CCRN Test QUESTIONS AND COMPLETE
SOLUTIONS
A 56 yr-old male is admitted to the ICU with a blood pressure of 225/135 and
complains of
a headache and nausea. He reports he ran out of blood pressure meds three
days ago, but
also appears to be confused to the date and situation. What is the most
appropriate
treatment approach?
Rapidly lower the diastolic pressure to 100 with IV antihypertensive meds,
then
continue to gradually reduce the diastolic pressure to 85 with oral
antihypertensive
meds.
The maximum initial decrease should be no more than 25% reduction from
initial
presenting value. Reducing the blood pressure too quickly can lead to cerebral
edema or renal failure.
A patient has sepsis, receives Lactated ringers 500ml IV bolus. Which finding
indicate that
this intervention is having it's intended effect?
ScvO2 of 72%
Early goal directed therapy for sepsis includes early fluid resuscitation at 30
ml/kg
,to maintain a CVP of 8-12 or 12-15 if mechanically ventilated, MAP greater
than 65,
ScvO2 greater than 70%, and urine output greater than 0.5 kg/hr
72 male patient in ICU for 6 days on the ventilator for treatment of a COPD
exacerbation.
He has been receiving VTE prophylaxis and subcutaneous Heparin since
admission. Today
his platelet count decreased significantly to 43,000 and was found to have new
DVT on his
right upper extremity. What do you suspect is the most likely cause of these
findings?
HIT
The hallmark sign of HIT is a significant decrease in platelet count over a 24
hours
period (>50%) within 5-10 days of administering Heparin. The other hallmark
sign
is a new development of DVT despite being on VTE prophylaxis.
TRALI:
is a complication from a blood transfusion reaction, which causes acute lung
injury
typically within 6 hours of a blood transfusion.
2 Hallmark signs of HIT:
Decrease in platelet count over a 24 hr period.
New development of DVT despite being on VTE prophylaxis.
Values in Early compensated Hypovolemic shock?
CO 4.0 L/min, HR 135, SV 65, SVR 1700, MAP 65
In hypovolemic states, circulating volume is depleted therefore preload and
contractility are decreased which leads to a decrease in SV and CO. HR and SV
,increase as compensatory measure to preserve CO, MAP and cerebral
perfusion.
Post-renal failure values:
Urine output < 200>
gravity 1.010
BUN: Creatinine ratio is 15:1, but both the BUN & creatinine are elevated.
Urine
sodium is typically 1-40 mEq/L.
What to do in the event of HIT:
Stop Heparin and administer an alternative direct thrombin inhibitor.
Warfarin is contraindicated in HIT? T/F
True - there is also no evidence that shows protamine, corticosteroids, and
benadryl
are effective treatments for HIT
Patients with right ventricular infarctions become preload dependent. Meds
that decrease
preload should be avoided - which meds are these?
Morphine, Nitro, Beta blockers and diuretics.
Polymorphic ventricular tachycardia aka Torsades is treated by?
Magnesium
Myocardial contusions generally impact which parts of the heart? and what
would the
values be?
Atria & right ventricle because of the position of the heart in the chest.
PAOP 6, PA Pressure 40/24, RA Pressure 16
Neurogenic shock signs?
CVP: 3, CI: 2.5, SVR: 650, SBP: 88
Neuro shock is associated with a loss of sympathetic tone causing extensive
, peripheral vasodilation. Clinical signs and symptoms include hypotension, a
low SVR,
low CVP and low normal CI
What causes a larger than normal A wave on a PAOP?
Mitral stenosis - causes increased left atrial pressure during atrial contraction.
Pulmonary HTN will result in what?
Elevated PA pressures but have no impact on PAOP.
Infective Endocarditis can cause what kind of impairment?
Neurologic impairment. One of the risks of infective endocarditis is the
bacterial
strand breaking in the heart and throwing bacterial emboli forward into the
lungs
from the right side of the heart or to the brain/body from the left side of the
heart.
Which of the following would be the earliest auscultatory finding in left
ventricular failure (LVF)?
A. Crackles
B. S3
C. Murmur of mitral regurgitation
D. Pericardial friction rub - {answer}-B. S3
LVF would be the most subtle because early changes are usually subtle
changes. Choose "S3."
SOLUTIONS
A 56 yr-old male is admitted to the ICU with a blood pressure of 225/135 and
complains of
a headache and nausea. He reports he ran out of blood pressure meds three
days ago, but
also appears to be confused to the date and situation. What is the most
appropriate
treatment approach?
Rapidly lower the diastolic pressure to 100 with IV antihypertensive meds,
then
continue to gradually reduce the diastolic pressure to 85 with oral
antihypertensive
meds.
The maximum initial decrease should be no more than 25% reduction from
initial
presenting value. Reducing the blood pressure too quickly can lead to cerebral
edema or renal failure.
A patient has sepsis, receives Lactated ringers 500ml IV bolus. Which finding
indicate that
this intervention is having it's intended effect?
ScvO2 of 72%
Early goal directed therapy for sepsis includes early fluid resuscitation at 30
ml/kg
,to maintain a CVP of 8-12 or 12-15 if mechanically ventilated, MAP greater
than 65,
ScvO2 greater than 70%, and urine output greater than 0.5 kg/hr
72 male patient in ICU for 6 days on the ventilator for treatment of a COPD
exacerbation.
He has been receiving VTE prophylaxis and subcutaneous Heparin since
admission. Today
his platelet count decreased significantly to 43,000 and was found to have new
DVT on his
right upper extremity. What do you suspect is the most likely cause of these
findings?
HIT
The hallmark sign of HIT is a significant decrease in platelet count over a 24
hours
period (>50%) within 5-10 days of administering Heparin. The other hallmark
sign
is a new development of DVT despite being on VTE prophylaxis.
TRALI:
is a complication from a blood transfusion reaction, which causes acute lung
injury
typically within 6 hours of a blood transfusion.
2 Hallmark signs of HIT:
Decrease in platelet count over a 24 hr period.
New development of DVT despite being on VTE prophylaxis.
Values in Early compensated Hypovolemic shock?
CO 4.0 L/min, HR 135, SV 65, SVR 1700, MAP 65
In hypovolemic states, circulating volume is depleted therefore preload and
contractility are decreased which leads to a decrease in SV and CO. HR and SV
,increase as compensatory measure to preserve CO, MAP and cerebral
perfusion.
Post-renal failure values:
Urine output < 200>
gravity 1.010
BUN: Creatinine ratio is 15:1, but both the BUN & creatinine are elevated.
Urine
sodium is typically 1-40 mEq/L.
What to do in the event of HIT:
Stop Heparin and administer an alternative direct thrombin inhibitor.
Warfarin is contraindicated in HIT? T/F
True - there is also no evidence that shows protamine, corticosteroids, and
benadryl
are effective treatments for HIT
Patients with right ventricular infarctions become preload dependent. Meds
that decrease
preload should be avoided - which meds are these?
Morphine, Nitro, Beta blockers and diuretics.
Polymorphic ventricular tachycardia aka Torsades is treated by?
Magnesium
Myocardial contusions generally impact which parts of the heart? and what
would the
values be?
Atria & right ventricle because of the position of the heart in the chest.
PAOP 6, PA Pressure 40/24, RA Pressure 16
Neurogenic shock signs?
CVP: 3, CI: 2.5, SVR: 650, SBP: 88
Neuro shock is associated with a loss of sympathetic tone causing extensive
, peripheral vasodilation. Clinical signs and symptoms include hypotension, a
low SVR,
low CVP and low normal CI
What causes a larger than normal A wave on a PAOP?
Mitral stenosis - causes increased left atrial pressure during atrial contraction.
Pulmonary HTN will result in what?
Elevated PA pressures but have no impact on PAOP.
Infective Endocarditis can cause what kind of impairment?
Neurologic impairment. One of the risks of infective endocarditis is the
bacterial
strand breaking in the heart and throwing bacterial emboli forward into the
lungs
from the right side of the heart or to the brain/body from the left side of the
heart.
Which of the following would be the earliest auscultatory finding in left
ventricular failure (LVF)?
A. Crackles
B. S3
C. Murmur of mitral regurgitation
D. Pericardial friction rub - {answer}-B. S3
LVF would be the most subtle because early changes are usually subtle
changes. Choose "S3."
