ACCS Clinical Knowledge and Skills 2 — Questions and Answers
Question 1: A patient with ARDS is on mechanical ventilation with FiO2 0.8 and PEEP 14 cmH2O. PaO2 is 58 mmHg. What is the most appropriate next intervention?
- Increase FiO2 to 1.0
- Initiate prone positioning (Correct answer)
- Decrease PEEP to reduce barotrauma
- Administer IV furosemide
Correct answer: Initiate prone positioning
Prone positioning improves V/Q matching and oxygenation in moderate-to-severe ARDS (PaO2/FiO2 <150) when conventional ventilation fails.
Question 2: Which hemodynamic pattern is most consistent with cardiogenic shock?
- High CO, low SVR, low PCWP
- Low CO, high SVR, high PCWP (Correct answer)
- Low CO, low SVR, low PCWP
- High CO, high SVR, high PCWP
Correct answer: Low CO, high SVR, high PCWP
Cardiogenic shock is characterized by reduced cardiac output, elevated systemic vascular resistance (compensatory), and elevated pulmonary capillary wedge pressure reflecting fluid backup.
Question 3: A patient develops sudden severe hypertension, diaphoresis, and bradycardia after a spinal cord injury at T4. What is the priority intervention?
- Administer IV labetalol
- Sit the patient upright and identify the noxious stimulus (Correct answer)
- Increase IV fluid rate
- Apply cooling blankets
Correct answer: Sit the patient upright and identify the noxious stimulus
Autonomic dysreflexia requires immediate upright positioning and removal of the precipitating stimulus (e.g., bladder distension) to relieve the hypertensive crisis.
Question 4: Which acid-base disturbance is expected in a patient with prolonged nasogastric suction?
- Metabolic acidosis with anion gap elevation
- Metabolic alkalosis with hypochloremia (Correct answer)
- Respiratory alkalosis
- Normal anion gap metabolic acidosis
Correct answer: Metabolic alkalosis with hypochloremia
Loss of hydrochloric acid via NG suction causes metabolic alkalosis accompanied by hypochloremia and often hypokalemia.
Question 5: A patient receiving total parenteral nutrition develops hyperglycemia, elevated serum osmolality, and altered mental status without ketosis. What complication is most likely?
- Diabetic ketoacidosis
- Hyperosmolar hyperglycemic state (Correct answer)
- Refeeding syndrome
- Sepsis-induced encephalopathy
Correct answer: Hyperosmolar hyperglycemic state
Hyperosmolar hyperglycemic state presents with extreme hyperglycemia, elevated osmolality, and altered mentation without significant ketoacidosis.
Question 6: Which finding on a 12-lead ECG is most specific for hyperkalemia at life-threatening levels?
- Prolonged PR interval
- Sine wave pattern (Correct answer)
- ST elevation in V1-V2
- Tall T waves in precordial leads
Correct answer: Sine wave pattern
A sine wave pattern on ECG represents severe, life-threatening hyperkalemia where P waves disappear and QRS complexes merge with T waves.
Question 7: In managing elevated intracranial pressure, which intervention is CONTRAINDICATED?
- Head of bed elevation to 30 degrees
- Hypotonic IV fluid administration (Correct answer)
- Short-term hyperventilation to PCO2 35 mmHg
- Osmotic therapy with mannitol
Correct answer: Hypotonic IV fluid administration
Hypotonic fluids lower serum osmolality and worsen cerebral edema, making them contraindicated in elevated ICP management.
ACCS Clinical Knowledge and Skills 2
A patient with ARDS is on mechanical ventilation with FiO2 0.8 and PEEP 14 cmH2O.
PaO2 is 58 mmHg.
What is the most appropriate next intervention?