two drugs do not interact
  2. Double the digoxin dose to compensate for enzyme induction
  3. Increase the digoxin dose and monitor renal function weekly
  4. Reduce the digoxin dose by approximately 50% Correct answer.

Explanation

Amiodarone inhibits P-glycoprotein and reduces digoxin clearance, raising serum digoxin concentrations. The digoxin dose is typically halved when amiodarone is started, with concentration monitoring. Signs of toxicity should be reviewed at follow-up.

Question 18Cardiovascular Disorders

A patient with heparin-induced thrombocytopenia and severe renal impairment requires parenteral anticoagulation. Which agent is appropriate?

  1. Enoxaparin at a reduced dose
  2. Fondaparinux at a standard dose
  3. Argatroban Correct answer.
  4. Unfractionated heparin at a reduced dose

Explanation

Argatroban is a direct thrombin inhibitor cleared primarily by the liver, making it a suitable choice in heparin-induced thrombocytopenia with renal impairment. All heparin products are stopped once HIT is diagnosed. Bivalirudin is an alternative but is partly renally cleared.

Question 19Cardiovascular Disorders

A patient has received 5000 units of unfractionated heparin and requires reversal with protamine. Which dose is appropriate?

  1. 50 mg IV Correct answer.
  2. 25 mg IV
  3. 250 mg IV
  4. 10 mg IV

Explanation

Protamine is dosed at 1 mg per 100 units of heparin remaining, so 5000 units is reversed with about 50 mg. It is given slowly because rapid administration can cause hypotension and anaphylactoid reactions. Lower doses are used when the heparin dose has partially cleared.

Question 20Cardiovascular Disorders

Which characteristic distinguishes ticagrelor from clopidogrel in the management of acute coronary syndromes?

  1. It binds reversibly to the P2Y12 receptor Correct answer.
  2. It is preferred in patients at high bleeding risk due to lower bleeding rates
  3. It is a prodrug that requires hepatic activation
  4. It binds irreversibly to the P2Y12 receptor

Explanation

Ticagrelor is an active drug that binds reversibly to the P2Y12 receptor, so its effect wanes as the drug clears. Clopidogrel and prasugrel are prodrugs that bind irreversibly. Ticagrelor also carries a higher rate of non-CABG-related bleeding and a risk of dyspnea.

Question 21Cardiovascular Disorders

A patient with an anterior STEMI treated with primary PCI is now 30 hours post-reperfusion with a blood pressure of 86/58 mmHg, a heart rate of 104 beats/min, and rales over half the lung fields. What is the most appropriate decision regarding early beta blockade?

  1. Withhold beta blockade until hemodynamically stable Correct answer.
  2. Start metoprolol tartrate 50 mg every 6 hours immediately
  3. Start atenolol 100 mg daily to reduce infarct size
  4. Give intravenous esmolol because it is titratable

Explanation

Early beta blockade after myocardial infarction is withheld when there are signs of heart failure, hypotension, bradycardia, or cardiogenic shock. Starting therapy in this patient risks precipitating shock. Beta blockade is re-evaluated and started at a low dose once the patient is stabilized.

Question 22Cardiovascular Disorders

Four days after an anterior myocardial infarction, a patient with an ejection fraction of 35% is hemodynamically stable with potassium 4.2 mEq/L and a creatinine clearance of 55 mL/min. Which is the most appropriate long-term therapy?

  1. Lisinopril started low and titrated to target Correct answer.
  2. Losartan 100 mg daily as first-line therapy
  3. Spironolactone alone without an ACE inhibitor
  4. Enalapril 20 mg twice daily started at discharge

Explanation

An ACE inhibitor is indicated after myocardial infarction with left ventricular dysfunction, started at a low dose within the first day or two and titrated to the target dose as tolerated. Starting high risks hypotension and renal dysfunction. An ARB is generally reserved for ACE inhibitor intolerance.

Question 23Cardiovascular Disorders

Which patient with heart failure and reduced ejection fraction is an appropriate candidate for spironolactone?

  1. eGFR 45 mL/min/1.73 m2 and potassium 5.4 mEq/L
  2. eGFR 25 mL/min/1.73 m2 and potassium 4.8 mEq/L
  3. Potassium 5.6 mEq/L and eGFR 60 mL/min/1.73 m2
  4. eGFR 55 mL/min/1.73 m2 and potassium 4.2 mEq/L Correct answer.

Explanation

Mineralocorticoid receptor antagonists are initiated when the eGFR is above 30 mL/min/1.73 m2 and potassium is below 5.0 mEq/L. Renal function and potassium are rechecked within days of starting. The combination of preserved renal function and normal potassium makes this the appropriate candidate.

Question 24Cardiovascular Disorders

A patient taking enalapril 10 mg twice daily is transitioning to sacubitril/valsartan. What washout period is required after the last enalapril dose?

  1. 24 hours
  2. 6 hours
  3. 36 hours Correct answer.
  4. 12 hours

Explanation

A 36-hour washout is required when switching from an ACE inhibitor to sacubitril/valsartan because concurrent neprilysin and ACE inhibition markedly increases the risk of angioedema. The same interval applies when switching back to an ACE inhibitor. Blood pressure and potassium should be reassessed after the switch.

Question 25Cardiovascular Disorders

Which benefit has been demonstrated with SGLT2 inhibitors such as dapagliflozin in patients with heart failure with reduced ejection fraction?

  1. Lower incidence of atrial fibrillation as the primary outcome
  2. Fewer heart failure hospitalizations and cardiovascular deaths Correct answer.
  3. Reduced mortality only in patients with concomitant type 2 diabetes
  4. Improved glucose control as the sole mechanism of benefit

Explanation

SGLT2 inhibitors reduce the composite of worsening heart failure and cardiovascular death in heart failure with reduced ejection fraction. The benefit appears independent of diabetes status and is not explained by glucose lowering alone. They are now part of guideline-directed medical therapy regardless of baseline HbA1c.

Question 26Cardiovascular Disorders

A patient with a mechanical mitral valve prosthesis and no additional thromboembolic risk factors is beginning long-term warfarin therapy. Which INR target is recommended?

  1. 2.5 to 3.5 Correct answer.
  2. 3.5 to 4.5
  3. 2.0 to 3.0
  4. 1.5 to 2.0

Explanation

Mechanical valves in the mitral position carry a higher thromboembolic risk than those in the aortic position, so guidelines recommend a more intense anticoagulation target of INR 2.5 to 3.5. Aortic mechanical valves are typically managed to an INR of 2.0 to 3.0.

Question 27Cardiovascular Disorders

An adult with stable paroxysmal supraventricular tachycardia is to receive adenosine. What is the appropriate initial intravenous dose?

  1. 6 mg rapid IV push Correct answer.
  2. 0.1 mg/kg rapid IV push
  3. 3 mg rapid IV push
  4. 12 mg rapid IV push

Explanation

The initial adult dose of adenosine for stable supraventricular tachycardia is 6 mg given as a rapid IV push with an immediate saline flush, followed by a 12 mg dose if the first is ineffective. The 0.1 mg/kg dose is used in pediatric patients.

Question 28Cardiovascular Disorders

A patient with recurrent ventricular tachycardia receives an amiodarone loading bolus and is transitioned to a continuous infusion. Which maintenance regimen is recommended after the bolus?

  1. 2 mg/min for 6 hours, then 1 mg/min
  2. 1 mg/min for 24 hours, then no further infusion
  3. 1 mg/min for 6 hours, then 0.5 mg/min Correct answer.
  4. 0.5 mg/min for 6 hours, then 1 mg/min

Explanation

After the loading bolus, amiodarone is infused at 1 mg/min for 6 hours to achieve adequate tissue concentrations, then reduced to 0.5 mg/min for the remaining 18 hours of the standard 24-hour regimen. The tapering schedule limits the hypotension and bradycardia associated with higher cumulative doses.

Question 29Cardiovascular Disorders

A patient taking warfarin for atrial fibrillation has an INR of 6.5 at a routine visit. She has no bleeding, no high-risk features, and no planned procedure. Which management is most appropriate?

  1. Hold warfarin and recheck the INR tomorrow Correct answer.
  2. Transfuse 2 units of fresh frozen plasma
  3. Administer 10 mg of intravenous vitamin K now
  4. Give four-factor prothrombin complex concentrate

Explanation

For an INR between roughly 4.5 and 10 without bleeding, the recommendation is to omit warfarin doses and monitor, without routine administration of vitamin K. Coagulation factor products are reserved for major bleeding or urgent reversal, and high-dose vitamin K can create prolonged warfarin resistance.

Question 30Cardiovascular Disorders

A patient who ingested a large quantity of extended-release verapamil remains bradycardic and hypotensive despite intravenous calcium, fluid resuscitation, and atropine. Which therapy is best supported for refractory calcium channel blocker poisoning?

  1. Naloxone 2 mg IV
  2. Glucagon 5 mg IV followed by infusion
  3. Sodium bicarbonate 1 mEq/kg IV push
  4. High-dose insulin euglycemia therapy Correct answer.

Explanation

High-dose insulin with dextrose is recommended for calcium channel blocker toxicity that persists despite calcium and vasopressors, because insulin improves myocardial carbohydrate utilization and inotropy in this setting. Glucose and potassium must be monitored closely during therapy.

Question 31Pulmonary Disorders and Mechanical Ventilation

According to the ARDSNet lung-protective ventilation protocol, what initial tidal volume should be set for a patient with acute respiratory distress syndrome?

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

Explanation

The ARDSNet protocol targets 6 mL/kg of predicted body weight, with reduction to as low as 4 mL/kg if plateau pressure remains above 30 cm H2O. Ventilation is titrated to predicted, not actual, body weight because lung size correlates with height and sex rather than total body mass.

Question 32Pulmonary Disorders and Mechanical Ventilation

Which plateau pressure target is used to limit ventilator-induced lung injury in a patient with ARDS?

  1. ≤10 cm H2O
  2. ≤45 cm H2O
  3. ≤30 cm H2O Correct answer.
  4. ≤60 cm H2O

Explanation

Plateau pressure approximates alveolar distending pressure, and maintaining it at or below 30 cm H2O is a core component of lung-protective ventilation. If the plateau pressure exceeds this threshold, tidal volume is reduced in stepwise fashion toward 4 mL/kg.

Question 33Pulmonary Disorders and Mechanical Ventilation

Which agent is the cornerstone of initial bronchodilator therapy for an acute severe asthma exacerbation?

  1. Inhaled albuterol Correct answer.
  2. Intravenous aminophylline
  3. Inhaled ipratropium alone
  4. Oral montelukast

Explanation

Inhaled short-acting beta-2 agonists such as albuterol are first-line therapy because they produce rapid, dose-dependent bronchodilation. Ipratropium is added as an adjunct rather than used alone, and methylxanthines are not recommended for routine use.

Question 34Pulmonary Disorders and Mechanical Ventilation

Which intervention reduces intubation rate and mortality in a COPD exacerbation complicated by acute hypercapnic respiratory acidosis?

  1. Intermittent positive pressure breathing
  2. High-flow nasal cannula oxygen
  3. Noninvasive ventilation Correct answer.
  4. Chest physiotherapy

Explanation

Noninvasive positive pressure ventilation improves gas exchange, reduces work of breathing, and lowers both intubation and mortality rates in COPD exacerbations with respiratory acidosis. Benefit is greatest when acidosis is moderate and the patient is alert and cooperative.

Question 35Pulmonary Disorders and Mechanical Ventilation

What head-of-bed elevation is recommended to reduce the risk of ventilator-associated pneumonia in mechanically ventilated patients?

  1. Reverse Trendelenburg 15 degrees
  2. 30 to 45 degrees Correct answer.
  3. 10 to 15 degrees
  4. Flat supine position

Explanation

Elevating the head of the bed 30 to 45 degrees reduces aspiration of oropharyngeal and gastric secretions and is part of standard VAP prevention bundles. The position is combined with daily sedation interruption and oral care.

Question 36Pulmonary Disorders and Mechanical Ventilation

Which set of findings best supports that a mechanically ventilated patient is ready for a spontaneous breathing trial?

  1. FiO2 of 0.40 or less with PEEP of 8 cm H2O or less and adequate oxygenation Correct answer.
  2. Copious tracheal secretions requiring frequent suctioning
  3. PaO2/FiO2 of 150 on FiO2 0.8 and PEEP of 12 cm H2O
  4. Core temperature of 39.0 degrees Celsius with hemodynamic instability

Explanation

Readiness criteria include a low FiO2 requirement, PEEP of 8 cm H2O or less, adequate oxygenation, hemodynamic stability, and manageable secretions. Patients who fail these criteria have a high likelihood of failing the trial and being reintubated.

Question 37Pulmonary Disorders and Mechanical Ventilation

A ventilated patient with COPD has an auto-PEEP of 8 cm H2O and new hypotension. Which ventilator adjustment is most appropriate?

  1. Decrease the set respiratory rate Correct answer.
  2. Increase the inspiratory time
  3. Increase the set respiratory rate
  4. Increase the tidal volume

Explanation

Auto-PEEP results from incomplete exhalation and can impair venous return and cause hypotension. Reducing the set respiratory rate lengthens expiratory time and allows the lung to empty more completely.

Question 38Pulmonary Disorders and Mechanical Ventilation

A 175 cm tall man with ARDS is being started on lung-protective ventilation at 6 mL/kg of predicted body weight. What tidal volume should be set?

  1. 300 mL
  2. 540 mL
  3. 420 mL Correct answer.
  4. 360 mL

Explanation

Predicted body weight for a male is calculated as 50 + 0.91 x (height in cm - 152.4), which yields about 70.6 kg at 175 cm. Multiplying by 6 mL/kg gives approximately 423 mL, rounded to 420 mL.

Question 39Pulmonary Disorders and Mechanical Ventilation

Which empiric regimen is appropriate for hospital-acquired or ventilator-associated pneumonia in a patient at risk for both MRSA and Pseudomonas aeruginosa?

  1. Vancomycin plus cefepime Correct answer.
  2. Ceftriaxone monotherapy
  3. Ampicillin-sulbactam monotherapy
  4. Metronidazole plus azithromycin

Explanation

Empiric therapy for hospital-acquired or ventilator-associated pneumonia in at-risk patients should combine an agent active against MRSA with an antipseudomonal beta-lactam. Therapy is then narrowed once culture and susceptibility results are available.

Question 40Pulmonary Disorders and Mechanical Ventilation

A patient with severe asthma has persistent bronchospasm despite repeated inhaled albuterol, ipratropium, and systemic corticosteroids. Which adjunct is most appropriate next?

  1. Inhaled salmeterol 50 mcg
  2. Oral prednisone 60 mg daily
  3. IV magnesium sulfate 2 g Correct answer.
  4. Intravenous epinephrine 1 mg push

Explanation

Intravenous magnesium sulfate is a recommended adjunct for severe asthma that responds poorly to first-line inhaled therapy and steroids. It relaxes bronchial smooth muscle and is given as a 2 g dose infused over about 20 minutes.

Question 41Pulmonary Disorders and Mechanical Ventilation

What systemic corticosteroid regimen is recommended for a COPD exacerbation requiring hospitalization?

  1. Prednisone 60 mg daily for 21 days
  2. Hydrocortisone 100 mg IV every 8 hours for 10 days
  3. Prednisone 40 mg daily for 5 days Correct answer.
  4. Methylprednisolone 125 mg IV every 6 hours for 3 days

Explanation

Guidelines recommend a short course of systemic corticosteroids, typically prednisone 40 mg daily for 5 days, which improves FEV1, oxygenation, and recovery time. Longer courses add adverse effects without additional benefit.

Question 42Pulmonary Disorders and Mechanical Ventilation

Which patient with a COPD exacerbation has the strongest indication for antibiotic therapy?

  1. New wheezing with a normal chest radiograph
  2. Isolated low-grade fever without any sputum change
  3. Increased dyspnea alone with clear sputum
  4. Increased purulence, dyspnea, and sputum volume Correct answer.

Explanation

Antibiotics are indicated when the patient has increased sputum purulence together with increased dyspnea or sputum volume, the Anthonisen criteria for a bacterial exacerbation. Patients with only one of these features or with noninfectious findings generally do not benefit.

Question 43Pulmonary Disorders and Mechanical Ventilation

A patient with ARDS has been ventilated for 24 hours. Which finding most supports initiating prone positioning?

  1. PaO2/FiO2 of 280 on FiO2 0.6 and PEEP of 8 cm H2O
  2. PaO2/FiO2 of 350 on FiO2 0.4 and PEEP of 5 cm H2O
  3. PaO2/FiO2 of 400 on FiO2 0.3 with resolving infiltrates
  4. PaO2/FiO2 of 120 despite optimized ventilation Correct answer.

Explanation

Prone positioning improves survival in moderate-to-severe ARDS, defined as a PaO2/FiO2 below 150 despite optimized ventilation, and is usually applied for at least 16 hours per day. Patients with milder oxygenation deficits have not shown the same mortality benefit.

Question 44Pulmonary Disorders and Mechanical Ventilation

Which finding in a patient with refractory ARDS best supports initiation of venovenous extracorporeal membrane oxygenation?

  1. FiO2 requirement of 0.50 with stable hemodynamics
  2. PaO2/FiO2 of 200 on FiO2 0.6 and PEEP of 10 cm H2O
  3. PaCO2 of 50 mm Hg with a pH of 7.35
  4. PaO2/FiO2 of 70 despite optimized ventilation Correct answer.

Explanation

Venovenous ECMO is considered for refractory hypoxemia, typically a PaO2/FiO2 below 80 despite optimized lung-protective ventilation, or for severe hypercapnic acidosis. It is a rescue therapy and requires that conventional management has already been maximized.

Question 45Pulmonary Disorders and Mechanical Ventilation

Which statement best describes the role of inhaled nitric oxide in ARDS?

  1. It improves oxygenation without a mortality benefit Correct answer.
  2. It shortens the duration of mechanical ventilation significantly
  3. It reduces mortality in severe ARDS
  4. It prevents ventilator-associated pneumonia

Explanation

Inhaled nitric oxide improves oxygenation by vasodilating ventilated lung units and reducing shunt, but trials have not shown a mortality benefit. Its use is therefore limited to rescue situations such as severe refractory hypoxemia or right ventricular failure.

Question 46Pulmonary Disorders and Mechanical Ventilation

A spontaneously breathing patient has a rapid shallow breathing index of 60 breaths/min/L. How should this result be interpreted?

  1. It is uninterpretable without a negative inspiratory force measurement
  2. It favors a successful spontaneous breathing trial Correct answer.
  3. It indicates the patient requires tracheostomy
  4. It predicts a high likelihood of weaning failure

Explanation

The rapid shallow breathing index is calculated as respiratory rate divided by tidal volume in liters, and a value below 105 breaths/min/L predicts a higher likelihood of weaning success. A value of 60 is well below this threshold and is favorable.

Question 47Pulmonary Disorders and Mechanical Ventilation

A patient with a massive pulmonary embolism is hypotensive and hypoxic after fluid resuscitation. Which therapy is most appropriate?

  1. Apixaban 10 mg twice daily
  2. Aspirin 325 mg chewed
  3. Alteplase 100 mg IV over 2 hours Correct answer.
  4. Unfractionated heparin infusion alone

Explanation

Hemodynamic instability defines high-risk pulmonary embolism, for which systemic thrombolysis is indicated and reduces mortality. Alteplase is given as 100 mg infused over 2 hours, followed by anticoagulation.

Question 48Pulmonary Disorders and Mechanical Ventilation

A patient with pulmonary embolism and heparin-induced thrombocytopenia requires parenteral anticoagulation. Which agent is most appropriate?

  1. Unfractionated heparin infusion
  2. Argatroban infusion Correct answer.
  3. Warfarin monotherapy at diagnosis
  4. Enoxaparin 1 mg/kg twice daily

Explanation

Heparin-induced thrombocytopenia is an immune-mediated reaction to heparin, so all heparin products including low-molecular-weight heparin must be stopped and a non-heparin anticoagulant started. Argatroban, a direct thrombin inhibitor, is a standard choice and does not require dose adjustment for renal impairment.

Question 49Pulmonary Disorders and Mechanical Ventilation

Which therapy has been shown to improve survival in patients with idiopathic pulmonary arterial hypertension?

  1. Continuous intravenous epoprostenol Correct answer.
  2. Sildenafil 20 mg three times daily
  3. Digoxin for right ventricular support
  4. High-dose nifedipine for vasoreactivity

Explanation

Continuous intravenous epoprostenol was the first therapy shown to improve survival in idiopathic pulmonary arterial hypertension and remains the standard for high-risk patients. Other agents improve exercise capacity and hemodynamics but have not consistently demonstrated a mortality benefit.

Question 50Pulmonary Disorders and Mechanical Ventilation

Which inhaled therapy for cystic fibrosis works by cleaving neutrophil-derived DNA to reduce sputum viscosity?

  1. Inhaled tobramycin
  2. Inhaled hypertonic saline 7%
  3. Inhaled dornase alfa Correct answer.
  4. Inhaled colistimethate

Explanation

Dornase alfa is a recombinant DNase that degrades extracellular DNA released by neutrophils, lowering sputum viscosity and improving FEV1. It is typically administered once daily via nebulizer as part of airway clearance.