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AGACNP SPRING 2024 EXAM 2 QUESTIONS WITH 100% CORRECT ANSWERS!!
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AGACNP SPRING 2024EXAM 2 QUESTIONS
WITH 100% CORRECT
ANSWERS!!
AGACNP
Evatee 9/16/24 AGACNP
,AGACNP SPRING 2024 EXAM 2 QUESTIONS
WITH 100% CORRECT ANSWERS!!
A 23-year-old man is brought to the emergency department after being found
obtunded on the street. The history suggests that he may have ingested 180
mg of his friend's methadone during a suicide attempt. On arrival he has a
Glasgow Coma Scale (GCS) score of 6, with hypoactive bowel sounds and
pinpoint pupils. His initial vital signs are temperature 36C, heart rate 56/min,
blood pressure 103/70 mm Hg, respiratory rate 6, and oxygen saturation 84%
on room air. Blood glucose is 4.6 mmol/L. Initially, his ventilation was
supported through bag-valve-mask (BVM) apparatus but after three doses of
0.4 mg IV naloxone there is improvement in his respiratory effort. He is
transferred to the ICU. What is the most appropriate management?
A. Intubation for airway protection
B. Naloxone boluses as needed plus activated charcoal
C. Naloxone infusion at 0.4 mg/h
D. Naloxone infusion at 0.8 mg/h Answer - The correct answer is D.
Rationale: This patient's presentation is consistent with opioid toxicity.
Immediate resuscitation and administration of antidotal therapy are the most
important initial steps in management. Given the hypoxia and bradypnea,
supplemental oxygen without assisted ventilation is of minimal benefit. As a
disease of hypoventilation, opioid toxicity requires ventilation. This is achieved
through BVM and administration of opioid antagonists. Methadone is a long-
acting opioid, with expected clinical toxicity to last beyond 24 hours. The
proper dosing of a naloxone infusion per hour is 2/3 the dose required to
adequately reverse the patient. This patient responded to 1.2 mg IV naloxone,
so the infusion dose should start at 0.8 mg/h (choice D is correct). If naloxone
was not available, intubation would be an option, but there is no need to do so
at this time (choice A is incorrect). Methadone is a liquid product with rapid
absorption, so activated charcoal would be of no benefit and potentially
,harmful as the fluctuating level of consciousness may result in aspiration, and
lower doses of naloxone would be insufficient (choices B and C are incorrect).
A 48-year-old woman is brought in after being found unconscious in a house
fire. She was intubated in the emergency department and transferred to the
ICU for further management. She received 2L IV Ringer lactate and is now on a
norepinephrine infusion. Her Glasgow Coma Scale (GCS) score has remained at
3 since arrival. Her vitals are temperature 37.2 C, HR 120/min, BP 70/50 mm
Hg, respiratory rate 18 set by ventilator, and oxygen saturation 95% on 100%
FiO2. Blood glucose is 8.5 mmol/L. Initial laboratory testing reveals pH 6.98,
pCO2 34 mm Hg, bicarbonate 6 mmol/L, and lactate 17 mmol/L. What is the
most appropriate next step in management?
A. Dantrolene
B. Hydroxocobalamin
C. Hyperbaric oxygenation
D. Methylene Blue Answer - The correct answer is B.
Rationale: This clinical presentation is highly suggestive of cyanide toxicity.
Patients with hyperlactatemia after a fire should be assumed to have inhaled
cyanide. Obtundation, hypotension, and tachycardia all support the diagnosis.
Treatment of cyanide toxicity is prompt administration of hydroxocobalamin
(choice B is correct). Dantrolene would be used in patients with significant
hyperthermia and muscle rigidity secondary to malignant hyperthermia (choice
A is incorrect). Carbon monoxide toxicity is also a concern after a fire, and a
carboxyhemoglobin level should certainly be obtained. However, given the
elevated lactate and hemodynamic instability, management of suspected
cyanide
takes precedence over transfer to a hyperbaric chamber for carbon monoxide
toxicity (choice C is incorrect). Methylene blue is therapy for
methemoglobinemia (choice D is incorrect).
A 38-year-old man is admitted to the ICU after being intubated for severe
agitation. He was brought to the emergency department after being detained
, at an international airport for aggressive behavior. He required prehospital
sedation with intramuscular midazolam to facilitate transport. On arrival, his
vital signs were temperature 40.2 C, HR 165/min, BP 180/100 mm Hg,
respiratory rate 24, and oxygen saturation 96% on room air. Blood glucose 10.5
mmol/L
(189 mg/dL). He was intubated using rocuronium and was started on a
propofol infusion at 4 mg/kg/hr. Vitals signs have not significantly changed.
What is the most appropriate management?
A. Active cooling
B. Active cooling, increased sedation
C. Active cooling, increased sedation, and β-blockade
D. Active cooling, increased sedation, and paralysis Answer - The correct
answer is D.
Rationale: This patient's presentation is consistent with significant toxicity
from sympathomimetic agents (such as cocaine or amphetamines). His most
immediate life-threatening problem is his hyperthermia, and goal is to cool the
patient, which will be facilitated by a neuromuscular blocker (choice D is
correct). Cooling with sedation alone are insufficient (choices A and B are
incorrect) and β-Blockade is not indicated (choice C is incorrect).
Sympathomimetic toxicity is a centrally driven disease (symptoms are due to an
increase in excitation in the central nervous system). β-Blockade does not
address this, as it only targets the peripheral symptoms of that centrally
mediated process. Furthermore, β-blockers pharmacologically result in
unopposed alpha stimulation, though the clinical significance of this has been
recently debated.
A 24-year-old woman presents 45 minutes after an intentional ingestion of
approximately 25 g of acetaminophen (APAP). She denies any other ingestions.
Her vital signs are heart rate 80 beats/min, blood pressure 128/62 mm Hg,
respiratory rate of 18/min, temperature of 37 °C, and oxygen saturation 99% on
room air. Her physical examination is normal except for tearfulness. What is the
most appropriate next step in management?
A. Give activated charcoal
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