NRNP 6566 / NRNP6566 Advanced Care of Adults in Acute Settings I Week 9 Knowledge Check | Questions and Verified Answers | Latest Update

NRNP 6566 / NRNP6566 Advanced Care of Adults in Acute Settings I Week 9 Knowledge Check | Questions and Verified Answers A 32 year old preschool teacher complains of difficulty swallowing, s ore throat, and chills. She is febrile with a temperature of 101.6 along with white patches on her tonsils. Her rapid strep test is positive. Her past medical history is positive for an anaphylactic reaction to cefaclor two years ago. What antibiotic could be safely utilized in this patient? Correct Answer: Streptococcus is usually treated with amoxicillin. Her type 1 anaphylactic re- action to a cephalosporin means you should not use a cephalosporin or peni- cillin. Acceptable alternatives would be macrolide such as azithromycin or clindamycin. A 20-year old woman was seen by her primary care provider last week and diagnosed with a lower track UTI. Her complaints at that time included burning on urination, frequent urination of a small amount, and superpubic pain. She was prescribed a 3 day course of Bactrim which she completed. She is admitted to the step down unit today with complaints of fever (102.6 and above) for the past 24 hours and CVA tenderness. She appears very ill and is somewhat confused today. Her BP is 100/62. Her family indicates that she has been vomiting for the last 24 hours and been unable to keep food or fluids down. What would your initial plan for this patient include? Correct Answer: This patient has classic symptoms of pyelonephritis as well as sepsis. Her high temperature, low blood pressure, vomiting, dehydration, and confusion indicate a need for admission and IV antibiotics. Initial antibiotic options include ceftriazone or ciprofloxin PLUS gentamicin OR ampicillin/ sulbactam. Intravenous fluid administration is also indicated. According to the Surviving Sepsis campaign, an initial bolus of 30 ml/kg over 30-60 minutes should be administered. Urine culture and sensitivity should be sent. Antibiotics should be adjusted based on the results of these tests. A 26 year old male is scheduled for a lumbar laminectomy tomorrow. Penicil-lin causes a rash in this patient. His preoperative orders include cefazolin 2 gm IV to be given on call to the OR. The NP is called to change the antibiotic order due to the patients allergy. What is the best action for the NP to take? Correct Answer: There is a 5-8% cross allergy between pencilling and cephalosporins in pa- tients that are allergic to penicillin. The most current literature indicates that patients with a Type 1 anaphylactic reaction to penicillin should not be given cephlosporins. Since this patient has a rash reaction, proceeding with the cefazolin order would be within the current recommendations. Some facilities still have guidelines in place that would prevent a penicillin allergy patient from getting a cephlosporin. In this instance, the Surgical Care Improvement Pro-ject (SCIP) includes alternate recommendations of Vancomycin 1-2 grams IV 1 hour prior to surgery or Clindamycin 900 mg IV 1 hour prior to surgery. What factors are considered when making empiric antibiotic decisions? Apply those factors to a patient with suspected acute otitis media. Correct Answer: Once a clinical diagnosis is made based on patient symptoms and exam findings, factors that assist in making empiric antibiotic decisions include the most common bacteria that cause this type of infection, the patients immunocompetence status, knowledge of any recent antibiotic use, past medical history, and recent health history, The most common bacterial pathogen for acute otitis media is streptococcal pneumoniae followed by haemophilus influenza and moraxelia catarrhalis. If the patient has a competent immune system and no previous antibiotics in the past 30 days, then amoxicillin or amoxicillin / clavulanic acid would be considered the best first line treatment. If the patient had been on amoxicillin for a throat infection two weeks ago, then a different antibiotic such as cefdinir or cefuroxime (considered second line antibiotic) would be selected now. It would be assumed that the bacteria causing the acute otitis is not sensitive to the amoxicillin that was given previously. Also, the cephlosporins have more activity against gram negative bacteria (such as H. Influenza and M. Catarrhalis) then amoxicillin does. Recent inpatient hospitalizations or more than two episodes of acute otitis media in the past few months may also indicate the need to choose a second or third line antibiotic because of suspected resistance to the first line drug (amoxicillin). A 42 year old female has a severe bacterial infection. She is being treated with a broach spectrum IV drug. The drug is administered too rapidly causing hypotension, flushing and itching over the upper portion of her chest, neck, and face. What antibiotic is likely responsible for these symptoms? Correct Answer: Vancomycin is the likely culprit in causing these symptoms. This is common- ly referred to as “red man” syndrome. These are caused by histamine relief when vancomycin is infused too rapidly. A 72 year old male is admitted to the hospital from his long term can facility after complaints of dyspnea and cough for 1 week. He was diagnosed with a COPD exacerbate and started on azithromycin. He has had little improvement after 3 days on this antibiotic. His past medical history includes hypertension, COPD, and hyperlipidemia. Current medications include lisinopril, atrovastatin, salmeterol, and albuterol inhaler. Current symptoms include fever, chills, productive cough, and worsening dyspnea. Current vital signs T 101.6 HR 92. RR 20 BP 138/82. O2 saturation is 96% on 4L of O2 Chest x-ray shows consolidation in the left lower lobe CBC and CMP are all within normal limits. How would you manage this patient? Correct Answer : blood cultures and sputum culture and gram staining. Start patient on ciprofloxacin 500mg PO BID x7 days, piperacillin/tazobactam 3.375g Q6hrs x7, Vancomycin weight based dose IV q12hr x 7 days. Adjust antibiotics one culture and sensitivity report is finalized. Since this patient is transferred from another health care facility, he should be treated for health care acquired pneumonia (HAP). Initial treatment is empiric and very broad spectrum until patient specific culture and sensitivity results are available. Initial antibiotic coverage should include a 3 drug resume to cover multi drug resistant pathogens including pseudomonas and MRSA. Sample combinations to utilize would be: -cefepine, meropenem, piperacillin/tazobactam, OR aztreonam PLUS -ciprofloxin, levofloxacin, gentamicin, OR tobramycin PLUS -vancomycin, linezolid, OR telavancin Once culture and sensitive results are available the 3 drug regime should be deescalated and replaced with appropriate antibiotics. A 54 year old women is 7 days post op following a breast lump removal. She complains of pain, redness, and swelling around her left breast incision. She has a low grade temperature (99.6). The NP determines that she has a post operative wound infection. What antibiotics would be indicated to treat her infection? Correct Answer: Most post operative skin infections are caused by staphylococcus. Cephalosporins have traditionally been utilized to treat these infections be- cause the penetrate skin tissue very well. If there is concern that MRSA is the causative agent, then Bactrim, doxycycline, or clindamycin should be utilized. Treatment should continue for a minimum of 10 days. Any drainage from the would should be sent for culture and sensitivity. A 16 year old male is admitted to the step down unit following laparotomy for appendici- tis. It was determined during surgery that the appendix had ruptured causing a perito- nitis. What antibiotics would be indicated to treat the peritonitis? Correct Answer: Initial antibiotics would include cefoxitin or piperacillin/tazobactam. Antibiotics are con-tinued until the patient is afebrile and leukocytosis is corrected. For a more severe peritonitis, a carbapenems (such as Merrem) should be utilized. A 19 year old female presents with complaints of crampy abdominal pain. The pain has been present for about 7 days. She verifies unprotected sexual activity with multiple partners over the past 6 months. The pain is worse with movement and exercise. She has purulent vaginal discharge and a low grade temperature (99.6). PID is suspected and cultures have been sent off. What are the most common bacteria in this patient and how are they treated? Correct Answer: Approximately 50% of PID is causes by N. gonorrehea or C. trichmonas. Other pathogens include Gardnerella vaginalis, Haemophilus influenzae, and anaerobes such as Peptococcus and Bacteroides. Treatment should begin immediately and should include empirical broad- spectrum antibiotics to cover the full range of common organisms. All regimens must be effective against C trachomatis and N gonorrhea. Patients on an intravenous (IV) PID regimen can be transitioned to oral antibiotics 24 hours after clinical improvement. These should be continued for a total of 14 days. The CDC has identified 2 potential antibiotic treatment regimes for PID. Regimen A consists of the following: Ceftriaxone 250 mg intramuscularly (IM) once as a single dose plus Doxycycline 100 mg orally twice daily for 14 days Metronidazole 500 mg orally twice daily for 14 days can be added if there is evidence or suspicion of vaginitis or if the patient underwent gynecologic instrumentation in the preceding 2-3 weeks Regimen B consists of the following: Cefoxitin 2 g IM once as a single dose concurrently with probenecid 1 g orally in a single dose, or another single-dose parenteral third-generation cephalosporin (eg, ceftizoxime or cefotaxime) plus Doxycycline 100 mg orally twice daily for 14 days Metronidazole 500 mg orally twice daily for 14 days can be added if there is evidence or suspicion of vaginitis or if the patient underwent gynecologic instrumentation in the preceding 2-3 weeks A 42 year old man is evaluated for redness, pain, swelling, and tenderness on the anterior right thigh. His symptoms started about 4 days ago with a small 1 cm blister on his thigh. The area has gotten bigger over the past 4 days and is now 4 cm x 6 cm. He indicates that has been having fever and chills over the past couple of days. The NP diagnoses him with cellulitis. What would your treatment for this be? Correct Answer : Factors to consider for this patient is to verify his immune system is competent and the risk of MRSA exposure / infection. If he is immunocompetent with a low MRSA risk, the first line antibiotic would be a cephalosporin or such as cephalexin 500 mg po qid for 7-10 days. If the risk of MRSA is elevated, an antibiotic that provides coverage should be selected such as clindamycin or sulfamethoxazole/trimethoprim. Show Less