PCCN MASTER EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+

1 PCCN MASTER EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+ 1. Cardiac Correct Answer: 1. Cardiac Pt's EKG shows ST elevation in leads II, III, and aVF. Where is the MI? Correct Answer: Inferior wall MI, Right coronary artery "Reciprocal changes are often seen ini leads I and aVL" Pt's EKG shows ST elevation in leads V1 and V2. Where is the MI? Correct Answer: Septal area, Left Anterior Descending Artery Pt's EKG shows ST elevation in leads V3 and V4. Where is the MI? Correct Answer: Anterior area Pt has ST elevation in leads V1-V4. Which coronary artery is occluded? Correct Answer: Left Anterior Descending Artery EKG shows: ST segment ELEVATION. What does this indicate? 2 Correct Answer: MI or INFARCTION EKG shows: ST segment DEPRESSION. What does this indicate? Correct Answer: Myocardial ISCHEMIA A sign of necrosis on an EKG would include: Correct Answer: Acute ST elevation. abnormal Q wave. Along with acute ST elevation, another indicator of necrosis would be an abnormal Q wave. If the Q wave appears within about 6 hours of a transmural MI, it is an ominous sign. If the Q wave is more than 0.04 seconds long, it is a sign of necrosis. In an inferior MI, the Q wave should not exceed 0.03 seconds or it is indicative of necrosis. EKG shows: Tall peaked T waves and wide QRS What does this indicate? Correct Answer: hyperkalemia EKG shows: Prominent U wave and flat T wave What does this indicate? Correct Answer: hypokalemia EKG shows: PR interval >.2 3 What does this indicate? Correct Answer: 1st degree AV block EKG shows: Progressive prolongation of PR interval until QRS complex is dropped What does this indicate? Correct Answer: Second degree AV block type 1 or Mobitz (type I) Difference between 2nd degree AV block type I vs II Correct Answer: 2nd degree AV block type I: PR interval progressively lengthens Mnemonic: (couple is progressively ignoring each other) 2nd degree AV block type II: PR interval remains constant but there is a drop QRS complex here and there Mnemonic: (couple acts fine then one day, one partner doesn't come home) EKG shows: No association with P wave and QRS complexes What does this indicate? Correct Answer: 3rd degree AV block aka complete heart block MEDICAL EMERGENCY Mnemonic: (couple is divorced, not talking to each other) 4 Pt with 2nd degree AV block type II with 5s pauses will need... Correct Answer: emergent pacing bc these long pauses can cause inadequate perfusion and may lead to cardiac arrest. How do you tx atrial fibrillation? Correct Answer: 3 principles: 1. Rate control (B-blockers / non DHP Ca2+ CB 2. Rhythm control (anti arrhythmic) 3. Stroke prevention (Warfarin) **If patient is hemodynamically unstable --> direct cardioversion with 100 joules Which arrhythmia is commonly associated with left-sided heart failure? Correct Answer: Atrial Fibrillation bc blood is not moving d/t left ventricular hypertrophy Sometimes certain medications prolong the QT interval, potentially causing polymorphic ventricular tachycardia. The drug of choice to treat this rhythm is? Correct Answer: MAGNESIUM Magnesium acts on the processes by which calcium is transferred both across the cell membrane and within the cell itself. If high doses of Magnesium are given, it may slow AV conduction 5 The QT interval may be prolonged by use of tricyclic antidepressants, erythromycin (ABX), quinidine (antiarrhythmic) or terfenidine (antihistamine). Preload vs Afterload Correct Answer: Preload: is pressure at end of diastole aka filling of heart Afterload: the resistance needed to pump blood out of heart aka systole What does an S3 sound indicate? S4? Split S1 Correct Answer: S3 indicates volume overload aka heart failure S4 indicates ventricular hypertrophy aka decreased compliance. When ventricles thicken, it is harder to fill adequately, the atria eject more forcefully causing an S4 sound. Split S1 indicates a BBB (bundle branch block) or PVCs Where is murmur heard in pt with: Aortic stenosis Mitral Stenosis 6 Aortic Regurgitation Mitral Regurgitation Correct Answer: Aortic stenosis: Systole Mitral Stenosis: Diastole Aortic Regurgitation: Diastole Mitral Regurgitation: Systole Mneminic: A for Systolic (bc first) "Regurgitations" are opposite of stenosis When pt has acute mitral valve regurgitation, they will have increased pressure in what area of the heart? Correct Answer: Increased in left atrial diastolic pressure bc blood is flowing back from the valve. How does chronic aortic stenosis lead to left ventricular hypertrophy? Correct Answer: Chronic aortic stenosis leads to left ventricular hypertrophy bc of increased workload of pumping blood through a narrow opening. The left atrium can also enlarge but mainly causes left ventricular hypertrophy. The right ventricle will remain normal for a period of time. That's why LHF happens first then leads to RHF. Chronic mitral stenosis will cause enlargement in which area? Correct Answer: Left atria hypertrophy. 7 In pt with Mitral valve stenosis, their valve thickens, reducing blood flow from left ventricle to left atria. The pressure in left atria becomes high, causing enlargement overtime, then pt will be at risk for a fib bc the left atria becomes so thick than it cannot properly contract and just quivers so higher risk for blood ctot bc the blood isn't moving. Pt with left atria hypertrophy are at risk for... Correct Answer: A fib Left atria becomes so thick that it cannot properly contract and just quivers so higher risk for blood clot bc blood isn't moving What is the most common cause of mitral valve stenosis? Correct Answer: Rheumatic fever which causes inflammation of the valves Pt with hypertrophic cardiomyopathy should be on what med? Correct Answer: Beta-blocker like Metoprolol (Lopressor) and Calcium Channel blockers In hypertrophic cardiomyopathy, the heart becomes so thick that it cannot pump effectively so pt needs beta-blocker or CCB to slow down the heart rate to maximize diastolic filling time in a reduced left ventricle 8 Pt with dilated cardiomyopathy should be on what med? Correct Answer: FIRST give meds that reduce afterload THEN escalate to inotropic drugs like Digoxin In dilated cardiomyopathy the heart becomes weak and can't pump as hard so you need a positive inotropic med like digoxin to help heart pump harder Pts with dilated cardiomyopathy will have what symptoms? Correct Answer: Ventricular dysrhythmias d/t poor contractility. Dilated cardiomyopathy --> poor contractility --> ventricular dilation and increase in blood volume --> mitral valve regurgitaton. ***Cardiogenic shock will cause... High or low preload? High or low afterload? Correct Answer: High preload bc heart can't pump High afterload because the blood vessels vasoconstricts as a compensation mechanism for decreased stroke volume aka perfusion. What are sx of cardiogenic shock? Correct Answer: JVD (back up of blood) Hypotension 9 Tachycardia (compensation mechanism) Pt has these symptoms: hypotension, narrowing pulse pressure, thready pulse, and tachypnea What do they have? Correct Answer: Cardiac tamponade Wide mediastinum on chest x-ray: aka large accumulation of blood Narrow pulse pressure: low SBP (not pumping) but high DBP (vasoconstriction) Hypotension: heart not pumping blood out to body Cardiac Tamponade: - Definition - Sx - Tx Correct Answer: Definition: when heart is compressed by blood or fluid in pericardial space so it cannot relax and fill during diastole. Cannot pump!!! Too much pressure! Sx: hypotension (compressed heart not pumping), JVD (back up of blood), narrow pulse pressure (bad), Pt will have "muffled heart sounds", and "distant heart tones" 10 Tx: emergency pericardiocentesis Beck's triad is a combination of symptoms useful in diagnosing cardiac tamponade. They are? Correct Answer: Distended neck veins Muffled heart sounds Hypotension Tachycardia is an early sign of tamponade. A narrowed pulse pressure occurs, and fluid cannot be ejected from the heart. The muffled heart sounds occur because the fluid in the sac minimized the transmission of sound waves. Which of the following hemodynamic changes will occur with cardiac tamponade? • Increased cardiac output • Stroke volume decrease • Contractility increases • Decreased heart rate Correct Answer: STROKE VOLUME DECREASE Because the heart cannot adequately fill or eject its contents, stroke volume (SV) decreases and causes a decreased cardiac output (CO). Contractility decreases because the muscles cannot stretch and, therefore, cannot contract effectively. 11 Which position would you place her in to help alleviate some of the pain from percarditis? Correct Answer: SIT UP AND LEANING FORWARD ON A STABLE BEDSIDE TABLE Pericarditis results in inflamed layers of the pericardial sac. Upright and forward positioning pulls the heart away from the diaphragmatic pleura of the lungs and eases cardiac pain. Deep respirations, trunk rotation and flat positioning allow the parietal and visceral layers of the pericardial sac greater ability to rub against each other. Mrs. B was admitted for observation post falling 10 feet into a ravine. She was diagnosed with SLE (systemic lupus erythematosus) 2 yrs ago. She suffered a concussion, 3 fx-ed ribs, a fx-ed radius, and sprained ankle. She is on a Holter monitor and receiving IVF and ABX. Which of the following conditions would be exacerbated by the SLE?• Hypotension • Constipation • Pericarditis • Polycythemia Correct Answer: PERICARDITIS 12 SLE - systemic lupus erythematosus is a chronic inflammatory autoimmune disease that affects the vascular and connective tissues within any body system or organ. As a result of the SLE, inflammation may be increased and the stress of injury would further exacerbate the disease. S/S to monitor closely for include:Pericarditis, HTN, diarrhea, thrombocytopenia, anemia, leucopenia, joint and muscle pain, vasculitis, proteinurea, seizures, depression, PNA, pleural effusions, nausea and ulcers. What medications should pt with HF be on if they are... 1. Asymptomatic 2. Sympatomatic Correct Answer: 1. Pt with ASYMPTOMATIC HF should be on: ACE Inhibitor and Beta blocker 2. Pt with SYMPTOMATIC HF should be on ACE Inhibitor, Beta blocker, AND Diuretic ACE inhibitors decrease circulating volume aka preload and venous pressure. NSAIDS are contraindicated in the treatment of pts with heart failure because they? Correct Answer: ROMOTE FLUID RETENTION 13 And may also contribute to renal insufficiency Right sided heart failure will have: Increased/decreased cardiac output? Increased/decreased preload? Correct Answer: Increased preload (right ventricle not strong enough to pump blood forward, causing back up and increased preload) The most common precipitating cause of dissecting aneurysms is: Correct Answer: HTN Weakness of vessel walls, heart failure and atheroembolism may contribute to an aneurysm, but HTN remains the primary cause of dissecting aneurysms. Constant pressure on the vessel walls will weaken the vessel over time. Which of the following is a complication of infective endocarditis? A. Myocarditis B. Heart faiure C. Emboli D. Pericarditis Correct Answer: C. Emboli 14 The bacteria looks like a long strand of yarn being moved by blood flow through the heart. If the strand breaks, it can travel to heart or brain. Pt at risk for MI or stroke. In early stage of sepsis, the blood vessels vasodilates causing... Increased/Decreased: Preload Increased/Decreased: Afterload Increased/Decreased: Cardiac output Correct Answer: Decreased: Preload (vasodilation) Decreased: Afterload (vasodilation) Increased: Cardiac output (compensation mechanism to push out more blood to boost BP) During sepsis, our blood vessels dilate due to inflammation. Does this increase or decrease right atrial preload? Correct Answer: During sepsis our body's inflammatory response causes our blood vessels to leak out fluids and vasodilate which DECREASES preload. Tx: fluid resuscitation 15 Massive volume resuscitation with 0.9% saline can cause what? Correct Answer: Massive volume resuscitation with 0.9% saline can cause metabolic acidosis because CL is an acid which causes hyperchloremic metabolic acidosis. 2. Pulmonary Correct Answer: 2. Pulmonary Normal pH range: Normal pCO2 range: Normal bicarb range: Correct Answer: Normal pH range: 7.35-7.45 Normal pCO2 range: 35-45 mm Hg Normal bicarb range: 22-26 meq/L If pt has Respiratory acidosis, they will be "partially compensated" if the bicarb is high to compensate for acidosis. What are some causes of metabolic alkalosis? Correct Answer: - vomiting (loss of HCL) - diarrhea - prolonged diuretics What are some causes of metabolic acidosis? 16 Correct Answer: - AKI (kidneys cannot remove K) = DKA (Ketones and retention of K) - Lactic Acidosis (sepsis) - ASA toxicity - Massive 0.9% NS fluid resuscitation (Cl is acidic) What are some causes of respiratory acidosis? Correct Answer: - hypoventilation - narcotic overdose (opioids causes depressed RR) - Neuromuscular weakness (ALS, myasthenia gravis) COPD (cannot expel CO2) What are some causes of respiratory alkalosis? Correct Answer: hyperventilation (d/t anxiety, fear, pulmonary embolism) What is an ominous sign of impending respiratory failure in pt with asthmatic exacerbation? Correct Answer: Hypercapnia aka increased CO2 bc can't get out of system. Also if the pt "stops wheezing" this is BAD. Means pt cannot expel air out anymore bc airway is closing up. MEDICAL EMERGENCY 17 Pt in status asmaticus, you increase O2 from 2L to 5L. If pt's wheezing slows or even stops, that means pt is getting: Better or worse? Correct Answer: GETTING WORSE. No sound is produced bc air cannot pass through an opening, this is a medical emergency and pt needs to be intubated ASAP. If pt has a stable pulmonary embolism aka VSS, what med do you give? Correct Answer: heparin gtt, check PTT daily, and add Coumadin 1-2 days after. 3. Endocrine Correct Answer: 3. Endocrine What are the two common cause of diabetes insipidus or SIADH? Correct Answer: Head trauma and ICP. Both can cause pituitary dysfunction leading to a lot or not enough release of ADH Pt with Diabetes insipidus will have: Increase/Deceased urine output Increase/Deceased serum sodium Increase/Deceased serum osmolality (Normal: 275 to 295 mOsm/kg) Increase/Deceased urine specific gravity (Normal: 1.005 to 1.030) 18 Correct Answer: Diabetes insipidus (DI) = Dehydration so pee everything out b/c not enough ADH -Increase urine output (no ADH hormone) -Increase serum sodium (dehydrated so high Na) -Increase serum osmolality (dehydrate so high solutes) -Deceased urine specific gravity (peeing everything out so pee would be diluted) What is the treatment of diabetes insipidus? Correct Answer: Vasopressin aka ADH + fluids to rehydrate - watch out for hx of CAD bc can cause MI d/t vasoconstriction Pt with SIADH will have: Increase/Deceased urine output Increase/Deceased serum sodium Increase/Deceased serum osmolality (Normal: 275 to 295 mOsm/kg) Increase/Deceased urine specific gravity (Normal: 1.005 to 1.030) Correct Answer: SIADH= syndrome of inappropriate ADH so pt will retain all the fluid -Deceased urine output (ADH makes pt retain) -Deceased serum sodium (Too much water dilutes Na, pt is at risk for seizure) 19 -Deceased serum osmolality (water dilutes solutes) -Increase urine specific gravity (pt is retaining water so when pt does pee, it will be concentrated and amber) If a pt with SIADH has a sodium of 115, what should you do? Correct Answer: Priority is to maintain a safe environment bc low Na can cause confusion and seizures Why can't you correct Na too fast? Correct Answer: Correcting Na too fast might cause acute osmotic myelinolysis (demyelination syndrome) which is an IRREVERSIBLE CONDITION that causes AMS, lethargy, dysphagia Sodium replacement should not exceed 0.5mEq/L per hour What is DKA? Correct Answer: Diabetic (usually DM1): pt's body no longer makes insulin → body cannot use sugar Keto: to compensate, body breaks down muscles for energy → releases ketones Acidosis: Ketones and K goes up, causing pt to be acidotic 20 Goal is to "close Anion Gap", lower BG, lower K, hydration. (Normal: 8 to 16 mmol/l) What are Sx of DKA? Correct Answer: - Serum glucose >300 - 800 - **Low/Normal Na lvls, but HIGH K (acidosis)** - Elevated ketones, elevated Cr/BUN - ABG: Metabolic acidosis - Kussmaul's breathing aka breathing fast to excrete sugars - Dehydrated: bc body is trying to pee out glucose How to treat DKA? Correct Answer: Insulin gtt + fluids to rehydrate When treating pt with DKA, you put them on insulin gtt. What do you do after BG reaches 250? Correct Answer: Give D5NS or D51/2NS to prevent hypoglycemia What is Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHNS)? How to treat? Correct Answer: hyperglycemic CRISIS that causes dehydration and EXTREMELY high BG (>700) (Type II DM) 21 Pt is SEVERELY DEHYDRATED Tx: give fluids ASAP!!! To reverse the hyperglycemic hyperosmolar state, the nurse will first prepare to administer: a. insulin. b. fluids. c. glucagon. d. sodium bicarbonate Correct Answer: B. Fluids Why? bc pt is DEHYDRATED from peeing out all the water Metabolic syndrome: a cluster of conditions that occur together 5 risk factors: - Men waist >40 inches/Women waist >30 inches - Men HDL<40/Women HDL<50 - Triglycerides >150 - BP >125/85 - Fasting BG >110 Correct Answer: Metabolic syndrome: a cluster of conditions that occur together 5 risk factors: - Men waist >40 inches/Women waist >30 inches - Men HDL<40/Women HDL<50 - Triglycerides >150 - BP >125/85 22 - Fasting BG >110 The cardinal sign of syndrome of inappropriate antidiuretic hormone (SIADH) is a. Hyponatremia b. Urinary output of 10 liters a day c. Hypotension d. Systemic edema Correct Answer: a. Hyponatremia SIADH causes retention of water and low urine output. This causes a drop in serum sodium since the patient fluid overloaded. Which of the following are characteristics of diabetes insipidus (DI)? a. Low urine osmolality b. Increased serum osmolality c. Elevated serum sodium d. All of the above Correct Answer: d. All of the above The syndrome of DI is characterized by large urine output with low intravascular volume. This causes a loss of free water and a high serum sodium level. 23 When plasma glucose falls to 250 mg/dL in acute diabetic ketoacidosis (DKA), intravenous fluids should be change to D5 1/2 NS to prevent which of the following? a. Hyperglycemia b. Hyperkalemia c. Cerebral edema d. Somogyi effect Correct Answer: c. Cerebral edema When lowering blood sugar in DKA, the patient is also fluid depleted secondary to hyperosmolar diuresis. In that hypovolemia state with lowered blood glucose, the brain requires fluid replacement. Dropping blood sugar too quickly without fluid replacement will cause severe cerebral edema. Dehydration in hyperosmolar hyperglycemic non-ketotic ketoacidosis (HHNK) coma is primarily dye to which event? a. Lack of diuretic hormone (ADH) b. Inability of the kidney to concentrate urine c. Nausea and vomiting d. Osmotic diuresis from elevated blood glucose levels Correct Answer: d. Osmotic diuresis from elevated blood glucose levels In HHNK, the patient's blood sugar is extremely high causing a severe fluid deficit. This dehydration is significant and can lead to embolism, myocardial infarction and renal 24 failure. Dehydration is the leading cause of mortality and morbidity in the patient population. In diabetic ketoacidosis (DKA), the patient has an increased serum osmolarity. In the initial state of DKA, what is another dangerous electrolyte abnormality? a. Hypernatremia b. Hyponatremia c. Hypocalcemia d. Hyperkalemia Correct Answer: d. Hyperkalemia Initially, the patient has a high serum potassium secondary to the metabolic acidosis present from the ketones. This acidosis pulls potassium from the cell making the patient hyperkalemic. As soon as insulin is given, however, potassium reenters the cell and ketosis stops. In hyperosmolar hyperglycemic nonketotic ketoacidosis (HHNK), the patient has an initial hypokalemia. The nurse should evaluate: a. The patient;s potassium level before giving insulin b. Continuously monitor the patient's potassium level while giving insulin c. Continuously monitor the patient's urine output d. All of the above Correct Answer: d. All of the above 25 The patient in HHNK will have a slow sodium and low potassium initially and may require electrolyte replacement therapy before insulin is started. Once insulin is initiated, continuous monitoring of potassium is required. A potential complication form hyperosmolar hyperglycemic non-ketotic ketoacidosis (HHNK) treatment may include: a. Renal failure b. Hypoxemia c. Metabolic alkalosis d. Respiratory alkalosis Correct Answer: a. Renal failure The older patient with HHNK may become hypovolemic that renal injury occurs. Since the patient have renal insufficiency secondary to their diabetes, the kidneys are at risk. Renal function should be monitored. Syndrome of inappropriate diuretic hormone (SIADH) is clinically manifested by a. Hyperosmolarity b. Low output c. Myxedema d. Water intoxication Correct Answer: d. Water intoxication 26 Patients with SIADH hold on to sodium and water, have little urine output and are volume overloaded. With hypervolemia, the patient's sodium is lowered. They appear to have "water" intoxication. Antidiuretic hormone is formed in the a. Hypothalamic supraoptic nuclei b. Juxtaglomerular cells c. Pineal gland d. Posterior hypophysis Correct Answer: a. Hypothalamic supraoptic nuclei ADH is formed in the posterior pituitary, or the hypothalamic supraoptic nuclei The distal convoluted tubules in the kidneys are influenced by antidiuretic hormone (ADH) to a. Concentrate the urine b. Reabsorb potassium c. Dilute the urine d. Increase sodium loss in the urine Correct Answer: a. Concentrate the urine 27 ADH's effect on the kidneys is to decrease urine output and conserve water for the body. Its effect is to reabsorb sodium & water and reduce urine output to maintain intravascular volume. The normal serum osmolality is within the range of: a. 145-155 mOsm/L b. 200-250 mOsm/L c. 275-295 mOsm/L d. 325-375 mOsm/L Correct Answer: c. 275-295 mOsm/L Normal serum osmolality is 275-295 mOsm/L. If the osmolality is increased, it indicates dehydration. If the osmolality is low, it is an indication of fluid overload In addition to its effect on body water equilibrium, antidiuretic hormone (ADH) is also: a. An inotrope b. A beta stimulator c. A vasopressor d. A carbonic anhydrase inhibitor Correct Answer: c. A vasopressor ADH is the same molecule as vasopressin. Both cause peripheral vasoconstriction. 28 Which of the following is NOT consistent with hyperosmolar hyperglycemic non-ketotic ketoacidosis (HHNK)? a. Kussmaul's respirations b. Significant elevated serum glucose levels c. Severe dehydration d. Serum pH of 7.36 Correct Answer: a. Kussmaul's respirations Kussmaul's respirations are fast (greater than 28 breaths per minute), secondary to metabolic acidosis. Remember that with HHNK, the patient should have normal pH (without acidosis) The symptomatology the nurse would assess in the patient with syndrome of inappropriate antidiuretic hormone (SIADH) results from: a. Elevated potassium levels b. Water intoxication c. Increased serum osmolality d. Precipitating factors of SIADH Correct Answer: b. Water intoxication The symptomatology of SIADH results form holding on to water and sodium resulting in hypervolemia-fluid overload and low serum sodium levels. 29 Symptoms of hypoglycemia include: a. Decreased deep tendon reflexes, hypertension, and difficulty swallowing b. Increased deep tendon reflexes, hypertension and slow heart rate c. Increased heart rate, increased irritability and nausea d. Decreased heart rate, increased irritability and slow heart rate Correct Answer: c. Increased heart rate, increased irritability and nausea Early hypoglycemia causes sympathetic nervous system stimulation resulting in symptoms such as elevated heart rate, increased irritability and nausea. Laboratory assessment of the patient with hyperosmolar hyperglycemic non-ketotic ketoacidosis (HHNK) is likely to reveal: a. A serum pH of 7.0 b. Significant ketones in the urine c. Azotemia d. A hematocrit of 29% Correct Answer: c. Azotemia The patient with HHNK is severely dehydrated. Intra vascular volume is depleted due to osmotic diuresis and therefore may cause renal injury with resulting azotemia. Patients will die from this severe dehydration. Which of the following patients would be most likely to develop diabetes insipidus (DI)? 30 a. An elderly patient with non-insulin dependent diabetes b. A young woman with severe pneumonia c. A middle aged man with esophageal varices and GI bleeding d. A head trauma patient with a skull fracture Correct Answer: d. A head trauma patient with a skull fracture One of the most common causes of DI is head injury with resulting increased cerebral edema. The edema causes increased intracranial pressure which in turn increases pressure on the pituitary. This then may result in DI. Blood sugar elevation in the critically ill adult is common. Which of the following mechanism explains this increase in blood sugar in the non-diabetic patient? a. Medications such a epinephrine b. Shivering c. Temperature elevation d. Change in position Correct Answer: a. Medications such a epinephrine Epinephrine is a pure catecholamine. This activates the sympathetic nervous system and thereby increases blood sugar by the fight/flight mechanism. 5. Renal Correct Answer: 5. Renal 31 How does AKI cause acidosis? Correct Answer: Decreased urine output impairs potassium excretion. The resulting hyperkalemia causes a shift in H+, the accumulation results in acidosis 4. Neurology Correct Answer: 4. Neurology ***What does Cushing's triad indicate? What are the 3 signs of Cushing's triad? Correct Answer: Increased ICP Three classic signs - Bradycardia - Systolic hypertension - Wide pulse pressure and bradypnea—seen with pressure on the medulla as a result of brain stem herniation How can you tell difference between subdural vs epidural hematoma? Correct Answer: Subdural hematoma: SLOW accumulation of venous bleed. Ex: pt fell and hit head 1 week ago, just now starts to have a headache 32 Epidural hematoma: FAST accumulation of arterial bleed Pt is going for a cardiac cath where he will be getting contrast dye. What is the most effective way of preventing contrast induced nephropathy? Correct Answer: Give them LR at 100cc 12hrs before and after procedure This will dilute the contrast dye, making it easier for kidneys to get rid of them. Pt has epigastric pain, nausea, vomiting, and rebound tenderness. What is the possible dx? What should you do? Correct Answer: Dx: acute pancreatitis What to do: 1L NS for fluid hydration In acute pancreatitis, goals are: rest pancreas, pain control, and fluid resuscitation d/t large third spacing in response to inflammatory mediators. (Thats why they are also at risk for ARDS) 6. GI Correct Answer: 6. GI When pt is admitted for acute necrotizing pancreatitis, after the n/v has stopped, should you feed them via jejunal route or TPN 33 Correct Answer: Feed them via jejunal route to minimize pancreatic stimulation. Tube feedings is better than TPN bc it maintains guy integrity while minimizing pancreatic stimulation! How is acute pancreatitis treated? Correct Answer: hydration, electrolyte balance, nutrition and pain control Pt with pancreatitis will have: Hypoglycemia or hyperglycemia? Hypocalcemia or hypercalcemia? Hypokalemia or hyperkalemia? Why? Correct Answer: Hyperglycemia: pancreas cannot produce enough insulin Hypocalcemia: lots of pancreatic enzymes released, binds to Ca, lowers Ca. Do a Chvostek sign test aka tap cheek to see if it twitches Hypokalemia: from excessive vomiting Why are pts with pancreatitis at risk for ARDS? 34 Correct Answer: Pts are at risk for ARDS bc of third spacing and inflammation. Pancreas sits under lungs so fluid can permeate into lungs causing ARDS. Which of the following serum laboratory values is increased in acute pancreatitis? a. Bilirubin b. Amylase c. Lactate dehydrogenase d. Ammonia Correct Answer: ANS: B Serum amylase will rise with acute pancreatitis. The other values are affected by hepatocellular disease. You receive a 42 year old male patient from the Emergency Department who is being admitted with suspected acute pancreatitis. You know the blood test most specific to acute pancreatitis is: A. Serum ammonia level. B. Urine amylase Level. C. Serum lipase Level. D. Serum amylase level. Correct Answer: C. Serum lipase level. Amylase will rise first but Lipase is MORE SPECIFIC to pancreatitis. Therefore, serum amylase is considered an early marker but serum lipase is a confirmatory marker when elevated 3 times normal. Urine amylase will often rise with pancreatitis but again, serum lipase is more specific to pancreatitis. 35 You receive a 42 year old male patient from the Emergency Department who is being admitted with acute pancreatitis. His blood pressure is 92/70, heart rate 100, respiratory rate 16, temperature 37.2 C. He is experiencing pain of 8/10 and continues to have nausea. Priority initial interventions in treating acute pancreatitis include all of the following EXCEPT:A. Pain management.B. NPO status to decrease pancreatic activity.C. Cardiac monitoring.D. Fluid resuscitation. Correct Answer: C. Initial priorities are aimed at decreasing the release of pancreatic enzymes by placing the patient on NPO status. Pain management is a priority to not only provide comfort but also assure the patient is able to participate in deep breathing activities to prevent pulmonary complications often associated with pancreatitis. Fluid resuscitation is needed secondary to third space shifting of fluids and the associated hypovolemic state. Your 78 year old male patient with acute pancreatitis is ordered fluid resuscitation with 0.9% Normal Saline at 250cc per hour over 4 hours. This patient has a history of a significant myocardial infarction in the past. Over the next 4 hours your clinical assessment priority will be: A. Assessment of pain to assure he does not become overstressed and increase his myocardial demand. B. Monitor weight for signs of fluid overload. C. Assessment of lung sounds for signs of pulmonary edema. D. Assessment of extremities for signs of increasing peripheral edema. 36 Correct Answer: C. With a past cardiac history of significant myocardial infarction the addition of large volumes of fluid can result in fluid overload and pulmonary edema if the patient has a reduced ejection fraction. Fluid resuscitation is important but large volumes of fluid in the cardiac patient require careful, frequent assessments. Many patients with acute pancreatitis already have edema secondary to the third spacing of fluids during the acute phase of pancreatitis. Therefore, peripheral edema and weight gain may be related to third spacing of fluid and not increased circulating volume. All patients with pancreatitis require careful pain management with the primary goal of assuring good respiratory effort to avoid pulmonary complications. Patients with pancreatitis often take small breaths due to the pain they are experiencing. Nutrition support is important in the patient with acute pancreatitis. You anticipate once the nausea and vomiting has subsided nutrition will be provided in the following manner: A. Soft, low fat diet. B. Continuous tube feedings with a nasojejunal tube. C. Total parental nutrition with no lipids. D. Clear liquid diet. Correct Answer: A. Soft, low fat diet. The newest literature supports feeding the patient as early as possible to prevent an empty bowel and the complications associated with lack of nutrition in the gut. Oral feedings are preferred over tube feedings or TPN if the patient is able to tolerate. Soft diet is recommended over clear liquids. 37 When caring for a patient with acute pancreatitis who is hypotensive the nurse knows the primary intervention is going to be: A. Vasopressors to counteract the effects of alpha blockage. B. Inotropes to increase cardiac output. C. Aggressive fluid resuscitation. D. Emergent surgery. Correct Answer: C. Aggressive fluid resuscitation. In acute pancreatitis hypoalbuminemia is often present which leads to a decrease in oncotic pressure. In conjunction with severe inflammation this can lead to large amounts of fluid leaking into the peritoneal or even retroperitoneal space. Aggressive fluid administration to maintain adequate preload is a priority treatment consideration. Cardiac output is adversely affected in acute pancreatitis due to a deficit in preload and not due to a contractility problem. Vasopressors may be needed if fluid resuscitation is not effective in achieving an adequate mean arterial pressure. However, fluid should be used first because the physiological alterations in acute pancreatitis result in a reduction of preload.Pancreatitis is managed medically except in rare cases of necrotizing pancreatitis. The most common causes of acute pancreatitis are: A. Cholelithiasis and heavy alcohol use. B. Hepatitis and stress ulcers. C. Stress ulcers and cholelithiasis. 38 D. Heavy alcohol use and hepatitis. Correct Answer: A. Cholelithiasis and heavy alcohol use. Pancreatitis occurs when pancreatic enzymes are activated while still in the pancreas and the enzymes autodigest the pancreas. This occurs as a result of an obstruction. Gallstones and heavy alcohol intake are the two most common causes. Gallstones located in the distal common bile duct can block the pancreatic duct. This can lead to a reflux of bile into the pancreas. When gallstones are the etiology the serum alanine aminotransferase (ALT) is elevated. Alcohol use is the most common cause of pancreatitis. Alcohol can increase the protein content of pancreatic fluid and therefore predispose the patient to blockages within the ducts. Alcohol may also cause spasm of the sphincter of Oddi which increases pressure within the ducts. A patient with hepatic failure demonstrates deterioration in handwriting and when asked on exam to hold his arm and hand out like a stop sign, involuntary flapping of the hand (asterixis) is observed. These symptoms are most likely due to: A. Intracranial hemorrhage. B. Sub clinical seizure. C. Alcohol withdrawal. D. Encephalopathy. Correct Answer: D. Encephalopathy. 39 Encephalopathy is an anticipated complication of hepatic failure and is caused by high ammonia levels, which cause neurotoxicity. In failure, the liver loses its ability to normally metabolize and detoxify substances. Ammonia is produced by bacteria in the bowel and is a byproduct of protein metabolism. Normally, the liver metabolizes ammonia into urea for excretion. In liver failure, ammonia levels rise. You are caring for a 44 year old male who is being admitted with acute upper GI bleeding. He is vomiting bright red blood, his skin is cold and clammy, BP is 86/52, heart rate is 120. You know that the main priority in his care right now is: A. Inserting an NG tube to decompress the stomach and assess rate of bleeding. B. Administering crystalloid IV fluids and/or blood products to prevent or treat hypovolemic shock. C. Administering an H2 blocker to decrease gastric acid production. D. Preparing him for endoscopy to locate the site of bleeding. Correct Answer: B. Administering crystalloid IV fluids and/or blood products to prevent or treat hypovolemic shock. The most important immediate treatment of GI bleeding is maintaining adequate intravascular volume to prevent or manage hypovolemic shock. Hypotension due to hypovolemic shock can result in multiple organ damage. Two large bore IV lines should be inserted and crystalloid IV fluids (NS or lactated Ringers) should be started immediately. Blood should be obtained for type and cross matching for packed RBCs. Hemodynamic status should be monitored closely with frequent vital signs and possibly 40 invasive monitoring with a CVP or pulmonary artery catheter.An NG tube can be inserted to monitor bleeding and help remove blood from the stomach, but this is not the first priority of care in this patient.An endoscopy is needed to identify the site of bleeding as soon as possible, but stabilizing hemodynamics is the most immediate priority.H2 blockers are used to decrease gastric acid production and prevent ulcers. They are not used as immediate therapy for GI bleeding. Pharmacological treatment of bleeding gastric ulcers or gastritis can include all of the following EXCEPT: A. Nonsteroidal anti-inflammatory drugs (NSAIDS) to decrease gastric inflammation. B. Antibiotics to treat H. pylori infections. C. Histamine H2 blockers or proton pump inhibitors (PPI) to decrease acid production. D. Antacids or sucralfate to protect stomach mucosa. Correct Answer: A. Nonsteroidal anti-inflammatory drugs (NSAIDS) to decrease gastric inflammation. Patients with gastric ulcers should avoid NSAIDs because they can contribute to development of ulcers by inhibiting prostaglandins. Stomach or duodenal ulcers are common side effects of long-term NSAID use.Histamine H2 blockers decrease stimulation of H2 receptors in gastric cells that are responsible for secretion of hydrochloric acid, resulting in a decrease in gastric acid secretion. PPIs totally block stomach acid secretion and are the most powerful drugs for treating peptic ulcer disease. Antacids neutralize stomach acid to decrease irritation and inflammation of 41 gastric mucosa. Sucralfate coats the gastric mucosa to reduce its exposure to stomach acids. 80% to 90% of gastric ulcers are caused by infection with Heliobacter pylori (H. pylori) bacteria. Antibiotics used to treat H. pylori infections include tetracycline, amoxicillin, clarithromycin (Biaxin), and metronidazole (Flagyl). When caring for a patient admitted to the critical care unit with an acute illness accompanied by hypotension, the nurse recognizes the patient is at risk for developing the following that may predispose the patient to a gastrointestinal (GI) bleed: A. Stress ulcer. B. AV malformation. C. Mallory-Weiss tear. D. Esophageal varices. Correct Answer: A. Stress ulcer. Upper GI bleed is more common than lower GI bleed. Approximately 20 to 25% percent of patients who experience an upper GI bleed are already hospitalized. Ruptured esophageal varices, AV malformation, and Mallory-Weiss tear (longitudinal tear of the esophagus caused by forceful retching) can all cause upper GI bleeding. However, the most common cause of upper GI bleeding is a peptic ulcer. Peptic ulcers include both gastric and duodenal ulcers. Peptic ulcers occur when the normal protective mechanisms fail to work. Stress ulcers have the same etiology as peptic ulcers although they are typically limited to the stomach. They can develop within hours of admission to the hospital. Contributing factors include decreased mucosal blood flow leading to 42 ischemia and degeneration of the mucosal lining. Once the protective lining is penetrated, gastric secretions autodigest the layers of the stomach. This leads to damage of the mucosal and submucosal layers. Damage can penetrate to the blood vessels and result in hemorrhage. The critically ill patient with no nutritional intake will develop nutritional deficiencies and malnutrition. Inactivity of the GI tract can result in: A. Profound diarrhea. B. Bowel obstruction. C. Increased rate of infection. D. Gastrointestinal bleeding. Correct Answer: C. Increased rate of infection. Normal bowel function prevents the millions of bacteria normally circulating In the GI tract from colonizing. Lack of GI motility allows bacteria to accumulate. Critical illness can result in the breakdown of the normal barriers in the gut. With normal defenses down, the accumulated bacteria can translocate to the lymphatic system placing the patient at a higher risk of infection. A common culprit of recurrent peptic ulcer disease is: A. Haemophilus influenza. B. Klebsiella pneumoniea. C. Streptococcus pneumoniae. 43 D. Helicobacter pylori. Correct Answer: D. Helicobacter pylori. Helicobacter is the bacterial agent that is been identified as the most common cause of recurrent peptic ulcer disease. Streptococcus pneumoniae is a very common cause of community acquired pneumonia.Haemophilus influenza is a cause of community acquired pneumonia often seen in smokers.Klebsiella pneumoniae is a cause of community acquired pneumonia often seen in those with chronic alcoholism. Strategies that can be used in the treatment of upper GI hemorrhage to help control bleeding include of the following except: A. Endoscopy with sclerotherapy. B. Vasopressin. C. Octreotide (sandostatin). D. Gastric lavage. Correct Answer: D. Gastric lavage. D. The use of gastric lavage in upper GI bleeding is aimed at emptying the upper GI tract of blood and to monitor the bleeding but is not beneficial in treating the bleeding. Octreotide (Sandostatin) reduces splanchnic blood flow and also decreases the secretion of gastric acid and reduces GI motility. Endoscopy is used for diagnosis of GI bleeding. The use of sclerotherapy involves the injection of an agent around and into the bleeding vessels. For this procedure epinephrine is often used. Vasopressin helps 44 control bleeding by causing vasoconstriction of the arterioles in the splanchnic bed. It also decreases portal venous pressure. A patient with acute liver failure is prone to all of the following complications except: A. Infection and sepsis. B. Ischemic stroke and bowel infarction. C. Renal failure and GI bleeding. D. Cerebral edema and increased intracranial pressure. Correct Answer: B. Ischemic stroke and bowel infarction. Ischemic stroke and bowel infarction would most likely occur as a result of thrombus formation or embolization. In liver failure, coagulation proteins and clotting factors are not produced by the liver, resulting in an increased risk of bleeding rather than a risk of clotting. Patients with acute liver failure are susceptible to encephalopathy, cerebral edema, renal failure, hypoglycemia, metabolic acidosis, sepsis, coagulopathy, and multiorgan failure. Encephalopathy can result from increased ammonia levels and other metabolic abnormalities that occur with liver failure. Hepatorenal syndrome is a form of renal failure that occurs with severe liver disease and is thought to be due to portal hypertension that causes renal vasoconstriction and decreased renal perfusion. Patients with liver failure often develop coagulopathy and bleed due to the diminished capacity of the liver to synthesize coagulation factors. The most common site of bleeding is the gastrointestinal tract. An increase in blood-brain barrier permeability occurs in severe liver failure for unknown reasons and can lead to exposure of the brain 45 to ammonia and other neurotoxic substances that can result in cerebral edema. Cerebral edema often leads to an increase in ICP. Patients with liver failure are at increased risk of infection and sepsis related to a variety of immunologic dysfunctions, including complement deficiency, increased gut bacterial translocation, and white blood cell dysfunction. The most common sites of infection are the respiratory and urinary tracts and blood. You are caring for a patient who had bariatric surgery. You know that these patients are at particular risk for all of the following complications in the earlypost op period EXCEPT: A. Pulmonary embolus and DVT. B. Airway obstruction and oxygenation issues. C. Gastrointestinal leaks and sepsis. D. Coagulopathies and DIC. Correct Answer: D. Coagulopathies and DIC. Pulmonary embolism (PE) is the most common cause of mortality in the early post-op period after weight-loss surgery and is responsible for more than 50 percent of deaths. The most common risk factors associated with PE include severe venous stasis disease,severe obesity (BMI >60), and obesity-hypoventilation syndrome. Strategies for preventing PE and DVT include use of sequential compression devices, subcutaneous unfractionated or low molecular weight heparin, and early ambulation when possible. Ambulation is a particular challenge with extremely obese patients, and pain 46 management is an important consideration when promoting ambulation.Airway obstruction and oxygenation problems are common because many of these patients have sleep apnea preoperatively which increases their risk postoperatively. Close monitoring of oxygenation and respiratory status and use of CPAP or BiPAP machines help minimize the risk.A gastrointestinal leak can occur at sites of anastomosis and result in bleeding or leaking of gastric contents into the peritoneal space. If not discovered early, a leak can result in sepsis. Most leaks occur early in the first week after surgery but can occur up to a month after the operation. Signs a symptoms that can indicate a leak include fever, tachycardia, tachypnea, and abdominal or left shoulder pain. Coagulopathies and DIC are not particularly associated with this type of surgery, although DIC could occur in association with sepsis as a result of the inflammatory response. Clotting factors are made in the liver, and bariatric procedures do not alter liver anatomy or function. Pt with AAA is in 10/10 pain. What should you do? Correct Answer: Must control pain to control BP. (decrease risk of rupture) Pt with ESLD admitted with confusion, high ammonia, low albumin, and ascites. The BP is downtrending and is now 82/46. What is the best immediate intervention to improve BP? Correct Answer: Position the pt on his left side 47 The ascites causes the IVC to be compressed, which decreases preload, which leads to hypotension. Putting pt on left side can displace the fluid enough to allow blood to flow normally through the vena cava and restore preload and cardiac output. Hematology Correct Answer: Hematology What should you watch out for in pt suspected of Heparin Induced Thrombocytopenia (HIT)? Correct Answer: Watch out for sx of venous thrombosis, DVT/PE, stroke, and MI. HIT will lower plts which causes them to bleed then clot a lot! Electrolytes Correct Answer: Electrolytes What symptoms of hyperkalemia? What are EKG changes of hyperkalemia? Treatment? Correct Answer: Sx: bradycardia, low urine output tremors, twitching muscles Mnemonic: Everything up except HR and UO EKG: Tall Peaked T waves and Wide QRS Treatment: Three Part Therapy - Cardiac Protect: Calcium Gluconate 48 - Shift Potassium into Cell: Insulin + Dextrose; Sodium Bicarb - Remove the Potassium: Kayexalate, Diuretic, HD What symptoms of hypokalemia? What are EKG changes of hypokalemia? Correct Answer: Sx: Hypo so all DOWN, Lethargy, bradypnea, constipation, +1 reflex, obtunded, stupor, HIGH HR and HIGH urine output (pees all the K+ out the body) EKG: Flat T waves and prominent U waves Medication Correct Answer: Medications **TPA is used for pts with ischemic stroke. What are contraindications aka exclusion criterias? Correct Answer: Inclusion criteria: >18 yo, <3 hr since onset of symptom and CT scan to verify ischemic stroke Exclusion criteria: recent surgery in past 2 weeks, recent bleed like GIB, pt TBI in last 3 months, or if pt has a seizure at onset of the stroke. If pt has a seizure with the stroke, you cannot give TPA*** Warfarin is indicated for which of the following conditions? 49 Correct Answer: DVT, A-fib, heart valve replacement DVT, A-fib, heart valve replacements and MI are conditions that REQUIRE the use of warfarin. Patients with DVT, A-fib, and heart valve replacements will take warfarin on a chronic basis. By comparison, MI patients may be weaned off warfarin in 3 to 4 months. What is the antidote to each drug? Warfarin: Heparin: Lorazepam (Benzodiazepine overdose): Opioid overdose: Calcium channel blocker: Beta-blocker: Tylenol: Correct Answer: Warfarin: Vitamin K Heparin: Protamine sulfate Lorazepam (Benzodiazepine overdose): Flumazenil Opioid overdose: naloxone Calcium channel blocker: calcium Beta-blocker: Glucagon 3mg IV Tylenol: Mucomyx 50 Pt is experiencing hyperactive delirium. She is trying to full out her foley and get OOB. What medication should you give to treat hyperactive delirium? A. Diazepam B. Haloperidol C. Lorazepam D. Midazolam Correct Answer: B. Haloperidol - good for delirium Lorazepam is for ETOH withdraw sx ASA inhibits the release of what? A. Platelet B. Fibrinogen C Thromboxane A2 D. Nitric Oxide Correct Answer: Thromboxane A2 ETC info Correct Answer: ETC info What components are needed to calculate anion gap? 51 Correct Answer: Sodium, potassium, chloride and bicarbonate Normal: (8 to 16 mmol/l) How can you differentiate neurogenic shock from other forms of distributive shock? Correct Answer: All shocks will have low BP but neurogenic shock will also have low HR (Ex HR 45) aka bradycardia Pt is admitted to hospital with severe vomiting for 2 days after beginning chemotherapy. Pt then has bright red emesis. What complication does the nurse suspect? A. Esophageal variceal rupture B. Gastric perforation C. Gastritis D. Mallory-Weiss Tear Correct Answer: D. Mallory-Weiss Tear SEVERE VOMITING can cause pt to have a mallory-weiss Tear **Pt is getting 6 units of PRBC for GI bleed. What electrolyte should you monitor? Correct Answer: Calcium Calcium citrate is used as a preservative in the blood bank but it binds to calcium once given in the body so giving PRBCs will lower Ca levels