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NRNP 6566 KNOWLEDGE CHECK COMPLETE A+ GUIDE
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NRNP 6566 WEEK 9 KNOWLEDGE CHECK WITH ANSWERS
NRNP 6566 WEEK 9 KNOWLEDGE CHECK WITH ANSWERS • Question 1 A 32 year old preschool teacher complains of difficulty swallowing, sore throat, and ... [Show More] 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 reaction to a cephalosporin means you should not use a cephalosporin or penicillin. Acceptable alternatives would be macrolide such as azithromycin or clindamycin. • Question 2 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. • Question 3 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 patients 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. • Question 4 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). • Question 5 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 commonly referred to as “red man” syndrome. These are caused by histamine relief when vancomycin is infused too rapidly. • Question 6 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? 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. Correct Answer 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. • Question 7 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 because 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. • Question 8 A 16 year old male is admitted to the step down unit following laparotomy for appendicitis. It was determined during surgery that the appendix had ruptured causing a peritonitis. 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. • Question 9 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? [Show Less]
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NRNP 6566 WEEK 8 KNOWLEDGE CHECK WITH ANSWERS
NRNP 6566 WEEK 8 KNOWLEDGE CHECK WITH ANSWERS • Question 1 What type of ICU sedation would be appropriate for a 32 year old male patient who ... [Show More] is intubated with bilateral chest tube following a motor vehicle crash. Correct Answer: The Society of Critical Care Medicine publishes a guideline on sedation. It is: Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (2018). Light sedation is suggested for intubated ICU patients. Non-benzodiazepine sedatives (either propofol or dexmedetomidine) are preferable to benzodiazepine sedatives (either midazolam or lorazepam) in critically ill, mechanically ventilated adults. • Question 2 Describe the levels of sedation (minimal, moderate, deep, general anesthesia, and dissociation) and its affect on consciousness, airway, ventilation, and reflexes. Correct Answer: Sedation decreases a patient’s awareness to the environment and their responses to external stimulation. Sedation occurs a long a continuum which includes minimal, moderate, deep, general anesthesia, and dissociation. Minimal sedation is a drug induced relief of anxiety or apprehension with minimal to no affection on sensorium. Most often this is achieved with an antianxiety medication. Moderate sedation causes a depression of consciousness but the patient can still respond to external stimuli. Airway, spontaneous ventilation, and cardiovascular function are maintained. Deep sedation causes a depression of consciousness in which the patient cannot be aroused but responds purposefully to repeated or painful stimuli. Cardiovascular function is maintained but airway and spontaneous ventilation may be compromised. General anesthesia is a state of unconsciousness where the patient is unable to respond to any stimuli. Close monitoring of all airway, ventilation, and cardiovascular function is essential. Dissociation is considered to be a type of moderate sedation that occurs when using medications in the phencyclidine group (such as ketamine). They cause a dissociation of the limbic system preventing higher centers from receiving sensory stimuli. Like moderate sedation, airway reflexes, spontaneous ventilation, and cardiovascular function are all maintained. • Question 3 The APRN has determined that a 21 year old motor vehicle crash victim needs a rapid sequence intubation. The patient weighs 77 kg. What medications are indicated to successfully achieve the rapid sequence intubation? Correct Answer: Rapid sequence intubation requires the use of induction agent to cause unresponsiveness and a neuromuscular blocking agent to cause muscular relaxation. It is the fast and most effective means of controlling the emergency airway. There are no contraindications to using Etomidate and Succinylcholine Etomidate 23 mg IV and Succinylcholine 115 mg IV Here are details about the different medications and their uses. INDUCTION AGENTS Etomidate 0.3mg/kg IV onset: 10-15 seconds Use: good option for most situations including hemodynamically unstable patient. Avoid in sepsis or seizures Can cause adrenal suppression, myoclonus, pain on injection Ketamine Dose: 1.5 mg/kg IV (4mg/kg IM) Onset: 60-90 sec Duration: 10-20 min Use: good option for any RSI,especially if hemodynamically unstable. May be used in TBI (no increase in ICP) and reactive airway disease (causes bronchodilation) Can cause an increase in secretions, caution in hypertension and tachycardia, may cause laryngospasm and increased intra-ocular pressure. Thiopentone Dose: 3-5 mg/kg IV TBW Onset: 30-45 sec Duration: 5-10 min Use: good option in hemodynamically stable patients, also for status epilepticus Causes histamine release, myocardial depression, vasodilation, hypotension Propofol Propofol 1.5-2.5 mg/kg x TBW as the general guide Onset: 15-45 seconds Duration: 5 – 10 minutes Use: should be used in hemodynamically stable patients, appropriate for patients with reactive airways disease or status epilepticus Can cause hypotension, myocardial depression, reduced cerebral perfusion muscular rigidity in high induction doses, bradycardia, tissue saturation at high doses PARALYTIC AGENTS Suxamethonium (aka succinylcholine) Dose: 1.5 mg/kg IV (2 mg/kg IV if myasthenia gravis) and 4 mg/kg IM (in extremities) Onset: 45-60 seconds Duration: 6-10 minutes Use: widely used unless contra-indicated; ideal if need to extubate rapidly following an elective procedure or to assess neurology in an intubated patient Drawbacks: numerous contra-indications (hyperkalemia, malignant hyperthermia, >5d after burns/ crush injury/ neuromuscular disorder), bradycardia (esp after repeat doses), hyperkalemia, fasciculations, elevated intra-ocular pressure, will not wear off fast enough to prevent harm in CICV situations Rocuronium Dose: 1.2 mg/kg IV IBW Onset: 60 seconds Use: can be used for any RSI unless contra-indication or require rapid recovery for extubation after elective procedure or neurological assessment; ensures persistent ideal conditions in CICV situation (i.e. immobile patient for cricothyroidotomy) – can be reversed by sugammadex Drawbacks: allergy (Rare) • Question 4 A 66 year old women in the ICU is diagnosed with delirium. What would be the best approach to treating her delirium? Correct Answer: Delirium is common in critically ill adults. Delirium is a clinical diagnosis which can be detected with some screening tools such as the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist. Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (2018) by the Society of Critical Care Medicine recommends a muticomponent, nonpharmacologic intervention focused on reducing modifiable risk factors. These interventions include reorientation, cognitive stimulation, use of clocks, improved sleep, reduced sedation, early rehabilitation and mobilization, use of hearing aids and eye glasses. Haloperidol is not routinely recommended and studies have not shown that it shortens the duration of the delirium. However, short term use of haloperidol or an atypical antipsychotic may be warranted for those patients who experience significant distress, agitation, or physical risk to themselves or others. • Question 5 The NP is beginning to repair a laceration on a 22 year old female. The patient mentions that she is allergic to lidocaine. What medication would be an appropriate alternative for this patient? Correct Answer: Local anesthetics include two classes of medications that include esters and amides. Lidocaine and bupivacaine are amide anesthetics. In this patient, an ester anesthetics should be utilized. Procaine is an example of an ester local anesthetic. • Question 6 A 54 year old 112 kg women is admitted for incision and drainage of a left renal abscess. She needs TID wet to dry dressing changes that are very painful. She rates the pain during the dressing change as a 10 and describes in as sharp, pulling, and burning. Prior to the last dressing change she received 2 mg of morphine IV which was totally ineffective in relieving any pain of the dressing change. How would you manage the medication dosing prior to the next dressing change? Correct Answer: Recommended IV morphine dosing is 0.05 to 0.1 mg/ kg. Based on her weight, the recommend-ed dose would be 6-12 mg IV every 1-2 hours. Since 2 mg was ineffective, it would be reasonable to increase the next dose to 6 mg IV 20 minutes prior to the dressing change. Assess her response to this dose increase and determine if it is appropriate or another increase (add 2 mg) is needed to achieve pain relief during the dress-ing change. • Question 7 A 36 year old man complains of sciatic type nerve pain in his left posterior leg. What medication would be best to manage his pain? Correct Answer: Nerve pain is usually poorly treated with opioids. Anti-inflammatories, anticonvulsants (such as gabapentin, carbamazepine, and pregabalin), and antidepressants are more effective in treating never pain such as sciatica, peripheral neuropathy, or other nerve related pain secondary to cancer or HIV. • Question 8 A 44 year old man was given fentanyl to achieve moderate sedation for a colonoscopy. During the procedure, the patients oxygen saturation begins to decline and while assessing the patient the NP notices chest wall rigidity. What is the cause of the rigidity and how would you treat it? Correct Answer: Intravenous administration of narcotics, especially fentanyl, can cause chest wall rigidity which is an uncommon but life threatening complication. The patient is unable to be ventilated because of the tightness in the chest wall. To treat this, succinylcholine should be administered and the patient ventilated with a bag-valve-mask device until his respiratory drive returns. A dose of naloxone should also be administered to combat the effects of the narcotics. Additional doses can be administered if needed. • Question 9 A 66 year old man is admired to the ICU with respiratory distress and bilateral pneumonia. He has a history of a CVA 2 years ago with right hemiplegia and aphasia. Current vitals signs are T 98.8 HR 115 BP 170/99. RR 32. Oxygen saturation is 90% on a nonrebreather mask. The patient weighs 70 kg. The NP decides to perform a rapid sequence intubation. What medications and doses would be appropriate for this patient? [Show Less]
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NRNP 6566 WEEK 7 KNOWLEDGE CHECK (VERIFIED)
NRNP 6566 WEEK 7 KNOWLEDGE CHECK • Question 1 A 54 year old female has a 30 year pack smoking history. She recently underwent pulmonary funct... [Show More] ion testing which showed moderate obstructive lung disease. What would your treatment plan (including medications) include for this patient? Correct Answer: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 suggests that smoking cessation should be immediately pursued if the patient is still smoking. Nicotine replacement (gum, inhaler, nasal spray, patch, lozenge, or sublingual tablet) are reliable methods to assist in long term smoking cessation. Varenicline, bupropion, and nortriptyline also increase long term quit rates but should be one part of an intervention program and not the sole intervention. Professional counseling and support have a positive impact on smoking cessation. Bronchodilators are the baseline medication for COPD patients. Patients can be initiated on short acting beta agonists (SABA) or long term beta agonists (LABA) based on their symptoms. Short acting medications come in various forms including inhaler, nebulizer, pills, or liquid syrup. Long acting bronchodilators are delivered via inhaler or nebulizer. Combinations of SABA and LABA s are common in treatment plans for COPD patients. LABA have a duration of action of 12 hours while SABA last for about 4-6 hours. SABA can provide immediate symptom relief. • Question 2 A 23-year-old male with Type 1 diabetes presents to the ER complaining of fatigue and malaise. He tells you he has skipped his insulin injections the previous two days. His labs are: PH 7.10 Na 140 BUN 35 PCO2 10 K 4.1 Crt 1.1 PO2 112 Cl 105 BS 845 HCO3 4 CO2 5 + ketonemia What is this patient's acid base status? What is your working diagnosis for this patient? Correct Answer: Metabolic acidosis with respiratory alkalosis pH is low Normal HCO3 is 22-26 so 4 is low causing acidosis Leading diagnosis – Diabetic Ketoacidosis Anion gap is elevated at 31 Elevated blood sugar with positive ketones present are key symptoms of diabetic ketoacidosis • Question 3 For the following ABGs, identify the level of hypoxemia, the primary acid base disorder, and the type of compensation. Example - acute respiratory acidosis with metabolic alkalosis and severe hypoxemia • Question 4 A 66 year old male is diagnosed with COPD. His current medications include hydrochlorothiazide 25 mg po daily, lisinopril 20 mg po daily, and Crestor 10 mg po daily. The APRN has ordered salbutamol 4 mg po TID. What side effects may occur? Correct Answer: Tachycardia and palpitations may occur due to the stimulation of the beta2adrenergic receptors. Older patients with higher doses of beta2-agonists may experience an exaggerated somatic tremor. Hypokalemia is possible especially when beta2-agonists are combined with thiazide diuretics. Oxygen consumption may be increased in rising conditions in patients with chronic heart failure those these effects can decrease over time. Hypertension, hypotension, angina, and arrhythmia are possible as well. • Question 5 A 62 year old patient with COPD is hypoxic and SOB. He is currently on BiPAP with the order reading 12/5 100% Rate 12. Explain what each number in the BIPAP order means. Describe what BIPAP is and when it can and cannot be utilized Correct Answer: 12 is the initial inspiratory positive airway pressure (IPAP) 5 is the initial expiratory positive airway pressure (EPAP) These rates can be increased by 2-5 cm H20 Rate of 12 breaths per minute FIO2 initially set at 100% (can be titrated down) Noninvasive positive pressure ventilation (NIPPV) refers to the delivery of positive pressure ventilator support without the insertion of an endotracheal tube. This intervention works to improve lung volumes and decrease the work of breathing. NIPPV can be considered in Type 1 Respiratory failure which is when the patient cannot oxygenate such as pulmonary edema. Also in Type 2 Respiratory failure which is when a patient cannot ventilate such as in COPD. Do not use it in patients that are apneic, hemodynamically unstable, or with excessive secretions. Endotracheal intubation would be indicated if the patient becomes acidotic (pH<7.25), respiratory rate greater than 30, shock, refractory hypoxemia, vomiting, or declining mental status. • Question 6 For the following ABGs, identify the level of hypoxemia, the primary acid base disorder, and the type of compensation. Example - acute respiratory acidosis with metabolic alkalosis and severe hypoxemia • Question 7 For the following ABGs, identify the level of hypoxemia, the primary acid base disorder, and the type of compensation. Example - acute respiratory acidosis with metabolic alkalosis and severe hypoxemia • Question 8 A 14 year old female asthmatic is brought to the ER in moderate respiratory distress. Her PEF is 55% of predicted. What would your immediate medication orders include? Correct Answer: Albuterol inhaled 0.5 mg / kg nebulizer every 20 minutes for 3 doses Prednisone 1 mg/ kg /day orally - give half dose even 12 hours Oxygen to maintain saturations of at least 90% although 94% is preferred in children Assess for presence of infection as a trigger for the acute asthma attack. Antibiotics would be added if bacterial infection is present. • Question 9 A 65-year-old female suddenly becomes hypotensive one day following surgery for a fractured femur. Her ABG before surgery on room air showed a pO2 of 84 and pCo2 of 39. FIO2 0.21 Hb 11.5 pH 7.47 pCO2 32 pO2 57 HCO3 23 SaO2 83% What are the major differential diagnoses to consider as an etiology for the change in her status? Correct Answer: Her acid base balance is essentially normal but she is hypoxic with low oxygen saturation. Her hemoglobin is normal so there is capacity to carry oxygen to the tissues. Potential diagnosis to consider would be: Pulmonary embolism - blood clots in the lung would prevent diffusion of oxygen and lead to low saturation Hypovolemic shock – low fluid volume leading to low blood pressure and poor perfusion would lead to low oxygen saturation and perfusion Pneumonia – infection in the lung with accumulated fluids would also prevent diffusion of oxygen • Question 10 For the following ABGs, identify the level of hypoxemia, the primary acid base disorder, and the type of compensation. Example - acute respiratory acidosis with metabolic alkalosis and severe hypoxemia [Show Less]
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NRNP 6566 WEEK 5 KNOWLEDGE CHECK (SET 2) VERIFIED
NRNP 6566 Week 5 Knowledge Check QUESTION 1 1. A 54-year women is 3 days post abdominal surgery for removal of a cancerous mass in her abdomen. She deve... [Show More] lops acute shortness of breath associated with tachycardia and hypotension. CT Scan of the chest is positive for multiple small pulmonary embolism. What medication and dosing would you order initially to treat the pulmonary embolism? This patient should be given fondaparinuc (Arixtra) subcutaneously. Dosing is weightbased: 1. 5 mg SQ once daily (for weight less than 50 kg 2. 7.5 mg SQ once daily (for weight ranges from 50-100 kg) 3. 10 mg SQ once daily (for weight exceeding 100 kg). QUESTION 2 1. A 64-year man is recovering from a transurethral resection of the prostate for treatment of benign prostate hyperplasia. The patient is receiving intravenous antibiotics for the urinary tract infection. The post-operative course has been smooth and the APRN is removing the 3-way Foley catheter when there is a sudden release of bright red blood with many blood clots in the Foley bag. The patient becomes hypotensive, tachycardic and the APRN notes new ecchymoses on the patient’s arms and legs. The patient was immediately transferred to the surgical intensive care unit (SICU) and a stat hematology consult was conducted. Stat CBC, d-dimer, peripheral blood smear, partial thromboplastin time, Prothrombin time/international normalization ratio (INR), and fibrinogen labs were drawn. Results were: CBC with markedly decreased platelet count, peripheral blood smear showed decreased number of platelets and presence of large platelets and fragmented red cells (schistocytes), prothrombin time prolonged as was the partial thromboplastin time. The d-dimer was markedly elevated, and fibrinogen level was low. Based on the clinical presentation and laboratory data provided, what is your working diagnosis? The working diagnosis for this patient is disseminated intravascular coagulation (DIC). It is an acquired coagulation disorder that is most commonly caused by infections (gram negative sepsis), malignant neoplasm, obstetric complication, liver disease, trauma, and burns. This patient is positive for urinary tract infection. Thrombocytopenia (decreased platelets), prolonged PT and aPTT, low fibrinogen levels, positive D-dimer, and schistocytes are all indicative of an acute uncompensated DIC (active hemorrhagic event). QUESTION 3 1. A 26-year-old male was injured in a motorcycle crash 3 days ago. He sustained an acute subdural hematoma, acetabular fracture, and L2 fracture with spinal cord injury and resulting paralysis. He has a warm swollen right lower leg. Duplex ultrasound of the right lower leg is positive. What is the best treatment for this patient? The duplex ultrasound of the right lower leg is positive indicating DVT. Patient is also at higher risk for pulmonary embolism with the paralysis and the acetabular fracture. Anticoagulation would have been indicated for this patient, but the subdural hematoma would be a contraindication for anticoagulation. According to the ACCP guidelines, patients with acute proximal DVT of the leg and contraindication to anticoagulation, the use of an IVC filter is recommended. QUESTION 4 1. A 44-year-old male is admitted to the orthopedic unit following a motor vehicle crash. He has a femur fracture of the right leg. He is not actively bleeding and healthy. He weighs 185 pounds. What should the APRN order as DVT prophylaxis? This patient is at an increased risk of thrombosis and has no active bleeding or low risk for bleeding, so the ACCP recommends anticoagulant thromboprophylaxis with LMWH (low molecular weight heparin), low dose unfractionated heparin (LDUH) BID, LDUH TID or fondaparinux (Grade1B). QUESTION 5 1. A 16-year-old male is brought to the Urgent Care by her mother who states that the girl has had an abnormal number of bruises and “funny looking red splotches” on her legs. Bruises were noted about 2 weeks ago and have increased in number since this time. There is no history of trauma to explain the bruising. Past medical history not remarkable and she takes no medications. The mother does state the girl is recovering from a “bad case of mono” and was on bedrest at home for the past 3 weeks. The girl noticed that her gums were slightly bleeding when she brushed her teeth that morning. Lab work completed show a normal hemoglobin and hematocrit with normal white blood cell (WBC) count and differential. Platelet count of 50,000/mm3 was the only abnormal finding. The staff also noticed that the venipuncture site oozed for a few minutes after pressure was released. Immune thrombocytopenia purpura (ITP) is suspected. What additional diagnostics should be ordered? If this diagnosis is confirmed, how would you treat it? [Show Less]
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NRNP 6566 WEEK 11 KNOWLEDGE CHECK (Verified).
NRNP 6566 WEEK 11 KNOWLEDGE CHECK • Question 1 How would you differentiate between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic sy... [Show More] ndrome (HHS)? Correct Answer: Both of these conditions will include high levels of blood glucose readings. DKA will exhibit acidosis and urinary ketones while HHS will not. Treatment for each condition is similar with fluid bolus and infusion as well as insulin bolus and infusion. • Question 2 Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data: Significant History Type 2 DM x 4 years, HTN Medications Lisinopril 10 mg daily Metformin 1000 mg po daily Glipizide 5 mg po daily Physical Exam Pale, lethargic gentleman Skin is very dry VS 94/64 P 112 RR 30 T 99.4 wt 195 pounds ht 5’11 » Lungs clear bilaterally, rapid respiration CV : RRR, no murmurs or gallops Abd: soft, non-tender, positive bowel sounds Labs: Hb 146 Hct 58% Cr 4.9 Bun 53 Cholesterol 238 Na 126 K 5.6 CL 95 Ca 8.8 Gluc 722 Phosphorus 5.8 Ketone Moderate AST 248 Alk Phos 132 ABG’s ph 7.01 Pco2 20 Po2 100 Sat 98% (on room air) HCO3 7.5 What are the appropriate initial orders to treat this patient? Correct Answer: Admission to the ICU Normal saline IV bolus to counter the vascular dehydration that has occurred. Bolus insulin dose followed by an insulin drip Electrolyte and blood glucose monitoring frequently fluid resuscitation and insulin administration. Bicarbonate is typically not administered unless the pH is below 7 Assess the patient for presence of any infection that may have precipitated this event • Question 3 Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data: Significant History Type 2 DM x 4 years, HTN Medications Lisinopril 10 mg daily Metformin 1000 mg po daily Glipizide 5 mg po daily Physical Exam Pale, lethargic gentleman Skin is very dry VS 94/64 P 112 RR 30 T 99.4 wt 195 pounds ht 5’11 » Lungs clear bilaterally, rapid respiration CV : RRR, no murmurs or gallops Abd: soft, non-tender, positive bowel sounds Labs: Hb 146 Hct 58% Cr 4.9 Bun 53 Cholesterol 238 Na 126 K 5.6 CL 95 Ca 8.8 Gluc 722 Phosphorus 5.8 Ketone Moderate AST 248 Alk Phos 132 ABG’s ph 7.01 Pco2 20 Po2 100 Sat 98% (on room air) HCO3 7.5 What is the “ corrected” sodium level for the hyperglycemia? What does this mean and how would it impact your treatment plan for this patient? Correct Answer: The equation for corrected sodium is: Corrected sodium (mEq/L) = measure sodium (mEq/L) + 0.016 {glucose (mg/dL)-100}. Juans corrected sodium is 136. 126+ 0.016 {722-100} = 135.95 The measured serum sodium concentration should be corrected for the hyperglycemia by adding 1.6 mEq per L to the measured sodium value. Corrected serum sodium concentrations of greater than 140 mE1 per L and calculated total osmolalities greater than 330 most per kg of water are associated with large fluid deficits. If the corrected sodium is less than 135 mEq/L, then isotonic saline should be continued at a rate of 250 to 500 mL/ hour. If the corrected sodium is normal or elevate, then IV fluid is generally switched to 0.45 normal saline. • Question 4 A 56 year old male with an acute COPD exacerbation is admitted to the ICU. He has type I diabetes and utilizes NPR and regular insulin twice a day to manage his diabetes. He is currently taking very little orally due to his shortness of breath. What would the best way to manage his diabetes and insulin needs in the ICU? Correct Answer: According to the American Diabetes Association (2019) guideline, basal long acting insulin should be administered once a day. Point of care blood glucose testing should be completed at least four times a day with sliding scale insulin coverage. The stress of illness will require the need for insulin but the evolution of the patients condition, varying oral intake, and medications will cause variations in the patients blood glucose. Point of care testing with sliding scale coverage along with basal insulin is the most flexible method to meet the patients insulin needs while in the ICU. • Question 5 A 56 year old male with an acute COPD exacerbation is admitted to the ICU. He has type I diabetes and utilizes NPR and regular insulin twice a day to manage his diabetes. He is currently taking very little orally due to his shortness of breath. What is the blood glucose goal for this patient in the ICU? Correct Answer: According to the American Diabetes Association (2019) guideline, pre-prandial blood glucose control of less than 126 is the goal. Post prandial no greater than 180. Hyperglycemia is associated with poor outcomes especially in critical illness. According to the NICE-SUGAR study, patients with goals lower than this (considered intensive insulin therapy) had increased mortality. • Question 6 Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data: Significant History Type 2 DM x 4 years, HTN Medications Lisinopril 10 mg daily Metformin 1000 mg po daily Glipizide 5 mg po daily Physical Exam Pale, lethargic gentleman Skin is very dry VS 94/64 P 112 RR 30 T 99.4 wt 195 pounds ht 5’11 » Lungs clear bilaterally, rapid respiration CV : RRR, no murmurs or gallops Abd: soft, non-tender, positive bowel sounds Labs: Hb 146 Hct 58% Cr 4.9 Bun 53 Cholesterol 238 Na 126 K 5.6 CL 95 Ca 8.8 Gluc 722 Phosphorus 5.8 Ketone Moderate AST 248 Alk Phos 132 ABG’s ph 7.01 Pco2 20 Po2 100 Sat 98% (on room air) HCO3 7.5 What patient education would be important to provided related to sick day management of his diabetes (include management of insulin) ? Correct Answer: Monitor your blood sugar frequently when you are sick - at least every 4 hours Keep a log of these readings in case you need medical care Take your usual dose of insulin as long as your blood glucose readings do no indicated hypoglycemia Basal insulin should be continued as normal. Call your provider should your blood glucose remain higher than 240 consistently Drink a glass of liquid (non-alcholic, caffeine free) every hour when sick. Try to intake foods like gelatin, crackers, soup, broth, and applesauce. Check your urine for ketones every 4 hours regardless of blood glucose readings. If your testing indicates a large volume of ketones, contact your provider immediately. • Question 7 A 37 year old female with a 20 year history of DM is post cholecystectomy with complications. She has been on four time daily blood sugar testing with sliding scale insulin coverage. She is preparing for discharge and wanted to return to her previous blood sugar management. Her pre-hospitalization insulin regime included: NPH insulin 16 units in AM and 8 units in PM Regular insulin 8 units in am and 3 units in PM She resumed this regime 2 days ago. Upon rounding this am, the patient tells the NP that she has woken up feeling awful. She is sweaty and shaky during the night and lethargic in the morning. The NP reviews her blood sugar readings and discovers this: [Show Less]
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NRNP 6566 WEEK 4 KNOWLEDGE CHECK (VERIFIED)
NRNP 6566 WEEK 4 KNOWLEDGE CHECK (VERIFIED) • Question 1 A 47 year old male admitted with an infected elbow wound. On his second day in the hospi... [Show More] tal you find him in his room confused and agitated. Vital signs are as follows: Temperature – 96.2 °F Pulse -140 beats per minute Respirations – 40 breaths per minute Blood Pressure – 90/40 mmHg Labs include a WBC count of 3,000 Pt weighs 185 pounds Further assessment of him includes: Urine output of 100cc for the last 8 hours Pulse oximetry of 88% on room air Pallor What is your working diagnosis? Corr ect There are 4 stages of sepsis. Ans Systemic Sepsis Severe Sepsis Septic Shock wer: Inflammatory Response Syndrome (SIRS) Criteria – any 2 of Meet SIRS criteria Sepsis criteria plus Severe sepsis the following: and have a possible evidence of organ criteria plus any one *Temperature over or documented system dysfunction of the following: 100.9 or less than source of infection *new need for *Tissue 96.8 *positive cultures or invasive or non- hypoperfusion *Heart rate over 90 possible infection invasive respiratory persists despite *Respirations over site intervention crystalloid fluid 20 per minute *BP less than 90 administered. *WBC over 12,000 or systolic, MAP less *need for less than 4,000 than 65, or Systolic vasopressors BP 40 mmHg less documented by BP than previous less than 90 systolic, documented BP MAP less than 65, or *New altered mental Systolic BP 40 status mmHg less than *Cr greater than 2 orprevious urine output less documented BP than 0.5cc/kg/hour * Lactate greater for 2 hours than 4 mm/L *Plateletssless than 100,000 *Lactate greater than 2 mm/L This patient meets the criteria for septic shock Temp – 96.2 Heart Rate 140 Respirations 40 WBC 3000 Source of infection – elbow wound o Question 2 A 50 year old woman is thought to be in septic shock. What physical assessment findings would you expect to find to confirm this type of shock? Correct Answer: Hypotension is the common finding in all shock states. In septic shock, you would also expect to find: Tachycardia Full bounding pulses Pink, warm, flushed skin Tachypnea Decreased urine output Fever Hemodynamic measures would indicate a decreased cardiac output, decreased systemic vascular resistance, and a decreased central venous pressure. o Question 3 Organ dysfunction – confused, urine output of 12 cc per hour (min 42 per weight) Blood pressure of 90/40 with a MAP of 56.5 A 56 year old man is thought to be in hypovolemic shock. What are the initial interventions for a patient in hypovolemic shock? Correct Answer: Initial treatment would include: *identify and stop fluid loss / bleeding if possible *Crystalloid fluid replacement – 0.9% NS or LR initially infuse 2 L of fluid and then reassess. *Hemorrhagic shock should be treated with a balanced infusion of packed red blood cells, plasma, and platelets. Type O negative PRBC can be administered until cross matched cells are available. *Vasopressors can worsen tissue hypoxia and are not initial treatment in hypovolemia or hemorrhage. o Question 4 Correct Answer: A 44 year old man is thought to be in cardiogenic shock. What are the initial interventions needed for a patient in cardiogenic shock? Initial treatment would include: *if STEMI is suspected – early and definitive restoration of coronary blood flow is the most important intervention (cardiology consult, alert cath lab) *Correction of electrolyte and acid base abnormalities (especially hypokalemia, hypomagnesemia, and acidosis) *Placement of central line (allows CVP monitoring, facilitate volume resuscitation, access for multiple infusions) *Dopamine, norepinephrine, and epinephrine are vasoconstricting drugs that help to maintain adequate blood pressure. Goal is MAP of 60-65. Dopamine increases myocardial contractility and increases but BP but it may increase myocardial oxygen demand. Dobutamine may be preferable if the systolic BP is higher than 80 mmHg since it does not effect myocardial oxygen demand as much as dopamine. Dopamine and dobutamine may cause tachycardia precluding their use in some patients. If hypotensive persists, a direct vasoconstrictor (norepinephrine) may be utilized. Norepinephrine will increase afterload and decrease cardiac output so their use is reserved for refractory hypotension and organ hypoperfusion. o Question 5 *Monitor electrolytes and acid base status* Fluid repletion can be monitored by measuring blood pressure, urine output, mental status, and peripheral edema. What is the mechanism of action and common side effects of dobutamine, norepinephrine, labetalol, and amiodarone? Correct Answer: Drug Mechanism of Action Side Effects Dobutamine Dobutamine directly increased heart rate, stimulates beta-1 increased blood receptors of the heart to pressure, increase myocardial ventricular ectopic contractility and stroke activity, volume, resulting in nervousness, increased cardiac output headache, nausea, vomiting, palpitations, Norepinephrine It stimulates α1 and α2 decreased heart rate adrenergic receptors to increased blood pressure cause blood vessel arrhythmias contraction confusion anxiety shortness of breath headache nausea and vomiting Labetalol Labetalol is a dual alpha Decreased heart rate (α1) and beta (β1/β2) Shortness of breath adrenergic receptor Chest pain blocker and competes Swelling of feet and legs with other Fatigue Catecholamines for Dizziness binding to these sites. Amiodarone Amiodarone is a class III See table below antiarrhythmic that works primarily by blocking potassium rectifier currents that are responsible for the repolarization of the heart during phase 3 of the cardiac action potential. Organ Amiodarone Side effects system Lungs Pulmonary toxicity Pulmonary fibrosis Chronic interstitial pneumonitis Organizing pneumonia ARDS Solitary pulmonary mass Thyroid May induce hypothyroidism and/or hyperthyroidism May aggravate pre-existing thyroid conditions Liver AST/ALT > 2x normal If patients experience more than a two-fold elevation, drug therapy should be discontinued. LFTs should be monitored at baseline and every 6 months. Hepatitis and cirrhosis Heart Bradycardia and AV block Eyes Corneal micro-deposits Optic neuritis GI tract Nausea, anorexia, and constipation Skin Photosensitivity Blue discoloration CNS Various manifestations, esp. peripheral neuropathy (also ataxia, paresthesias, sleep disturbance, impaired memory, and tremor) GU tractEpididymitis and erectile dysfunction o Question 6 A 56 year old Caucasian man is seen in the office as a new patient. He complains of headaches occurring with increasing frequency and attributes them to increased stress at work. He denies any chest pain, shortness of breath, or dyspnea. He smokes one pack cigarettes per day and has two glasses of wine with dinner. Physical exam – obese main (BMI 30) in no apparent distress. BP R arm 168/98 L arm 170/94. HR 64 regular. No thryomegly or lymphadenopathy. Fundascopic exam reveals narrowing of the arteries and arteriovenous nicking. Cardiac exam reveals that his point of maximal impulse (PMI) if displaced 2 cm to the left of the midclavicular line (MCL). No murmurs noted. Lung and abdomen examinations are normal. What tests should be ordered for this patient ? Correct Answer: CMP and CBC at a minimum CMP - evaluate electrolytes and kidney function. Especially important when considering what medication to order and ensuring there is not a renal cause of the hypertension CBC - evaluate for Hemoglobin and Hematocrit. Looking to establish a baseline and assess for anemias [Show Less]
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NRNP 6566 WEEK 3 KNOWLEDGE CHECK (verified)
NRNP 6566 WEEK 3 KNOWLEDGE CHECK • Question 1 Mrs. Franklin is a 68-year-old woman with long-standing, persistent AF being managed with rhythm cont... [Show More] rol on dofetilide. She also has type 2 diabetes mellitus (T2DM), hypertension, and a myocardial infarction 3 years ago. What is her CHADS2 and CHA2DS2-VASc score? How would you interpret those scores in deciding on treatment for Mrs. Franklin? Correct Answer: CHADS2 score=2 (HTN, T2DM) A score of greater than 2 is considered high risk for stroke. CHA2DS2-VASc score=5 (age >65, female, HTN, T2DM, coronary artery disease [CAD]) A score of greater than 2 is considered high risk for stroke. Many patients are hesitant to begin anticoagulation due to the expense and inconvenience. However, after understanding that a 4% annual risk for stroke (if the CHA2DS2-VASc Score is 4) equates to 40% risk over 10 years, patients are more willing to comply. • Question 2 A 58-year-old male complains of a galloping heart rate and shortness of breath. Vital signs are BP 110/74, P 156, RR 22 Oxygen sat is 96%. Continuous EKG monitoring identifies periods of sinus tachycardia as well as episodes of atrial fibrillation. Laboratory results for this patient show: Hemoglobin 13.3 g/dl Hematocrit 39% WBC 8.7 Platelets 172,000 Sodium 140 Potassium 3.7 TSH 0.0 mIU/L T4 3 mg/dl T3 6.6 pg/ml What is your working diagnosis and what two initial medications would you prescribe for this patient? Correct Answer: The low TSH combined with the high T4 and T3 are indicative of hyperthyroidism. A common side effect of the hypermetabolic state is atrial fibrillation. Two medications that should be considered for initial treatment are beta blockers and anti-thyroid drugs. Beta blockers offer quick relief symptoms of hyperthyroidism, such as tachycardia, palpitations, heat intolerance, and nervousness. Nonselective beta blockers, such as propranolol, are preferred because they have a more direct effect on hypermetabolism. Start propranolol at 10 to 20 mg every 6 hours and titrate upward until symptoms are controlled. Once the T4 and T3 have normalized, the propranolol can be tapered off. Methimazole is the drug of choice in nonpregnant patients because of its lower cost, longer half-life, and lower incidence of hematologic side effects. Start the medication at 15 to 30 mg per day. Monthly free T4 and T3 levels should be obtained and methimazole adjusted to reach an euthyroid state. Maintenance doses may be lower (5–10 mg daily). • Question 3 A 63-year-old female has been successfully cardioverted and is now on amiodarone for rhythm maintenance. The patient is on the following medications: Warfarin 10 mg po daily Lisinopril 20 mg po daily Amiodarone 400 mg po daily Prilosec 20 mg po daily Digoxin 4250 mcg po daily What interactions are possible and how would you monitor and adjust for them. Correct Answer: Amiodarone is known to interact with warfarin and digoxin. Digoxin levels may increase 30–50% when taken with amiodarone. Amiodarone increases digoxin concentrations by inhibiting the P-glycoprotein (P-gp) mediated transport that facilitates the elimination of digoxin from the body. The greater the concentration of amiodarone the greater the increase in serum digoxin levels. Patient’s digoxin levels should be closely monitored, and dosing should be decreased to account for this effect. Amiodarone is a potent inhibitor of the enzymes that metabolize warfarin. Decreased metabolism of warfarin leads to higher plasma concentration levels and increased risk of bleeding. Warfarin doses should be decreased, and frequent INR monitoring is indicated when initiating amiodarone treatment. [Show Less]
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NRNP 6566 WEEK 7 KNOWLEDGE CHECK (Verified)
NRNP 6566 WEEK 7 KNOWLEDGE CHECK • Question 1 A patient with respiratory failure has hemodynamic monitoring and is receiving mechanical ventila... [Show More] tion with peak end-expiratory pressure (PEEP) of 10 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial line shows a blood pressure of 90/46. b. The pulmonary artery pressure (PAP) is decreased. c. The cardiac monitor shows a heart rate of 58 beats/min. d. The pulmonary artery wedge pressure (PAWP) is increased. Correct Answer: The hypotension indicates that the high intrathoracic pressure caused by the PEEP may be de-creasing venous return and cardiac output (CO). Decreasing the PEEP should decrease the intrathoracic pressure and improving venous return and cardiac output. • Question 2 The APRN is monitoring a newly intubated patient. He appears to be very anxious and “fighting” the ventilator. What would be the most appropriate action? Correct Answer: Remove the patient from the ventilator and bag him with 100% FIO2. If the patient improves, then the problem is with the ventilator. Respiratory professional should check the ventilator function. If the patient does not improve, the problem is with the patient. If death appears imminent, airway obstruction pneumothorax, and dislodged endotracheal tube must be considered as the cause. If death is not imminent, close examination of the patient and chest X-ray should be completed. The need for additional sedation should be considered as well. • Question 3 A 59 year old man was admitted to the ICU for a COPD exacerbation. He was intubated earlier in the day. Initially after being intubated his static pressure was 23 cm H2o and peak pressure 47 cm H20. The APRN is notified that currently his peak pressure has risen to 62 cm H20 and the static pressure is 42 cm H20. His heart rate has increased from 88 to 112beats / minute and his blood pressure has decreased from 112/88 to 92/ 72. He has decreased breath sounds on the left side. Where do you think the problem lies with this particular patient? Correct Answer: This patient has had increases in both the peak and static pressures suggestion this patient has a new “compliance” problem. A patient with COPD who develops unilateral decreased breath sounds, tachycardia, and hypotension while on mechanical ventilation should be suspected that he has developed a tension pneumothorax. • Question 4 0.5 out of 1 points A 34 year ole email who weights 96 kg (211 lbs.) and is 165 cm (5 ft. 6 inches) tall has chest trauma due to a motorcycle accident. The patient has just been intubated, sedated and paralyzed with morphine sulfate and pancuronium bromide. What initial ventilator settings are appropriate for this patient? Correct Answer: Assist control mode (A/C) is utilized after intubation. Tidal volume is based on the patients ideal body weight (not actual body weight). Ideal body weight for this patient is 63 kg. Tidal volume is set at 8-10 ml/kg or 500-600 ml in this patient. FIO2 should initially be 100% with an initial PEEP of 5 and respiratory rate of 12 - 14. ABG should be obtained after intubation and appropriate adjustments made. • Question 5 A 40 year-old. 6-foot tall man has been inpatient on the step down unit for the past 2 days. He was admitted for fever and cough with production of yellow sputum. His admission blood pressure was 128/72 and initial chest x-ray showed a left lower lobe infiltrate. His ABG on room air showed: pH 7.31, PCO2 30, PO2 78, HCO3 17. He was started on antibiotics and progress notes from he past two days indicate improvement in his condition. The APRN is called by the nurse because of worsening of the patients condition. On your arrival to the room, vitals signs are. BP. 86/60 P 118 RR 38 oxygen saturation on a non-rebreather mask is 78% (this am it was 97% on 2L per NC). The patient is laboring to breath with accessory muscle use. He is less responsive, diaphoretic, and is speaking in short sentences. Repeat chest x-ray shows bilateral diffuse lung opacities. ABG on the non-rebreather mask show: pH 7.18, PCO2 47, PO2 56, HCO3 13. The decision to intubate the patient is made. What initial ventilator settings would you order? Correct Answer: Ventilator settings include the mode of mechanical ventilation, tidal volume, respiratory rate, the inspired oxygen concentration (FiO2), and the level of positive end expiratory pressure (PEEP). Assist control mode is usually initiated after intubation however there is varying data on the use of different modes without clear evidenced based guidelines on this. FiO2 is usually started at 100% and weaned down based on patient response. Tidal volumes are calculated based on the patient’s ideal body weight (not their actual weight). Ideal body weight is calculated by utilizing the patients height To calculate the ideal body weight in kilograms, you can use the following formulas: Men: [(height in inches – 60) X 2.2] + 50 Women: [(height in inches – 60) X 2.2] + 45 Once you have calculated the ideal body weight, the tidal volume is calculated at 6-8 cc/ kg The patient in this case is 6-foot tall (72 inches). Using the formula above, his ideal body weight is about 76kg. A tidal volume of 600 cc would be 8 ml/kg The respiratory rate should be determined based on an assessment of the patient’s minute ventilation requirements. For example, a patient with a normal bicarbonate of 24 who was intubated for a procedure may only need 68 liters/minute of ventilation whereas a patient in severe sepsis with a bicarbonate of 10 may require upwards of 20-25 liters/minute of ventilation to maintain an adequate acid-base status. Once you derive an estimate of the minute ventilation (VE ) needs of the patient, you can use your previously determined tidal volume and simple division to calculate an appropriate respiratory rate (RR = VE/tidal volume) The initial PEEP is usually set at 5 cm H2O. The PEEP is typically not decreased below 5 cm H2O but can be increased as necessary (up to 15 to 20 cm H20) to support oxygenation in patients with severe hypoxemia • Question 6 A 59 year old man was admitted to the ICU for a COPD exacerbation. He was intubated earlier in the day. Initially after being intubated his static pressure was 23 cm H2o and peak pressure 47 cm H20. The APRN is notified that currently his peak pressure has risen to 62 cm H20 and the static pressure is 42 cm H20. His heart rate has increased from 88 to 112beats / minute and his blood pressure has decreased from 112/88 to 92/ 72. He has decreased breath sounds on the left side. What management steps should you institute at this point? Correct Answer: A chest X-ray should be obtained to look for evidence of a pneumothorax, new pleural effusion, developing ARDS. Examine the patient for any abdominal distention. If the patient becomes hemodynamically unstable and there is high index of suspicion for a tension pneumothorax, a large bore needle should be placed into the second intercostal space along the mid-clavicular line to decompress the pneumothorax. Chest tube placement would be indicated after initial needle placement for decompression. • Question 7 Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmo-nary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3- of 23 mEq/. What change in ventilator settings would be indicated? Correct Answer: The patient's PaCO2 and pH indicate respiratory alkalosis. In mechanically ventilated patients who have respiratory alkalosis, the tidal volume and/or respiratory rate may need to be de-creased. Inadequate sedation and pain control may contribute to respiratory alkalosis in patients breathing over the set ventilator rate. The PaO2 is appropriate for a patient with COPD, • Question 8 The APRN is notified that an intubated patients endotracheal tube (ET) was marked at 21 cm and is not at the 24 cm line. The patient appears anxious and restless. What action should the APRN take? [Show Less]
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NRNP 6566 WEEK 6 KNOWLEDGE CHECK (verified)
NRNP 6566 WEEK 6 KNOWLEDGE CHECK • Question 1 A 54 year old female has a 30 year pack smoking history. She recently underwent pulmonary function... [Show More] testing which showed moderate obstructive lung disease. What would your treatment plan (including medications) include for this patient? Correct Answer: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 suggests that smoking cessation should be immediately pursued if the patient is still smoking. Nicotine replacement (gum, inhaler, nasal spray, patch, lozenge, or sublingual tablet) are reliable methods to assist in long term smoking cessation. Varenicline, bupropion, and nortriptyline also increase long term quit rates but should be one part of an intervention program and not the sole intervention. Professional counseling and support have a positive impact on smoking cessation. Bronchodilators are the baseline medication for COPD patients. Patients can be initiated on short acting beta agonists (SABA) or long term beta agonists (LABA) based on their symptoms. Short acting medications come in various forms including inhaler, nebulizer, pills, or liquid syrup. Long acting bronchodilators are delivered via inhaler or nebulizer. Combinations of SABA and LABA s are common in treatment plans for COPD patients. LABA have a duration of action of 12 hours while SABA last for about 4-6 hours. SABA can provide immediate symptom relief. • Question 2 A 23-year-old male with Type 1 diabetes presents to the ER complaining of fatigue and malaise. He tells you he has skipped his insulin injections the previous two days. His labs are: PH 7.10 Na 140 BUN 35 PCO2 10 K 4.1 Crt 1.1 PO2 112 Cl 105 BS 845 HCO3 4 CO2 5 + ketonemia What is this patient's acid base status? What is your working diagnosis for this patient? Correct Answer: Metabolic acidosis with respiratory alkalosis pH is low Normal HCO3 is 22-26 so 4 is low causing acidosis Leading diagnosis – Diabetic Ketoacidosis Anion gap is elevated at 31 Elevated blood sugar with positive ketones present are key symptoms of diabetic ketoacidosis • Question 3 For the following ABGs, identify the level of hypoxemia, the primary acid base disorder, and the type of compensation. Example - acute respiratory acidosis with metabolic alkalosis and severe hypoxemia • Question 4 A 66 year old male is diagnosed with COPD. His current medications include hydrochlorothiazide 25 mg po daily, lisinopril 20 mg po daily, and Crestor 10 mg po daily. The APRN has ordered salbutamol 4 mg po TID. What side effects may occur? Correct Answer: Tachycardia and palpitations may occur due to the stimulation of the beta2adrenergic receptors. Older patients with higher doses of beta2-agonists may experience an exaggerated somatic tremor. Hypokalemia is possible especially when beta2-agonists are combined with thiazide diuretics. Oxygen consumption may be increased in rising conditions in patients with chronic heart failure those these effects can decrease over time. Hypertension, hypotension, angina, and arrhythmia are possible as well. • Question 5 A 62 year old patient with COPD is hypoxic and SOB. He is currently on BiPAP with the order reading 12/5 100% Rate 12. Explain what each number in the BIPAP order means. Describe what BIPAP is and when it can and cannot be utilized Correct Answer: 12 is the initial inspiratory positive airway pressure (IPAP) 5 is the initial expiratory positive airway pressure (EPAP) These rates can be increased by 2-5 cm H20 Rate of 12 breaths per minute FIO2 initially set at 100% (can be titrated down) Noninvasive positive pressure ventilation (NIPPV) refers to the delivery of positive pressure ventilator support without the insertion of an endotracheal tube. This intervention works to improve lung volumes and decrease the work of breathing. NIPPV can be considered in Type 1 Respiratory failure which is when the patient cannot oxygenate such as pulmonary edema. Also in Type 2 Respiratory failure which is when a patient cannot ventilate such as in COPD. Do not use it in patients that are apneic, hemodynamically unstable, or with excessive secretions. Endotracheal intubation would be indicated if the patient becomes acidotic (pH<7.25), respiratory rate greater than 30, shock, refractory hypoxemia, vomiting, or declining mental status. • Question 6 For the following ABGs, identify the level of hypoxemia, the primary acid base disorder, and the type of compensation. Example - acute respiratory acidosis with metabolic alkalosis and severe hypoxemia [Show Less]
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NRNP 6566 WEEK 5 KNOWLEDGE CHECK (verified)
NRNP 6566 WEEK 5 KNOWLEDGE CHECK • Question 1 Renee is a 56-year-old female that fell about a week ago and sprained her R ankle. She states she ... [Show More] has been taking it easy and laying around her home for most of the last week so it would heal. Yesterday she noticed that her calf was sorer than it had been, and her R foot and ankle were more swollen than they had been. She came to urgent care today because she was afraid that the injury was worse than she thought it was. T 99.2 BP 128/77 HR 88 RR 18 Wt 126 pounds Heart S1S2 regular rate and rhythm, Lungs clear, Abdomen soft R ankle is swollen but not discolored. 1-2+ edema noted Dorsiflexion causes some discomfort in the ankle and calf area. Pedal pulses equal bilaterally The APRN orders a duplex ultrasound of the right leg. Radiology reports that the ultrasound is positive for a deep vein thrombosis. How would you manage this patient (include labs and meds)? Correct Answer: It is appropriate to treat her on an outpatient basis with appropriate education and support. Obtain baseline PT/INR, PTT, CBC labs Begin Xarelto 15 mg po bid Patient education on medication and potential complications – return to emergency department for new onset shortness of breath • Question 2 A 26-year-old female is currently on Lovenox 80 mg subq daily. What labs should the APRN order to monitor this patient? Correct Answer: Enoxaparin (Lovenox) is a form of heparin but its action does not affect any of the clotting studies (PTT or PT/INR) so there is no value in monitoring them. Low molecular weight heparin and fractionated heparin can cause heparin induced thrombocytopenia (HIT), Monitoring for enoxaparin (Lovenox) would include platelet counts to assess for HIT which can occur as soon as 3 days after the medication is initiated. • Question 3 A 64-year man is recovering from a transurethral resection of the prostate for treatment of benign prostate hyperplasia. The patient is receiving intravenous antibiotics for the urinary tract infection. The post-operative course has been smooth and the APRN is removing the 3-way Foley catheter when there is a sudden release of bright red blood with many blood clots in the Foley bag. The patient becomes hypotensive, tachycardic and the APRN notes new ecchymoses on the patient’s arms and legs. The patient was immediately transferred to the surgical intensive care unit (SICU) and a stat hematology consult was conducted. Stat CBC, d-dimer, peripheral blood smear, partial thromboplastin time, Prothrombin time/international normalization ratio (INR), and fibrinogen labs were drawn. Results were: CBC with markedly decreased platelet count, peripheral blood smear showed decreased number of platelets and presence of large platelets and fragmented red cells (schistocytes), prothrombin time prolonged as was the partial thromboplastin time. The d-dimer was markedly elevated, and fibrinogen level was low. Based on the clinical presentation and laboratory data provided, what is your working diagnosis? Correct Answer: Disseminated intravascular coagulation (DIC) is the most likely diagnosis. DIC can result from numerous clinical conditions, including sepsis, trauma, obstetric, emergencies, and malignancy. The presence of schistocytes (fragmented red blood cells) on the peripheral blood smear suggests red blood cell injury from damaged endothelium. Decreased platelet count and low fibrinogen would distinguish DIC from thrombotic thrombocytopenic purpura and hemolytic anemia. • Question 4 A 66-year-old man is taking warfarin due to his atrial fibrillation. He noted that his gums were bleeding yesterday while eating. Today he had a coughing spell and has been spitting up bright red blood ever since. The APRN is called by the ER with the result of the INR ordered. The INR is 9.8. What is the appropriate treatment of this patient? Correct Answer: The 2019 Chest guideline offers some specific guidance in the management of VKA (vitamin K antagonist). If the INR is 4.5 -10 with no evidence of bleeding, the recommendation is to hold the medication but NOT administer any vitamin k or other reversal agents. If there is bleeding (as in this patient), the guideline recommends rapid reversal with four factor prothrombin complex (PCC) rather than with plasma. In addition, 5-10 mg of vitamin K by slow IV injection in addition to the PCC. • Question 5 A 64-year-old man diagnosed with a pulmonary embolism is currently on warfarin. His INR readings have been very inconsistent, and the decision is made to change his medication to Rivaroxaban (Xarelto). What dose should be initiated and how would you discontinue the warfarin? Correct Answer: Warfarin should be discontinued. Once the INR reaches 2.0 or below, Xarelto 15 mg bid x 3 weeks would be initiated. After 3 weeks, the dose is changed to 20 mg daily. • Question 6 A 66-year-old man was evaluated for shortness of breath for the last three months. Diagnostic work up confirmed a pulmonary embolism. He is alert and oriented. Vital signs are stable. He is ambulatory. He has a stable home environment and good support from his wife. He is on day 2 of treatment with Lovenox 90 mg every 12 hours. The patient wants to go home. Would you discharge him? How would you manage his medications? Correct Answer: The 2019 Chest guideline supports outpatient treatment for stable, reliable patients with stable home environments. The patient should continue the Lovenox for a minimum of 5 days. He will need a minimum of 3 months treatment with an oral agent. If warfarin is selected, the patient should start on it now with the hope that his INR is therapeutic by day 5. NOTE- he should not stop the Lovenox until his INR is in the therapeutic range. If a direct thrombin inhibitor or factor Xa inhibitor is selected, he should start on day 5 taking the first dose 2 hours before the Lovenox dose is due. • Question 7 A 26-year-old male was injured in a motorcycle crash 3 days ago. He sustained an acute subdural hematoma, acetabular fracture, and L2 fracture with spinal cord injury and resulting paralysis. He has a warm swollen right lower leg. Duplex ultrasound of the right lower leg is positive. What is the best treatment for this patient? Correct Answer: This patient is high risk for development of deep vein thrombosis and potential pulmonary embolism. The acetabular fracture is a further complicating injury. An inferior vena cava filter would be indicated in this patient to prevent a pulmonary embolism. According to the 2019 Chest guidelines, IVC filters are not first line treatment but this patient is very high risk for VTE, and the subdural hematoma would probably make anticoagulants contraindicated. • Question 8 A 45-year-old male is evaluated for complaints of severe low back and left leg pain. His MRI shows a herniated disk at L4L5. He has been recommended for a lumbar laminectomy surgery to treat the herniated disk. The patient had a cardiac stent placed 3 weeks ago and is currently on Plavix post procedure. When will the patient be able to have the lumbar surgery? [Show Less]
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