BCEMP PRACTICE EXAM QUESTIONS AND ANSWERS
WITH COMPLETE SOLUTION
JD is a 65-year-old male presenting to the emergency department (ED) via
emergency medical services (EMS) transport from home for shortness of
breath and difficulty breathing. His wife reports that JD's condition has
progressively worsened over the past 12 hours, he has become more altered,
and he is difficult to arouse. The EMS staff report an initial oxygen saturation
(SpO2) of 74%. His vital signs on arrival at the ED are BP 178/109 mm Hg, HR
105 bpm, SpO2 97% on non-rebreather mask, and temp 37.1°C. JD is currently
unarousable by voice and noxious stimuli. The only available past medical
history is chronic obstructive pulmonary disease (COPD) secondary to cigarette
smoking and end-stage renal disease (ESRD) from an unknown cause. He is on
dialysis but has missed his last two dialysis sessions. The medical team is
preparing for intubation and asks for rapid sequence induction (RSI)
medications to be drawn up for a Answer - A) Etomidate 20 mg and
rocuronium 80 mg
Etomidate dosing for RSI is typically 0.3 mg/kg but may fall within a range of
approximately 0.2-0.6 mg/kg. A 20-mg dose of etomidate is slightly less than
0.3 mg/kg for this 70-kg patient and would be appropriate to use. Rocuronium
dosing for RSI is typically 1-1.2 mg/kg for adults, so 80 mg (i.e., 1.1 mg/kg for
this 70-kg patient) would be appropriate to use. The use of succinylcholine is
contraindicated in patients with hyperkalemia. JD's history of ESRD with two
recently missed dialysis sessions increases his risk of hyperkalemia. Because a
serum potassium concentration measurement is not available for JD,
succinylcholine use should be avoided.
The pharmacy leadership at your institution is currently considering changes to
the automated dispensing cabinet (ADC) workflow. Currently, all medications
,stored in ADCs in the emergency department (ED) are available "on override"
(i.e., access may be gained by overriding system prompts for authorization).
Your input about whether to allow overrides for medications stored in the
ADCs used specifically to treat anaphylaxis in the ED has been solicited. Which
of the following is the most appropriate response?
A) Epinephrine should be kept available by override because of the need for
rapid access to the drug and potential for respiratory or cardiac arrest within
minutes if prompt treatment is not provided.
B) Epinephrine should be removed from override because of the multiple
available concentrations and routes of administration, which could contribute
to medication errors.
C) Methylprednisolone should be kept availa Answer - A) Epinephrine should
be kept available by override because of the need for rapid access to the drug
and potential for respiratory or cardiac arrest within minutes if prompt
treatment is not provided.
Anaphylaxis is a medical emergency with a potential for severe complications
and death, which can occur within minutes without prompt treatment. Rapid
access to and administration of epinephrine are paramount. Epinephrine
should be stored in the ADCs in the ED and kept available by override due to its
life-saving potential. Although there is risk of dosing errors due to the
availability of multiple concentrations and inappropriate routes of
administration, this risk is outweighed by the potential benefit in this medical
emergency.
MR is a 44-year-old female who presented to the emergency department in
acute respiratory distress with hypoxia. She was subsequently intubated using
etomidate and rocuronium for impending respiratory failure and worsening
mental status approximately 5 minutes ago. Based on X-ray imaging results and
the history of present illness, the treatment team believes this patient's
condition is most likely the result of a viral respiratory illness. Prior to
intubation, MR's blood pressure was 155/102 mm Hg and heart rate was 105
bpm. Her current blood pressure is 81/48 mm Hg and heart rate is 116 bpm.
,Which of the following strategies is most appropriate to address this patient's
acute blood pressure change and post-intubation management needs?
A) Initiate a norepinephrine IV infusion but do not initiate post-intubation
analgesia and sedation until the blood pressure normalizes.
B) Initiate a norepinephrine IV infusion immed Answer - D) Administer a
crystalloid IV fluid bolus immediately followed by post-intubation analgesia and
sedation.
This patient is hypotensive immediately post-intubation, which could be due to
numerous factors, including but not limited to recent use of sedative induction
agents, critical illness, and positive pressure ventilation secondary to invasive
mechanical ventilation. The patient's mean arterial pressure (MAP) is less than
65 mm Hg (calculated by doubling the diastolic blood pressure of 48 mm Hg,
adding the systolic blood pressure of 81 mm Hg, and dividing the result by 3 =
59 mm Hg), so treatment is appropriate. In most patients, the first-line
treatment for hypotension or undifferentiated shock is volume resuscitation
with IV crystalloid fluids. It is common for certain analgesics and sedatives to
contribute to negative hemodynamic effects, including lowering of blood
pressure and heart rate. Nevertheless, the use of a long-acting paralytic agent
(rocuronium) for intubation with a short-acting sedative induction agent
(etomidate) places this patient at risk for awareness during paralysis unless
appropriate sedation and analgesia are provided. It is paramount to initiate
post-intubation sedation and analgesia management as soon as possible.
Therefore, initiating a crystalloid IV fluid bolus immediately followed by post-
intubation analgesia and sedation is the most appropriate choice for this
patient.
HM is a 35-year-old female recently diagnosed with a urinary tract infection by
her primary care provider. Sulfamethoxazole/trimethoprim 800 mg/160 mg
orally twice daily was prescribed by her primary care provider. Approximately
15 minutes after taking her first dose, HM developed a diffuse rash, urticaria,
and wheezing. Her husband called 9-1-1 for help and while paramedics were
loading HM into the ambulance for transport, she had two episodes of
, vomiting. Based on the Gell and Coombs classification, which of the following
categories of immunologic drug reactions is HM experiencing?
A) Type I
B) Type II
C) Type III
D) Type IV Answer - A) Type I
Type I immunologic drug reactions are mediated by IgE pathways and occur
immediately. They contribute to rash, urticaria, angioedema, shortness of
breath, nausea, vomiting, wheezing, and anaphylaxis. HM is experiencing some
of these symptoms currently, so the most likely Gell and Coombs classification
is Type I.
HM, the 35-year-old female recently diagnosed with a urinary tract infection
who experienced a reaction to sulfamethoxazole/trimethoprim at home,
presents to the emergency department (ED) via ambulance approximately 10
minutes after paramedics arrived on the scene. She received two 0.3-mg
intramuscular (IM) doses of epinephrine in the anterolateral aspect of her thigh
during transport with the last dose given 3 minutes ago. The emergency
medical services staff were able to obtain peripheral intravenous (IV) access
prior to arrival at the ED. On initial evaluation in the ED, HM has a diffuse rash
and urticaria that worsened during transport. She has audible wheezes and
reports that her throat feels like it is closing. Her only reported past medical
history includes paroxysmal atrial tachycardia diagnosed 10 years ago for which
she takes metoprolol succinate 50 mg orally daily. As the emergency medicine
team is prepari Answer - B) Glucagon 3 mg by slow IV push
HM probably is experiencing anaphylaxis. The initial recommended treatment
is epinephrine 0.3-0.5 mg IM in adults with the anterolateral aspect of the
thigh used as the preferred site. HM's condition is continuing to deteriorate
despite receiving two 0.3-mg IM doses of epinephrine. Alternative therapies
are recommended for patients with refractory anaphylaxis. Intravenous
WITH COMPLETE SOLUTION
JD is a 65-year-old male presenting to the emergency department (ED) via
emergency medical services (EMS) transport from home for shortness of
breath and difficulty breathing. His wife reports that JD's condition has
progressively worsened over the past 12 hours, he has become more altered,
and he is difficult to arouse. The EMS staff report an initial oxygen saturation
(SpO2) of 74%. His vital signs on arrival at the ED are BP 178/109 mm Hg, HR
105 bpm, SpO2 97% on non-rebreather mask, and temp 37.1°C. JD is currently
unarousable by voice and noxious stimuli. The only available past medical
history is chronic obstructive pulmonary disease (COPD) secondary to cigarette
smoking and end-stage renal disease (ESRD) from an unknown cause. He is on
dialysis but has missed his last two dialysis sessions. The medical team is
preparing for intubation and asks for rapid sequence induction (RSI)
medications to be drawn up for a Answer - A) Etomidate 20 mg and
rocuronium 80 mg
Etomidate dosing for RSI is typically 0.3 mg/kg but may fall within a range of
approximately 0.2-0.6 mg/kg. A 20-mg dose of etomidate is slightly less than
0.3 mg/kg for this 70-kg patient and would be appropriate to use. Rocuronium
dosing for RSI is typically 1-1.2 mg/kg for adults, so 80 mg (i.e., 1.1 mg/kg for
this 70-kg patient) would be appropriate to use. The use of succinylcholine is
contraindicated in patients with hyperkalemia. JD's history of ESRD with two
recently missed dialysis sessions increases his risk of hyperkalemia. Because a
serum potassium concentration measurement is not available for JD,
succinylcholine use should be avoided.
The pharmacy leadership at your institution is currently considering changes to
the automated dispensing cabinet (ADC) workflow. Currently, all medications
,stored in ADCs in the emergency department (ED) are available "on override"
(i.e., access may be gained by overriding system prompts for authorization).
Your input about whether to allow overrides for medications stored in the
ADCs used specifically to treat anaphylaxis in the ED has been solicited. Which
of the following is the most appropriate response?
A) Epinephrine should be kept available by override because of the need for
rapid access to the drug and potential for respiratory or cardiac arrest within
minutes if prompt treatment is not provided.
B) Epinephrine should be removed from override because of the multiple
available concentrations and routes of administration, which could contribute
to medication errors.
C) Methylprednisolone should be kept availa Answer - A) Epinephrine should
be kept available by override because of the need for rapid access to the drug
and potential for respiratory or cardiac arrest within minutes if prompt
treatment is not provided.
Anaphylaxis is a medical emergency with a potential for severe complications
and death, which can occur within minutes without prompt treatment. Rapid
access to and administration of epinephrine are paramount. Epinephrine
should be stored in the ADCs in the ED and kept available by override due to its
life-saving potential. Although there is risk of dosing errors due to the
availability of multiple concentrations and inappropriate routes of
administration, this risk is outweighed by the potential benefit in this medical
emergency.
MR is a 44-year-old female who presented to the emergency department in
acute respiratory distress with hypoxia. She was subsequently intubated using
etomidate and rocuronium for impending respiratory failure and worsening
mental status approximately 5 minutes ago. Based on X-ray imaging results and
the history of present illness, the treatment team believes this patient's
condition is most likely the result of a viral respiratory illness. Prior to
intubation, MR's blood pressure was 155/102 mm Hg and heart rate was 105
bpm. Her current blood pressure is 81/48 mm Hg and heart rate is 116 bpm.
,Which of the following strategies is most appropriate to address this patient's
acute blood pressure change and post-intubation management needs?
A) Initiate a norepinephrine IV infusion but do not initiate post-intubation
analgesia and sedation until the blood pressure normalizes.
B) Initiate a norepinephrine IV infusion immed Answer - D) Administer a
crystalloid IV fluid bolus immediately followed by post-intubation analgesia and
sedation.
This patient is hypotensive immediately post-intubation, which could be due to
numerous factors, including but not limited to recent use of sedative induction
agents, critical illness, and positive pressure ventilation secondary to invasive
mechanical ventilation. The patient's mean arterial pressure (MAP) is less than
65 mm Hg (calculated by doubling the diastolic blood pressure of 48 mm Hg,
adding the systolic blood pressure of 81 mm Hg, and dividing the result by 3 =
59 mm Hg), so treatment is appropriate. In most patients, the first-line
treatment for hypotension or undifferentiated shock is volume resuscitation
with IV crystalloid fluids. It is common for certain analgesics and sedatives to
contribute to negative hemodynamic effects, including lowering of blood
pressure and heart rate. Nevertheless, the use of a long-acting paralytic agent
(rocuronium) for intubation with a short-acting sedative induction agent
(etomidate) places this patient at risk for awareness during paralysis unless
appropriate sedation and analgesia are provided. It is paramount to initiate
post-intubation sedation and analgesia management as soon as possible.
Therefore, initiating a crystalloid IV fluid bolus immediately followed by post-
intubation analgesia and sedation is the most appropriate choice for this
patient.
HM is a 35-year-old female recently diagnosed with a urinary tract infection by
her primary care provider. Sulfamethoxazole/trimethoprim 800 mg/160 mg
orally twice daily was prescribed by her primary care provider. Approximately
15 minutes after taking her first dose, HM developed a diffuse rash, urticaria,
and wheezing. Her husband called 9-1-1 for help and while paramedics were
loading HM into the ambulance for transport, she had two episodes of
, vomiting. Based on the Gell and Coombs classification, which of the following
categories of immunologic drug reactions is HM experiencing?
A) Type I
B) Type II
C) Type III
D) Type IV Answer - A) Type I
Type I immunologic drug reactions are mediated by IgE pathways and occur
immediately. They contribute to rash, urticaria, angioedema, shortness of
breath, nausea, vomiting, wheezing, and anaphylaxis. HM is experiencing some
of these symptoms currently, so the most likely Gell and Coombs classification
is Type I.
HM, the 35-year-old female recently diagnosed with a urinary tract infection
who experienced a reaction to sulfamethoxazole/trimethoprim at home,
presents to the emergency department (ED) via ambulance approximately 10
minutes after paramedics arrived on the scene. She received two 0.3-mg
intramuscular (IM) doses of epinephrine in the anterolateral aspect of her thigh
during transport with the last dose given 3 minutes ago. The emergency
medical services staff were able to obtain peripheral intravenous (IV) access
prior to arrival at the ED. On initial evaluation in the ED, HM has a diffuse rash
and urticaria that worsened during transport. She has audible wheezes and
reports that her throat feels like it is closing. Her only reported past medical
history includes paroxysmal atrial tachycardia diagnosed 10 years ago for which
she takes metoprolol succinate 50 mg orally daily. As the emergency medicine
team is prepari Answer - B) Glucagon 3 mg by slow IV push
HM probably is experiencing anaphylaxis. The initial recommended treatment
is epinephrine 0.3-0.5 mg IM in adults with the anterolateral aspect of the
thigh used as the preferred site. HM's condition is continuing to deteriorate
despite receiving two 0.3-mg IM doses of epinephrine. Alternative therapies
are recommended for patients with refractory anaphylaxis. Intravenous
