CCRN QUESTIONS And Answers Rated 100% Correct

CCRN QUESTIONS The nurse is caring for a patient with acute inferior wall MI, post-coronary artery stent deployment, For optimal care of the patient, the nurse should: - ANS Continuously monitor the patient in lead II It is best practice to monitor the patient status post PCI with stent, in the lead that was most abnormal during the acute occlusion. The ECG demonstrates ST elevation in leads II, III and aVF. The nurse needs to monitor the patient closely for which of the following? - ANS Complication likely to occur after an acute inferior wall MI include bradycardia secondary to ischemia to the SA and/or AV node, and papillary muscle rupture or dysfunction due to the anatomical distance between the RCA and the papillary muscle. Which of the following hemodynamic profiles would benefit from the aggressive fluid administration, pressers and antibiotics therapy? a. RAP: 1mm Hg; PAOP: 4 mmHg; SVR: 1800 dynes/sec; CO: 2L/min b. RAP: 5; PAOP: 7; SVR: 400; CO; 8L - ANS B. the hemodynamic profile of RAP 5, PAOP 7, SVR 400 is typical of septic shock, and choice B would be the best approach. Which of the following is indicative of a mixed acid-base disorder? A. pH 7.18; PaCO2 25; PaO2 64; HCO3 11 B. pH 7.33; PaCO2 29; PaO2 72; HCO3 15 - ANS The decrease in PaCO2 is evidence of respiratory alkalosis and the decreased HCO3 is evidenced of a metabolic acidosis. The pt with severe sepsis or septic shock may present with this mixed acid-base disorder. The patient with a temporary pacemaker develops pacemaker malfunction. The oriented is instructed to reposition the patient to try and correct the problem. The cardiac monitor most likely demonstrates? - ANS Failure to capture (pacemaker without a QRS) may be corrected by repositioning the patient to the side. The patient with diastolic heart develops SVT, heart rate 220/min. The most dangerous hemodynamic effect is a decrease in: - ANS coronary artery perfusion. Diastolic heart failure results in a problem with left ventricular FILLING secondary to ventricular thickening, and contractility and ejection are maintained in diastolic failure. The rapid heart rate will decrease filling time, worsen left ventricular filling and because coronary artery perfusion occurs during diastole, this arrhythmia may be life-threatening. The patient is receiving heparin infusion for the treatment of pulmonary embolism. There has been a 60% decrease in the platelet count and no clinical change. Which of the following is indicated? - ANS Discontinue heparin and being argatroban. The patient most likely has HIT. Exposure to heparin needs to discontinued and a direct thrombin inhibitor started for continued anticoagulation. The patient with oat cell carcinoma has the following clinical findings: low urine output, low serum osmolality, hyponatremia, and elevated urine sodium. The nurse anticipates which of the following as part of the treatment plan? - ANS Phenytoin (Dilantin), 3% saline. The patient has signs of SIADH which results in production of excessive ADH. Dilantin will inhibit ADH secretion and 3% saline will increase serum sodium. Peep therapy and mechanical ventilation are ordered for the patient with acute respiratory failure. Which of the following is a possible complication? - ANS Barotrauma The addition of positive end-expiratory pressure will increase alveolar recruitment, prevent atelectasis and improve oxygenation. However, the increase in intrathoracic pressure may lead to pneumothorax or subcutaneous emphysema. The postoperative thoracic surgery patient has bubbling in the water seal drainage chamber of the chest tube. Which of the following interventions is indicated? - ANS avoid high airway pressures Bubbling in the water seal chamber is due to a pleural air leak, and high airway pressure will either prevent resolution of the current air leak or make it worse. Which clinical sign might patients with both systolic and diastolic heart failure have in common? - ANS Lung crackles Both a problem with systolic (ejection problem) and diastolic (filling problem) will increase left heart pressure and cause cardiogenic pulmonary edema (lung crackles). Which of the following is most likely to result in a low Sv02? A. Hypotermia B. Fever C. Severe sepsis - ANS Fever Fever increases metabolic rate and consumption, which may lead to a drop in mixed venous oxygen saturation. The nurse needs to assess adequacy of the tubing/catheter system for the arterial line. Which of the following interventions will best assess this? - ANS Perform a square wave test The patient requires fluid resuscitation and 8 units of PRBC's status post traumatic injury. Which of the following interventions is most appropriate? - ANS Warm blood products and crystalloids Warming fluids and blood needed for traumatic injury will prevent hypothermia and its related adverse effects. Which of the following therapies should be avoided for the patient with cardiogenic shock? - ANS high dose vasopressors Vasopressors increase left ventricular after load, which would increase myocardial work of a failing heart. The patient is status post repair of an aneurysm for subarachnoid hemorrhage. Which of the following interventions is indicated to prevent vasospasm? - ANS Nimodipine (Nimotop) is a calcium channel blocker that is started immediately post-op to prevent arterial spasm of the brain. The patient presents with a rigid abdomen, rebound tenderness, and a free air in the peritoneum seen on KUB x-ray. Which of the following should the nurse anticipate? - ANS Powell perforation; provide fluids, prepare for surgery. The clinical signs are those of bowel perforation. Which is the priority treatment for the pt with DKA who presents with hyperglycemia, ketosis, and normal serum potassium? - ANS replace potassium The patient with DKA will have a low pH and metabolic acidosis. In a state of metabolic acidosis, hydrogen ions move into the intracellular space. In exchange, potassium leaves the intracellular space. The movement of K into the extracellular space results in hyperkalemia. Which of the following is a systemic effect of the therapeutic hypothermia during the cooling phase? - ANS Hyperglycemia secondary to insulin resistance. During the cooling phase of clinical hypothermia there is typically insulin resistance. Additionally, during the phase there is vasoconstriction, decreased neutrophil production and during rewarming, rebound hyperkalemia may occur (not during the cooling phase). The patient presented to the ED with a history of palpitations and dyspnea, persisting on and off for one week. The heart monitor shows trail fibrillation with rapid ventricular response, blood pressure 112/70. Treatment will most likely include: - ANS CCB and anticoagulation The patient history seems to be one of intermittent atrail fibrillation over the past week. Controlling rate and addressing potential left atrial clot formation are priority treatments. Which of the following clinical findings would you expect to find in the patient with septic shock? - ANS Lactate 8, SvO2 85 Elevated lactate is evidence of anaerobic metabolism and elevated Sv02 is evidence of decreased oxygen utilization at the cellular level - both definitive for septic shock. The patient has a massive pulmonary embolism. Which of the following would be expected? - ANS Hypotension, increased alveolar dead space. Massive pulmonary embolism results in sudden extremely elevated pulmonary pressures with resultant right ventricular failure and decreased left ventricular pressure. The drop in CO results in hypotension. The clot obstructs pulmonary perfusion which results in increase headspace ventilation. The patient presents with left leg pain; ankle-brachial index (ABI) is 0.7. The patient would benefit from which of the following interventions? - ANS dependent position of legs The clinical signs are indicative of peripheral arterial occlusive disease. Dependent leg position will aid perfusion. Which of the following are clinical signs of variant (Prinzmetal's) angina? - ANS ST-elevation, resolves with nitrate therapy. This type of angina is thought to be due to arterial spasm at the point of coronary artery plaque, not due to plaque rupture. The ST elevation is transient because the spasm is relieved with nitrates; therefore infarction does not occur. The most specific clinical sign for the presence of brain death would include which of the following? - ANS Absent oculocephalic reflex If eyes remain midline or turn to the side of head rotation, it is a sign of cranial nerve VIII damage and possible brain death. The apnea test is positive in the presence of brain death; while coma is present during brain death, most patients with coma do not have brain death. The physician determines the patient has ARDS. The patient has developed refractory hypoxemia, bilateral infiltrates, and pulmonary edema on chest x-ray. What findings would be expected? a. increased lung compliance b. PAOP normal or low c. decreased cardiac output - ANS b. The pulmonary edema of ARDS is due to lung capillary leak at normal or even low left heart pressure, unlike cariogenic pulmonary edema, which results in pulmonary edema at higher than normal left heart pressure. The patient presents one month status post gastric bypass bariatric surgery with vomiting, headache, diplopia, and memory loss. These are clinical signs of which of the following? - ANS Malabsorption The signs and symptoms are those of malabsorption, which results in vitamin deficiency and may occur after bariatric surgery. The remaining choices are not manifested by the signs and symptoms described. Priority treatment for aortic dissection requires which of the following? - ANS Aggressive management of hypertension and emergent surgery. Emergent surgery is essential for survival, and blood pressure control is essential preoperatively. Pain control and transfusion may be indicated, but the remaining therapies are not beneficial. Inferior MI is associated with? - ANS RCA occlusion AV conduction disturbances: 2nd- degree Type 1, 3rd- degree heart block, Sick sinus syndrome, and sinus bradycardia Development of systolic murmur: mitral valve regurgitation secondary to papillary muscle rupture Also associated with RV infarct and posterior MI Right Ventricular Infarct S&S: What to avoid: - ANS JVD at 45 degrees High CVP Hypotension Usually clear lungs Bradyarrhythmias Avoid Preload reducers - nitrates, diuretics and caution with beta blockers Anterior MI Reciprocal changes in LAD? May develop? - ANS reciprocal changes (ST depression) in inferior wall (II, III, aVF) may develop 2nd degree type II or RBBB (the LAD supplies the common bundle of HIS)...ominous sign. Higher mortality than inferior: Heart Failure Complications of PCI: - ANS Stent thrombosis is most likely to be on the test (most incidents occur acutely within 24hours of stent placement or sub acutely within the first 30 days. Retroperitoneal bleed is most likely to be on test What two drugs do you use for HTN crisis/emergency? - ANS Nitroprusside and Labetalol Nitro is a preload and afterload reducer. Assess for cyanide toxicity secondary to drug metabolite (Thiocyanate): mental status change (restlessness, lethargy), tachycardia, seizure, a need for increase in dose. Tests to use for PAD? - ANS Ankle-brachial Index - used to access lower extremity perfusion; normal is greater than 1 Doppler ultrasound testing Arteriography Position for PAD patient? - ANS Bed in reverse Trendlenburg Do NOT elevate the affected extremity - will decrease perfusion Meds: Thromolytics, Anticoagulants, ASA, Vasodilators Drugs that cause Prolongation of the QT interval ? - ANS Procainamide, haloperidol, quinidine, amiodarone Electrolyte problems: hypokalemia, hypocalcemia, hypomagnesemia Pacemaker code: - ANS First initial: Paced 2nd initial: Sensed 3rd: inhibited What is contraindicated with Diastolic heart failure? - ANS Positive inotropes Dehydration further worsens filling Tachyarrhythmias decrease filling time and worsen symptoms Chest x-ray finding in systolic heart fx? - ANS may be evidenced by large, dilated heart or by normal heart size on chest film. Causes of Right side heart failure? - ANS Acute RV infarct Pulmonary Embolism Septal defects Pulmonary stenosis/regurgitation COPD Pulmonary htn Left Ventricular fx Cause of Left sided heart failure? - ANS CAD, ischemia Myocardial infarction Cardiomyopathy Fluid overload Chronic, uncontrolled htn Aortic stenosis/insufficiency Mitral stenosis/insufficiency Cardiac tamponade IABP: Inflates and deflates when? - ANS Inflates at the dicrotic notch of the arterial waveform, beginning of diastole Defeats right before systole begins - determined by set trigger for deflation, R wave of ECG or upstroke of the arterial pressure wave Post-Op CABG Assessment for complications of CABG: - ANS Tamponade Pericarditis Mediastinal tubes remove what? - ANS serosanguinous fluid from the operative site; whereas pleural chest tubes remove air, blood, or serious fluid from the pleural space. Treatment of Aneurysms: - ANS Aneurysms less than 5cm in diameter and no symptoms: Monitor regulary - ultrasound or CT scan, treat htn: drug choice is beta blockers, which may slow growth. Thoracic aneurysms causing symptoms or greater than 6cm: Surgical repair Disection: Surgery Aggressive treatment of htn and heart rate control - labetalol drip Neuro Assessment: First sign of a neuro problem? - ANS LOC - except for an epidural hematoma that may cause pupil changes before an LOC change. GSC Score: - ANS 15 (best) 3 (worst) If the score is 8 or less, outcome is poor Which is worse, obtunded or stuporous? - ANS Stuporous - pt cannot speak, moan, grimace. Obtunded - can speak, mumble words. Uncle Herniation: - ANS Lateral shift, NO initial change in LOC Most often caused by epidural hematoma that occurs in temporal area, some strokes Central Herniation: - ANS Swelling on both sides, downward displacement of hemispheres Slight change in LOC and then coma First both pupils are small (1-3mm) then parasympathetic innervation on both sides is suppressed and both pupils dilate Treatment of Vasospasm? - ANS Prevent vasospasm by providing CCB - nimodipine (Nimotop) 60mg q 4hrs, for aneurysmal SAH The first sign of an increase in ICP? - ANS LOC since the "higher" centers of the brain show symptoms first and then progress down toward the brain stem. Hypotension in the presence of Elevated ICP? - ANS Can be devastating!!! Higher MAP is better than low MAP Brain death is less 30mmHg s&s of increased ICP? - ANS Altered LOC Restlessness/agitation Headache Pupillary changes When using the fluid-filled system, the level of the transducer should be at the? - ANS External auditory meatus, which is at the level of the foramen of Monro Neuro Waves? - ANS "A" are awful "B" are bad "C" are common In the presence of Elevated ICP: AVOID? - ANS Acidosis - causes vasodilation which increases ICP Alkalosis - causes vasoconstriction which decreases flow to head. PEEP - increases thoracic pressure, prevents optimal jugular venous outflow Strategies to Lower ICP? - ANS Decrease volume: mannitol/furosemide/3% saline, patient position (upright to facilitate venous drainage from the brain) Propofol has been demonstrated to reduce ICP by as much as 15mmHg Difference between Bacterial and Viral meningitis? - ANS Bacterial has lower glucose Apnea test: Positive or Negative to support brain death? - ANS Positive supports brain death. When administering sodium pentobarbital (Nembutal) to a patient with a closed-head injury, the goal is ? - ANS Reduce cerebral metabolism This med will decrease seizure activity which are important to stop in this kind of injury. A patient with longstanding COPD is currently intubated and mechanically ventilated, has a cardiac monitor, and has an arterial line in his left radial artery. A nurse should be concerned with monitoring the ? - ANS Telemetry for arrhythmias A patient with a history of HTN and renal failure reports a headache: BP: is 210/126 HR: 106 RR: 22 - Which drug is the preferred choice? - ANS Labetalol (Trandate) is the drug of choice. giving Nitroprusside would be bad due to patient having renal failure. A patient with an inferior wall MI has sinus bradycardia with a BP 110/70 and HR 52. A nurse should plan to ? - ANS Continue to monitor vital signs A patient is at the highest risk of developing aspiration pneumonia? - ANS Pt with endotracheal intubation with nasogastric tube Which of the following physiological changes should a nurse anticipate when caring for a postoperative pt with morbid obesity ? - ANS Decreased functional residual capacity Which fluid is the initial treatment for severe DKA? - ANS IV fluids 0.9% Which of the following complicating factors is the most crucial in the care of a critically ill patient with CKD? - ANS Volume status, electrolyte imbalance, and vascular access A pt with a diagnosis of small bowel obstruction has a Miller-Abbott tube in place. A nurse's first priority in the management of this tube is to? - ANS Connect the tube to low intermittent suction A pt who is suspected to have developing SIRS, a nurse should monitor for? - ANS WBC of 14,000 and HR 123 Leukocytosis and tachycardia, along with hyper/hypothermia and tachypnea, are the defining criteria for SIRS ABG of early STATUS ASTHMATICUS? - ANS Respiratory Alkalosis Lab values of increased INR, PTT, and FSP. Hgb, platelets, and fibrinogen are decreased. These values indicate what? - ANS DIC The goal of permissive hypothermia is to do what? - ANS decrease the ICP 15 or less. Higher readings exert pressure on the structures of the brain and impede adequate blood flow to the brain. During resuscitation phase of caring for a patient with a liver injury from acute abdominal blunt force trauma, the focus should be to ? - ANS stabilize hemodynamics What lab value is consistent with Rhabdomyolysis? - ANS hyperkalemia and hypocalcemia Is pulmonary fibrosis related to Status Asthmaticus? - ANS PF is generally idiopathic and unrelated to Status Asthmaticus Which of the following alterations in pulmonary status is most likely to occur in a pt with status asthmaticus? - ANS Hyperinflation Which acid-base problem is mostly seen in pts with renal failure? - ANS metabolic acidosis A pt develops extreme dyspnea, anxiety and coughing, with expectoration of pink frothy sputum. Also has s3 gallop. What do you think this is? - ANS Pulmonary edema Use of histamine blockers can increase the risk of ? - ANS nosocomial pneumonia A patient with a history of a-fib developed arm weakness, blurred vision, and facial droop 5 hours ago. What should the nurse initially anticipate? - ANS a non-contrast CT scan to determine if it is ischemic or hemorrhagic stroke What signs would indicate that the pt is not tolerating the ventriculostomy? - ANS Leakage from the ventriculostomy site. Causes of Pancreatitis ? - ANS *Destruction of gallstones and pancreatic ducts *Alcoholism Trauma What disturbances do you develop during pancreatitis? - ANS Hypocalcemia and HHNK (hyperglycemia),left sided atelectasis and left sided pleural effusion and bilateral rales. What do people with pancreatitis die from? - ANS ARDS - it kills type II alveolar cells Why do people with liver dz not clot well? - ANS they don't have prothrombin and fibrinogen High levels of ammonia leads to what? - ANS hepatic encephalopathy Why do you not want people with liver dz to develop low potassium levels? - ANS because of the kidney will hold onto potassium which leads to high ammonia levels. BUN in liver dz? - ANS breakdown of BUN releases ammonia - so make sure patient is not dehydrated because this will lead to high levels of BUN Do you want people with liver dz to have high levels of protein? Why not? Do you want people with liver dz to have an increase in acid? - ANS No - it leads to ammonia which will lead to hepatic encephalopathy No! Metabolic acidosis due to low BP Do you give Ringers Lactate to someone with Liver dz? - ANS No! It cannot convert to bicarb because of the liver dz - it will convert to lactic acid Which medication do you give to someone with liver dz? - ANS Neomycin - because it does not release ammonia, BUT it leads to Vitamin deficiency How to tell if you have hepatic failure or billiary tract dz? - ANS Bilirubin and albumin are unconjucated until they go to the liver, where they get conjucated and go to the gallbladder. If someone has indirect or unconjucated bilirubin is it hepatic failure or billiary tract dz? - ANS Hepatic failure Opposite would be gallbladder problem Ruptured spleen has what signs? - ANS Kehrs sign - left shoulder pain What does diuretics do to someone with liver dz? - ANS Lowers their potassium Pre renal failure: - ANS kidneys are healthy, but blood is not getting down to the kidneys, so no urinary output. TX: FLUIDS or INOTROPIC DRUGS Renal stage of acute renal failure: - ANS Kidney damage - most common cause is acute tubular necrosis Nephrotoxicity is caused by: - ANS eating heavy metals/Meds/street drugs/ rhabdomyolysis How to tell Pre renal vs Renal? - ANS Pre renal - needs fluids and inotropic drugs - check urinary sodium level: 20 or less is pre renal. Check BUN/Creatinine levels: BUN 20:1 or Bun of 60 and creatinine of 3 is pre renal Renal - urinary sodium level: 40 or more is renal stage. BUN/Creatinine levels: BUN 10:1 Bun of 60 and Creatine 6 is Renal Treatment for hyperkalemia ? - ANS Calcium chloride and insulin and glucose and sodium bicarbonate People with kidney dz always have a low what? - ANS Calcium or high phosphate levels. This will lead to C&T signs. Low potassium levels S&S? - ANS U wave and ST depressions Sympathetic Nervous System increases what? - ANS Heart rate and contractility which maintains B/P Compensatory Phase of Shock: - ANS B/P maintained Tachycardia Skin pale, cool (except in early sepsis) Progressive Phase of Shock: - ANS Hypotension Clammy, mottled skin Further change in LOC Refractory Phase of Shock: - ANS Multisystem organ dysfunction Hypovolemic Shock effects on pulse pressure: - ANS NARROW pulse pressure Systolic decreases, diastolic maintains or elevates Do you give pressors for Hypovolemic shock? - ANS No! SVR is already high due to compensatory mechanism SIRS criteria: - ANS Must have 2 or more of the following: Temp 38*C or 36*C Heart rate 90 Resp 20 bpm WBC 12,000 or 4,000 OR bands 10% (shift to the left) Sepsis clinical manifestations: - ANS must include 2 or more of the SIRS criteria plus a documented infection (culture) or suspected infection. Suspected infection is the presence of one or more of the following: *positive culture results from blood, sputum, urine, etc. *receiving antibiotic, anti fungal, or other anti-infective therapy *altered mental status in elderly *possible pneumonia (infiltrate on chest radiograph) Severe Sepsis: - ANS sepsis PLUS markers of organ dysfunction. Examples of organ dysfunction: Hypotension Acute hypoxemia Lactate greater than 2 Platelets below 100,000 Septic shock: - ANS septic shock is severe sepsis plus one of the following: *Systemic MAP 65mmHg despite adequate fluid resuscitation *Maintaining the MAP65 requires a pressor, e.g., levo, dopamine, epi. S&S of early Septic Shock: S&S of late Septic Shock: - ANS Tachycardia, bounding pulse B/P normal or low Skin warm, flushed Respirations deep, somewhat fast Fever (temp38C) Hypotension Tachycardia, pulse weak and thready Skin cool, pale Temp 36C The patient with severe sepsis or septic shock always has positive blood culture T/F? - ANS True What is the reversal agent for benzodiazepine? - ANS Flumazenil (Romazicon) Tylenol poisoning: - ANS N-acetylcysteine (MUCOMYST), dosing effective for 8 hours after ingestion GI lavage with activated charcoal within 4 hours of after ingestion *Tylenol damages the liver: I - nausea II - RUQ pain III - Liver function abnormalities Cocaine poisoning: - ANS Activated charcoal, fluids, glucose, thiamine IV, cooling for hypothermia Salicylates (ASPRIN) poisoning: - ANS Activated charcoal, urine alkalization (bicarb), dialysis *causes Renal Tubular Acidosis Tricyclic antidepressants poisoning: - ANS Sodium bicarb, activated charcoal, fluids, cardiac monitoring Disseminated Intravascular Coagulation: - ANS Primary problem is clotting. Clotting turns into fibrin split products which make you bleed even more. Labs of DIC: - ANS *Decreased Fibrinogen levels* Increased or prolonged PT and PTT values Increased Fibrin Split Products Increased D-dimers values How do you treat people with DIC? - ANS HEPARIN, then fresh frozen plasma, then cryoprecipitate (8,13, fibrinogen) Get rid of the triggering event/cause Heparin: - ANS Heparin inhibits the conversion of prothrombin into thrombin Heparin inactivates circulating thrombin Heparin inhibits the conversion of fibrinogen into fibrin Heparin Induced Thrombocytopenia: - ANS In patients who do not have anti-thrombin III. Heparin may have the opposite effect, thus causing blood to clot. Idiopathic (immune) Thrombocytopenic Purpura: - ANS In ITP antibodies form and destroy the body's platelets resulting in thrombocytopenia Etiologies: Bone Marrow does not produce enough platelets Platelets become entrapped in enlarged spleen Use or destruction of platelets increases ITP s&s - ANS Platelets are less than 50,000 Both Hb and HCT are decreased Pallor, petchiae, purpura, ecchymoses, and oozing of blood from venipuncture sites Difference between DIC and ITP: - ANS DIC has increased fibrin splits products whereas ITP does not Multisystem Trauma: Know what? - ANS AMPLE a- allergies m- meds p- past illnesses l - last meal e- event preceding injury Release of what substance into the circulation secondary to retained dead fetus, abruptio placenta, and stress may cause disseminated intravascular coagulation? - ANS Tissue thromboplastin The beneficial effects of heparin in DIC are thought to be due to its: - ANS Neutralizing of free-circulating thrombin Complications of PEEP? - ANS Barotrauma (rupture of lung tissue) Renal transplant acute rejection occurs within? - ANS 1-2 weeks A-sline, dicrotic notch is the closure of ? - ANS aortic valve. ARDS...Keep patient what? Acidosis causes what? - ANS keep patient dry (decrease fluids) Increased potassium levels A 55-year-old man has had an anterior myocardial infarction. He developed a third-degree AV heart block and required insertion of a temporary transvenous pacemaker. The pacemaker is functioning in VVI mode. The rhythm strip shows pacing spikes landing indiscriminately in relation to the patient's inherent rhythm. Which of the following would be the best action to correct the situation? - ANS Increase the sensitivity If a nurse were to leave her unit and the hospital after deciding that staffing was inadequate, which ethical principle would be violated? - ANS Fidelity - refers to an individual's faithfulness or loyalty to agreements and responsibilities that the individual has accepted. If you have agreed to work a shift and you do not arrive to work or you leave work before the end of your shift, you have violated the ethical principle of fidelity. Diuretics can cause both hypokalemia and metabolic alkalosis T/F? - ANS True How would carbon dioxide levels change with an increase in minute ventilation? - ANS PaCO2 levels would go down, and end-tidal carbon dioxide would go down. An increase in minute ventilation would increase ventilation, so the PaCO2 and the end-tidal carbon dioxide would go down. Remember that the PetCO2 is usually 1 to 5 mm Hg below the PaCO2. Acute pancreatitis causes elevations in serum amylase, serum lipase, and possibly bilirubin, whereas calcium and albumin are decreased T/F? - ANS True The primary result of carbon monoxide poisoning is: - ANS Hypoxia Which of the following sign or symptom is most specific to a small-bowel obstruction? - ANS Vomiting of fecal matter Remember that time is muscle, so reperfusion is the priority. Also remember an actual problem (decreased contractility) takes priority over a potential problem (dysrhythmias) T/F? - ANS True patient returns to the critical care unit after insertion of a transvenous pacemaker. There are pacing spikes not followed by a QRS. Which of the following is a method to facilitate capture during pacing? - ANS Increase milliamperage Consider that failure to capture occurs when the electricity from the pacemaker does not cause depolarization of the ventricle (or atria if an atrial pacemaker). It would be logical to consider using more electricity (i.e., milliamperage). Which of the following statements about colloids is correct? - ANS They increase intravascular colloidal oncotic pressure. She has had a craniotomy to evacuate the clot, and an intraventricular catheter was placed during surgery. While the nurse is monitoring the patient's intracranial pressure (ICP), the pressure climbs to 40 mm Hg but returns to 15 mm Hg almost immediately. This describes which of the following? - ANS B wave Normal ICP has a pressure of 5 to 15 mm Hg. An elevation of ICP to 20 to 50 mm Hg occurring every 30 seconds to 2 minutes is a B wave. An elevation of ICP to 50 to 100 mm Hg lasting longer than 2 minutes is an A wave. An elevation of ICP to 20 to 25 mm Hg every 4 to 8 minutes is a C wave. What three things tell you heart catheter has flipped back into right ventricle? - ANS Three things tell you that the catheter has flipped back into the right ventricle: drop in diastolic pressure, loss of dicrotic notch, and initiation of ventricular ectopy. Which of the following is the preferred lead for ST segment monitoring for a patient with a suspected left anterior descending (LAD) artery occlusion? - ANS V3 Normal osmolality of body fluids? - ANS 275-295 Normal urine osmolality? - ANS 1.010 - 1.020 What is the biggest danger to hyponatremia? - ANS Seizure What is the dilute urine range of DI? - ANS 1.001 - 1.005 Treatment of DI? - ANS Give ADH (Pitressin, DDAVP) Characteristics of DKA? - ANS Blood sugar: 250 Elevated potassium in the presence of acidosis, although total body potassium is low, it decreases as acidosis is corrected Younger/Type 1 diabetes Insulin production: No Breathing pattern: Kussmaul Tx for DKA: - ANS Insulin, fluids 0.9 saline, 0.45 saline (if sodium high and B/P normal or high) Decrease blood sugar by 50-100 mg/hr Add dextrose to IV fluids after serum glucose reaches - 250mg Continue insulin infusion until acidosis is resolved Characteristics of HHNK: - ANS Older Type 2 diabetes Pancreatitis 600 blood sugar Insulin production: Yes Serum K: Often elevated due to insulin deficiency Tx for HHNK: - ANS Fluids, insulin 0.9 saline Decrease blood sugar by 50-100mg/hr Add dextrose to IV fluids Definitive test for DIC: - ANS FSP Normal: 10 Fibrinogen is 200-400 Tx for DIC: - ANS Eliminate the cause Vit K Platelets FFP (Fresh frozen plasma) Cryoprecipitate Heparin (low dose) is controversial so may not see it on test. S&S of HIT: - ANS Platelets 150,000 or drop 30% to 50% Early sign - PETECHIAE Clots may lead to PE, MI, stroke, amputation Tx for HIT: - ANS Stop HEPARIN (fractionated as well as unfractionated) Test for presence of heparin antibodies, ELISA, but do not wait for test results to stop heparin and start treatment Start warfarin Platelets 10,000, monitor for changes in LOC (intracranial bleed) What is decreased in Cardiogenic shock: - ANS BP CI/CO SvO2 Everything else is increased: RAP/PAOP/PAP/SVR/PVR What is increased in hypovolemic shock? - ANS SVR Everything else is decreased What is increased in Septic shock (early)? - ANS CO/CI/SV/SvO2 What is increased in Septic shock (late)? - ANS Just SVR and maybe PAOP What is decreased in pulmonary edema? - ANS CO/CI/SV/SvO2 What does dopamine do in medium (4-10) dose and high (11-20) dose do? Also, Levo/Neo and EPI doses? - ANS It increases everything: B/P CO/CI SVR/PVR HR PAP/RAP/PAOP What does Nitro do? - ANS It decreases everything except in cases of high dosage which could increase CO/CI/HR indirectly by decreasing Afterload What does Dobutamine do? - ANS It decreases PAOP/SVR It increases CO/CI/HR Preload therapies: Increases? - ANS Volume expanders: Crystalloids Colloids Pressors Preload therapies: Decreases? - ANS Diuretics Dilators: nitrates/nitroprusside/nesiritide Morphine After load therapies: Increases? - ANS Levo Neo High-dose dopamine Epi drip After load therapies: Decreases? - ANS Nitroprusside ACE Hydralazine CCB IABP Nitro (high doses) Contractility therapies: Increases? - ANS Positive Inotropes: Dobutamine Dopamine 5-10mcg/kg/min Primacor Epi drip Contractility therapies: Decreases? - ANS Negative inotropes: Beta blockers/CCB Metabolic problems: Metabolic acidosis/endotoxins of sepsis SvO2 Increases/decreases? - ANS Septic shock Hypothermia Paralysis Decreases: Low C/O Decreased PaO2 02 demand (fever, shivering, seizures, increased WOB) Giant V waves is most likely caused by? - ANS Mitral Valve Insufficiency TIA RIND Cerebral Infarct - ANS Transient Ischemic Attack - some one has a stroke, 24hrs later they're better. Reversible Ischemic Neuro deficit - same as TIA, except it takes three about 3 months to get better. Stroke - problem is caused by basal vestibular artery. Lacking blood to brain stem. When you have a stroke - what is the goal? - ANS Reduce cerebral edema. Give d5w Problem with the cortex? - ANS Decorticate Brainstem problem? - ANS Decerebrate Positive babinski in both feet - problem with what? - ANS Problems on both sides of your head. parasympathetic innervation makes pupil what? Sympathetic innervation makes pupil what? - ANS Pinpoint Dilates Lateral shift in the brain is called what? - ANS uncal herniation - first change is pupil dilation on affected side. Uncal herniation - don't give this? - ANS Mannitol - Supertorial herniation? - ANS Whole brain is coming down - change in LOC, then dilated pupils on both sides, then hyperventilation (to decrease ICP), last thing you get is Cushings dz. Cushing Dz? Tx? - ANS Brain is coming down through foramen magnum Widening pulse pressure (120/70, 200/70) RESP and HR Tx: Mannitol Does acidosis increases ICP? - ANS Yes - keep them alkalotic Do you give Dextrose or D5W to someone with ICP? - ANS NO! Decrease protein intake Wrist restraints ICP ICP - MAP = - ANS CPP - normal is 70-95 Basal skull fx: - ANS Raccoon eyes Battle signs Mastoid bone (black and blue) Leak CSF (check for glucose to confirm) Lose cranial nerve # 1 (can't smell) Bacterial vs Viral meningitis ? - ANS Bacterial is caused by staph problem usually. Has lower glucose CSP is purulent Leukocytes present Viral is caused by entero virus or herpes virus Glucose level is normal Kernig's sign? - ANS extend leg out and get pain in the neck. When you have a stroke - what is the goal? - ANS