A 68-year-old male patient is currently in the telemetry unit and receiving treatment for acute
decompensated heart failure with reduced ejection fraction. On day two of his admission, you
are called to the bedside to evaluate him for a complaint of chest pain. The patient reports
a severe, dull, pressure-like pain in the center of his chest with associated dyspnea. It is
substernal and radiates to both shoulders. He is diaphoretic and looks as though he does Acute coronary syndrome
not feel good. He has a past medical history of diabetes mellitus type 2 and hypertension. The clinical scenario is most consistent with acute coronary syndrome. The pain from an aortic
Vitals: 99.1-95-150/100, sat is 98% on RA. He has rales in his lungs, and his abdominal exam dissection feels like a tearing or ripping sensation between the scapula. Pleuritis causes a
is unremarkable. Which diagnosis is most important to keep in your ditterentials? sharp pain with inspiration. Stable angina is characterized by chest pain, brought on by activity
and relieved by rest.
Pleuritis
Aortic Dissection
Stable Angina
Acute coronary syndrome
A 68-year-old male patient is currently on the telemetry unit and receiving treatment for
acute decompensated heart failure reduced ejection fraction. On day two of his admission
you are called to the bedside to evaluate him for a complaint of chest pain. The patient
reports a severe, dull, pressure like pain in the center of his chest with associated dyspnea.
It is substernal in nature and radiates to both shoulders. He is diaphoretic and looks as
though he does not feel good. He has a past medical history of diabetes mellitus type 2
Serial Troponins
and hypertension. Vitals: 99.1-95-150/100, sat is 98% on RA. He has rales in his lungs and
The clinical scenario is most consistent with an acute coronary syndrome. The best test to make
his abdominal exam is unremarkable. Which diagnostic test will best help to confirm the
the diagnosis is serial troponins.
diagnosis?
Echocardiogram
Brain Natriuretic Protein
Serial Troponins
CK MB
Acute Coronary Syndrome may present atypically in which patient?
Those with chronic kidney disease Eldery
Eldery ACS may present atypically in the elderly, women, diabetics and sickle cell patients.
Caucasian Males
African American Males
Which patient is most likely to have chronically elevated troponin levels?
A 45-year-old male with an ejection fraction of 35%.
A 55-year-old female with a creatinine of 0.9 mg/dL. Chronically elevated troponins are seen in persons with heart failure and chronic kidney
A 45-year-old male with an ejection fraction of 35%. disease. The 45-year-old male with an ejection fraction of 35% has systolic heart failure and
A 70-year-old male with a metabolic acidosis. one would expect to see chronically elevated troponin levels in this patient.
A 30-year-old female with mitral valve prolapse.
Activate Cardiac Cath Team
A patient presents to the ED with a complaint of chest pain. The EKG results are below. Which
This patient is having a STEMI and must go for emergent reperfusion therapy, which requires
action should the AGACNP take first? the AGACNP to activate the cardiac cath team.
Order a troponin level
Call the intensivist
Activate Cardiac Cath Team
Repeat the EK
Post percutaneous treatment for a STEMI the patient should be transferred to which level of
care?
, Medical bed
Telemetry Intensive care
Observation bed A person post PCI for a STEMI should be admitted to the intensive care unit.
Intensive care
An AGACNP is treating a patient with a new onset of NSTEMI and an O2 sat of 94%. Which
therapy is most appropriate for the AGACNP to initiate?
Enoxaparin (Lovenox) and ASA
The AGACNP should initiate enoxaparin and ASA. Fibrinolytic therapy is contraindicated in
Fibrinolytic therapy
NSTEMIs because it does not have any ettect on mortality and increases the risk of intracranial
ASA and fibrinolytic therapy
hemorrhage. Oxygen is only indicated in ACS when the O2 sat is < 90%.
Enoxaparin (Lovenox) and ASA
Clopidogrel (Plavix) loading dose and oxygen
A 55-year-old male is evaluated during a routine examination at your cardiology prac-
tice. He has a 2-year history of non-ischemic cardiomyopathy with an ejection fraction of
35%. He denies any dyspnea and can walk 2 miles a day without symptoms. Past medical
Add amlodpine (Norvasc)
history is significant for hypertension. His current medications include lisinopril (Zestril)
This patient is on a three-drug regimen for heart failure, HTN management, and is still
40mg daily, carvedilol (Coreg) 25mg BID, and chlorthalidone (Thalitone) 25mg daily. Vitals:
hypertensive. He is on optimal doses of his current medications however he still needs to
98.6-65-16-160/90 mmHg. On exam there is no JVD, lungs are clear, and heart rate is regular
achieve better blood pressure control. The most appropriate action is to add amlodipine.
without murmur or gallops. No edema is present. How should the AGACNP modify this
Use of calcium channel blockers in systolic heart failure is generally reserved for treatment
patient's treatment plan?
of conditions such as hypertension or angina that are not optimally managed with maximal
doses evidenced based medications. Non-dihydropyridine calcium channel blockers, such a
Order an echocardiogram
diltiazem, are contraindicated in systolic heart failure, because they impair contraction.
Add amlodpine (Norvasc)
Increase the dose of chlorthalidone
Add diltiazem (Cardizem)
An 88-year-old patient is sent to the ED by his nursing home in acute decompensated heart
failure reduced ejection fraction. His dry weight is 71kg and current weight is 73.5kg. Heart
rate is 104, respiratory rate is 30/minute, BP of 120/60 mmHg, O2 sat 89% on RA. Heart rate
is regular, lungs have rales in the posterior lung fields and he is using accessory muscles. The
EKG, troponins, BMP
initial evaluation of this patient should include which tests?
The initial evaluation of this patient should include an EKG, troponins and BMP. This is the only
option which is completely correct. A BNP, CXR and CBC should also be completed.
CBC, EKG, D-dimer
INR, CT of the Head and EKG
BNP, Chest-x-ray, LFTs
EKG, troponins, BMP
An 88-year-old patient is sent to the ED by his nursing home in acute decompensated heart
failure reduced ejection fraction. His dry weight is 71kg and current weight is 73.5kg. Heart
rate is 104, respiratory rate is 30/minute, BP of 120/60 mmHg, O2 sat 89% on RA. Heart rate
is regular, lungs have rales in the posterior lung fields and he is using accessory muscles. To
which level of care should this patient be admitted? Intensive care
This patient has impending respiratory failure and requires ICU care
Observation
Telemetry
Intensive care
Medical
An 88-year-old patient is sent to the ED by his nursing home in acute decompensated heart
failure reduced ejection fraction. His dry weight is 71kg and current weight is 73.5kg. Heart
rate is 104, respiratory rate is 30/minute, BP of 120/60 mmHg, O2 sat 89% on RA. Heart rate is Consult cardiology and nephrology
regular, lungs have rales in the posterior lung fields and he is using accessory muscles. Initial The most appropriate intervention is to consult cardiology and nephrology. Discharge plan-
labs come back and he is noted to have a creatinine of 3.0 mg/dL and a potassium of 4.5
mEq/L. Baseline creatinine is 1.5 mg/dL. Which intervention should the AGACNP do next?
, Consult cardiology and nephrology
ning may be needed but it is not the most important action to take at this moment. There are
Consult the case manager for discharge planning
no signs of neglect or any current indication for palliative care.
Consult the palliative care team
Consult the social work for concern of neglect
A 40-year-old patient who is being discharged home after being treated for an acute de-
compensated heart failure reduced ejection fraction, admits to not taking his medications
or following his diet. Which response would best help the AGACNP provide anticipatory
guidance? What prevents you from taking your medications?
It is important to explore the reasons for his noncompliance in a non-threatening manner.
Not taking your medications will cause you to be readmitted. Identifying barriers to compliance may reveal areas where the provider can help.
I can call the Chaplin if you like?
What prevents you from taking your medications?
Would you like to speak with the social worker?
A 36-year-old, 72kg female, is intubated for a severe asthma exacerbation, and is on the
following ventilator settings: Tidal volume 650ml, simultaneous intermittent mandatory ven- Administer 1 amp of sodium bicarbonate
tilation (SIMV) with a rate of 14, and an Fio2 of 0.75. Her morning ABG results were: pH 7.18,
Asthmatic patients who require intubation for severe exacerbation should be treated with IV
PaCO2 55 mmHg, HCO3 21 mEq/L. Which order is the most appropriate in response to this
sodium bicarbonate for respiratory acidosis. Permissive hypercapnia is the recommended
ABG?
ventilatory strategy, however when the pH falls below 7.2 buttering agents should be admin-
istered. The goal is to provide adequate oxygenation for the patient, while minimizing high
Administer 1 amp of sodium bicarbonate
airway pressures and consequently the risk of barotrauma, while maintaining a pH that is
Increase SIMV to a rate of 18
consistent with the maintenance of extrapulmonary function.
Decrease Fio2 to 0.50
Increase tidal volume to 700m
A patient experiencing an asthma exacerbation is unarousable and has a decreasing respi-
ratory rate. Which action should the AGACNP take next? Prepare for intubation and admit to the ICU
This patient has impending respiratory failure which requires intubation and intensive care.
Order methylprednisolone (solumedrol) IV and albuterol continuous nebs Per the PER3 guidelines intubation should not be delayed when it is deemed necessary.
Begin BIPAP, check an ABG, and admit to the ICU During exacerbations one would expect to see tachypnea, not a decreasing rate. The patient
Consult pulmonary and begin a magnesium infusion is not arousable which likely means they are retaining CO2.
Prepare for intubation and admit to the ICU
A patient's chest X-ray reveals increased retrosternal airspace and a flattened diaphragm. The
AGACNP accurately interprets this as evidence of which diagnosis? COPD
This presentation is consistent with the chronic alveolar distention of COPD. ARDS reveals a
Asthma "white" radiograph as alveolar expansion is very limited. Emboli may be apparent as gray or
Acute Respiratory Distress Syndrome white areas on the radiograph, but not increased airspace. Asthma does not typically alter a
Pulmonary Embolism normal radiograph picture.
COPD
A 48-year-old female with acute pancreatitis is in the ICU and is ventilated. Current vitals are:
heart rate 116, BP 92/60 mmHg. Hemodynamics are: CVP 9 mmHg, PAP 29/18 mmHg, PCWP
14 mmHg. Ventilator settings are: Assist Control, Tidal volume 800ml, Rate 14, FiO2 0.85,
Increase PEEP 7.5 cm H2O
PEEP 5.0 cm H2O. ABG results are: pH 7.31, PaCO2 48 mmHg, PaO2 62 mmHg. The chest
This patient is at risk for developing ARDS secondary to her pancreatitis. Because of her low
x- ray shows dittuse, flutty infiltrates. Which intervention is most appropriate for the AGACNP
filling pressures, it is not likely that she is experiencing cardiogenic pulmonary edema. To
to complete?
improve oxygenation, increasing the PEEP is most beneficial. Increasing the FiO2 will increase
the risk of oxygen toxicity, and you will gain no oxygenation benefit from increasing the rate
An increase of rate to 18 bpm
or the tidal volume.
Increase tidal volume to 900ml
Increase FiO2 to 0.95
Increase PEEP 7.5 cm H2O
decompensated heart failure with reduced ejection fraction. On day two of his admission, you
are called to the bedside to evaluate him for a complaint of chest pain. The patient reports
a severe, dull, pressure-like pain in the center of his chest with associated dyspnea. It is
substernal and radiates to both shoulders. He is diaphoretic and looks as though he does Acute coronary syndrome
not feel good. He has a past medical history of diabetes mellitus type 2 and hypertension. The clinical scenario is most consistent with acute coronary syndrome. The pain from an aortic
Vitals: 99.1-95-150/100, sat is 98% on RA. He has rales in his lungs, and his abdominal exam dissection feels like a tearing or ripping sensation between the scapula. Pleuritis causes a
is unremarkable. Which diagnosis is most important to keep in your ditterentials? sharp pain with inspiration. Stable angina is characterized by chest pain, brought on by activity
and relieved by rest.
Pleuritis
Aortic Dissection
Stable Angina
Acute coronary syndrome
A 68-year-old male patient is currently on the telemetry unit and receiving treatment for
acute decompensated heart failure reduced ejection fraction. On day two of his admission
you are called to the bedside to evaluate him for a complaint of chest pain. The patient
reports a severe, dull, pressure like pain in the center of his chest with associated dyspnea.
It is substernal in nature and radiates to both shoulders. He is diaphoretic and looks as
though he does not feel good. He has a past medical history of diabetes mellitus type 2
Serial Troponins
and hypertension. Vitals: 99.1-95-150/100, sat is 98% on RA. He has rales in his lungs and
The clinical scenario is most consistent with an acute coronary syndrome. The best test to make
his abdominal exam is unremarkable. Which diagnostic test will best help to confirm the
the diagnosis is serial troponins.
diagnosis?
Echocardiogram
Brain Natriuretic Protein
Serial Troponins
CK MB
Acute Coronary Syndrome may present atypically in which patient?
Those with chronic kidney disease Eldery
Eldery ACS may present atypically in the elderly, women, diabetics and sickle cell patients.
Caucasian Males
African American Males
Which patient is most likely to have chronically elevated troponin levels?
A 45-year-old male with an ejection fraction of 35%.
A 55-year-old female with a creatinine of 0.9 mg/dL. Chronically elevated troponins are seen in persons with heart failure and chronic kidney
A 45-year-old male with an ejection fraction of 35%. disease. The 45-year-old male with an ejection fraction of 35% has systolic heart failure and
A 70-year-old male with a metabolic acidosis. one would expect to see chronically elevated troponin levels in this patient.
A 30-year-old female with mitral valve prolapse.
Activate Cardiac Cath Team
A patient presents to the ED with a complaint of chest pain. The EKG results are below. Which
This patient is having a STEMI and must go for emergent reperfusion therapy, which requires
action should the AGACNP take first? the AGACNP to activate the cardiac cath team.
Order a troponin level
Call the intensivist
Activate Cardiac Cath Team
Repeat the EK
Post percutaneous treatment for a STEMI the patient should be transferred to which level of
care?
, Medical bed
Telemetry Intensive care
Observation bed A person post PCI for a STEMI should be admitted to the intensive care unit.
Intensive care
An AGACNP is treating a patient with a new onset of NSTEMI and an O2 sat of 94%. Which
therapy is most appropriate for the AGACNP to initiate?
Enoxaparin (Lovenox) and ASA
The AGACNP should initiate enoxaparin and ASA. Fibrinolytic therapy is contraindicated in
Fibrinolytic therapy
NSTEMIs because it does not have any ettect on mortality and increases the risk of intracranial
ASA and fibrinolytic therapy
hemorrhage. Oxygen is only indicated in ACS when the O2 sat is < 90%.
Enoxaparin (Lovenox) and ASA
Clopidogrel (Plavix) loading dose and oxygen
A 55-year-old male is evaluated during a routine examination at your cardiology prac-
tice. He has a 2-year history of non-ischemic cardiomyopathy with an ejection fraction of
35%. He denies any dyspnea and can walk 2 miles a day without symptoms. Past medical
Add amlodpine (Norvasc)
history is significant for hypertension. His current medications include lisinopril (Zestril)
This patient is on a three-drug regimen for heart failure, HTN management, and is still
40mg daily, carvedilol (Coreg) 25mg BID, and chlorthalidone (Thalitone) 25mg daily. Vitals:
hypertensive. He is on optimal doses of his current medications however he still needs to
98.6-65-16-160/90 mmHg. On exam there is no JVD, lungs are clear, and heart rate is regular
achieve better blood pressure control. The most appropriate action is to add amlodipine.
without murmur or gallops. No edema is present. How should the AGACNP modify this
Use of calcium channel blockers in systolic heart failure is generally reserved for treatment
patient's treatment plan?
of conditions such as hypertension or angina that are not optimally managed with maximal
doses evidenced based medications. Non-dihydropyridine calcium channel blockers, such a
Order an echocardiogram
diltiazem, are contraindicated in systolic heart failure, because they impair contraction.
Add amlodpine (Norvasc)
Increase the dose of chlorthalidone
Add diltiazem (Cardizem)
An 88-year-old patient is sent to the ED by his nursing home in acute decompensated heart
failure reduced ejection fraction. His dry weight is 71kg and current weight is 73.5kg. Heart
rate is 104, respiratory rate is 30/minute, BP of 120/60 mmHg, O2 sat 89% on RA. Heart rate
is regular, lungs have rales in the posterior lung fields and he is using accessory muscles. The
EKG, troponins, BMP
initial evaluation of this patient should include which tests?
The initial evaluation of this patient should include an EKG, troponins and BMP. This is the only
option which is completely correct. A BNP, CXR and CBC should also be completed.
CBC, EKG, D-dimer
INR, CT of the Head and EKG
BNP, Chest-x-ray, LFTs
EKG, troponins, BMP
An 88-year-old patient is sent to the ED by his nursing home in acute decompensated heart
failure reduced ejection fraction. His dry weight is 71kg and current weight is 73.5kg. Heart
rate is 104, respiratory rate is 30/minute, BP of 120/60 mmHg, O2 sat 89% on RA. Heart rate
is regular, lungs have rales in the posterior lung fields and he is using accessory muscles. To
which level of care should this patient be admitted? Intensive care
This patient has impending respiratory failure and requires ICU care
Observation
Telemetry
Intensive care
Medical
An 88-year-old patient is sent to the ED by his nursing home in acute decompensated heart
failure reduced ejection fraction. His dry weight is 71kg and current weight is 73.5kg. Heart
rate is 104, respiratory rate is 30/minute, BP of 120/60 mmHg, O2 sat 89% on RA. Heart rate is Consult cardiology and nephrology
regular, lungs have rales in the posterior lung fields and he is using accessory muscles. Initial The most appropriate intervention is to consult cardiology and nephrology. Discharge plan-
labs come back and he is noted to have a creatinine of 3.0 mg/dL and a potassium of 4.5
mEq/L. Baseline creatinine is 1.5 mg/dL. Which intervention should the AGACNP do next?
, Consult cardiology and nephrology
ning may be needed but it is not the most important action to take at this moment. There are
Consult the case manager for discharge planning
no signs of neglect or any current indication for palliative care.
Consult the palliative care team
Consult the social work for concern of neglect
A 40-year-old patient who is being discharged home after being treated for an acute de-
compensated heart failure reduced ejection fraction, admits to not taking his medications
or following his diet. Which response would best help the AGACNP provide anticipatory
guidance? What prevents you from taking your medications?
It is important to explore the reasons for his noncompliance in a non-threatening manner.
Not taking your medications will cause you to be readmitted. Identifying barriers to compliance may reveal areas where the provider can help.
I can call the Chaplin if you like?
What prevents you from taking your medications?
Would you like to speak with the social worker?
A 36-year-old, 72kg female, is intubated for a severe asthma exacerbation, and is on the
following ventilator settings: Tidal volume 650ml, simultaneous intermittent mandatory ven- Administer 1 amp of sodium bicarbonate
tilation (SIMV) with a rate of 14, and an Fio2 of 0.75. Her morning ABG results were: pH 7.18,
Asthmatic patients who require intubation for severe exacerbation should be treated with IV
PaCO2 55 mmHg, HCO3 21 mEq/L. Which order is the most appropriate in response to this
sodium bicarbonate for respiratory acidosis. Permissive hypercapnia is the recommended
ABG?
ventilatory strategy, however when the pH falls below 7.2 buttering agents should be admin-
istered. The goal is to provide adequate oxygenation for the patient, while minimizing high
Administer 1 amp of sodium bicarbonate
airway pressures and consequently the risk of barotrauma, while maintaining a pH that is
Increase SIMV to a rate of 18
consistent with the maintenance of extrapulmonary function.
Decrease Fio2 to 0.50
Increase tidal volume to 700m
A patient experiencing an asthma exacerbation is unarousable and has a decreasing respi-
ratory rate. Which action should the AGACNP take next? Prepare for intubation and admit to the ICU
This patient has impending respiratory failure which requires intubation and intensive care.
Order methylprednisolone (solumedrol) IV and albuterol continuous nebs Per the PER3 guidelines intubation should not be delayed when it is deemed necessary.
Begin BIPAP, check an ABG, and admit to the ICU During exacerbations one would expect to see tachypnea, not a decreasing rate. The patient
Consult pulmonary and begin a magnesium infusion is not arousable which likely means they are retaining CO2.
Prepare for intubation and admit to the ICU
A patient's chest X-ray reveals increased retrosternal airspace and a flattened diaphragm. The
AGACNP accurately interprets this as evidence of which diagnosis? COPD
This presentation is consistent with the chronic alveolar distention of COPD. ARDS reveals a
Asthma "white" radiograph as alveolar expansion is very limited. Emboli may be apparent as gray or
Acute Respiratory Distress Syndrome white areas on the radiograph, but not increased airspace. Asthma does not typically alter a
Pulmonary Embolism normal radiograph picture.
COPD
A 48-year-old female with acute pancreatitis is in the ICU and is ventilated. Current vitals are:
heart rate 116, BP 92/60 mmHg. Hemodynamics are: CVP 9 mmHg, PAP 29/18 mmHg, PCWP
14 mmHg. Ventilator settings are: Assist Control, Tidal volume 800ml, Rate 14, FiO2 0.85,
Increase PEEP 7.5 cm H2O
PEEP 5.0 cm H2O. ABG results are: pH 7.31, PaCO2 48 mmHg, PaO2 62 mmHg. The chest
This patient is at risk for developing ARDS secondary to her pancreatitis. Because of her low
x- ray shows dittuse, flutty infiltrates. Which intervention is most appropriate for the AGACNP
filling pressures, it is not likely that she is experiencing cardiogenic pulmonary edema. To
to complete?
improve oxygenation, increasing the PEEP is most beneficial. Increasing the FiO2 will increase
the risk of oxygen toxicity, and you will gain no oxygenation benefit from increasing the rate
An increase of rate to 18 bpm
or the tidal volume.
Increase tidal volume to 900ml
Increase FiO2 to 0.95
Increase PEEP 7.5 cm H2O
