NAPLEX: Acute & Critical care Medicine

NS is a 32-year-old female in the coronary care unit after a sudden drop in blood pressure following her cardiac catheterization procedure earlier this morning. Her blood pressure remained stable for the past two hours without the use of medications. She is sitting up in bed and eating her lunch. The medical team is anticipating sending her home by this evening or early tomorrow morning. Is NS a candidate for stress ulcer prophylaxis?

A. Yes, since she is in the coronary care unit.

B. Yes, since she had a stressful medical procedure.

C. No, since she does not have any risk factors.

D. No, since she is under the age of 50.

E. There is not enough information provided to make a recommendation.

C. No, since she does not have any risk factors.

All of the following are risks of correcting hyponatremia too rapidly (> 12 mEq/L increase in 24 hours) EXCEPT:

A. Paralysis

B. Death

C. Seizures

D. Osmotic demyelination syndrome

E. Thrombosis

E. Thrombosis

Select the correct concentration of epinephrine that should be used to compound solutions intended for intravenous administration:

A. 1:2,500

B. 1:10,000

C. 1:1,000

D. 1:100,000
E. 1:1,000,000

C. 1:1,000

A patient with end-stage alcoholic cirrhosis is admitted to the medical floor. His serum sodium level is 122 mEq/L. On physical exam, he has ascites and peripheral edema, but only mild shortness of breath. What is the preferred treatment for this patient’s hyponatremia?

A. Sodium chloride tablets by mouth – start now.

B. 0.9% NaCl – start when serum sodium level drops below 120 mEq/L.

C. Diuresis and fluid restriction – start now.

D. Desmopressin – start when serum sodium drops below 115 mEq/L.

E. Lactated Ringer’s – start now. (4%)

C. Diuresis and fluid restriction – start now.

SS presented to the ED with severe dehydration. He was out hiking in the Arizona sun and forgot to bring water. He got lost, and a 1-hour hike turned into a 6-hour hike. He is lethargic and nauseous. The Chem-7 returned, and his serum sodium level is 131 mEq/L (135 – 145 mEq/L). He has no evidence of seizure activity presently. Which of the following represents the best initial therapeutic option to correct his sodium?

A. Conivaptan

B. 3% NaCl

C. D5W

D. 0.9% NaCl

E. Hydroxyethyl Starch

D. 0.9% NaCl

Which of the following represents the primary mechanism of action of dobutamine?

A. Phosphodiesterase-3 inhibitor

B. Alpha-1 agonist

C. Beta-1 agonist

D. Muscarinic antagonist

E. Alpha-2 agonist

C. Beta-1 agonist

Which of the following agents is associated with a risk of cyanide toxicity?

A. Nitroglycerin

B. Nitroprusside

C. Dobutamine

D. Eplerenone

E. Enalaprilat

B. Nitroprusside

A patient in septic shock is unresponsive to repeated doses of epinephrine, and his blood pressure continues to decline. The decision is made to initiate an intravenous vasopressin drip. What is the correct receptor pharmacology that explains the utility of vasopressin in the maintenance of blood pressure?

A. Alpha-1 agonist

B. Beta-1 agonist

C. Vasopressin agonist

D. Vasopressin antagonist

E. Dopamine-1 agonist

C. Vasopressin agonist

A patient in the ICU has an order for a continuous infusion of Nimbex. Which of the following statements is INCORRECT regarding this medication?

A. The medical staff must ensure that the patient is adequately sedated prior to the use of the Nimbex.

B. The medical staff must ensure that the patient is receiving appropriate analgesia prior to the use of the Nimbex.

C. Nimbex binds to the GABA receptor and blocks the actions of endogenous GABA.

D. A peripheral nerve stimulator can be used to monitor Nimbex.

E. A continuous infusion of Nimbex requires mechanical ventilation.

C. Nimbex binds to the GABA receptor and blocks the actions of endogenous GABA.

An ICU patient is receiving dexmedetomidine for sedation. Which of the following statements regarding dexmedetomidine is correct?

A. The duration of the infusion should not exceed 72 hours.

B. This agent has higher risk of causing respiratory depression compared to other sedatives.

C. Patients are arousable and alert upon stimulation when using this agent.

D. Dexmedetomidine is an alpha-2 adrenergic antagonist.

E. Patients receiving dexmedetomidine must be intubated.

C. Patients are arousable and alert upon stimulation when using this agent.

While reading an article about acute decompensated heart failure, a pharmacist notes that reduction in pulmonary capillary wedge pressure (PCWP) is often used in clinical trials as a measure of ADHF treatment success. How is PCWP monitored?

A. PCWP is available on the comprehensive metabolic profile (CMP)

B. PCWP is calculated from an arterial blood gas.

C. PCWP is determined from a chest radiograph.

D. PCWP is available from a Quinton catheter.

E. PCWP is available from a Swan-Ganz catheter.

E. PCWP is available from a Swan-Ganz catheter.

Which of the following represent risks associated with IVIG therapy? (Select ALL that apply.)

A. Acute renal damage

B. Infusion reactions

C. Acute liver damage

D. Fever

E. Pulmonary fibrosis

A. Acute renal damage

B. Infusion reactions

D. Fever

A patient with acute decompensated heart failure is receiving milrinone. Which of the statements concerning milrinone are correct? (Select ALL that apply.)

A. Milrinone is a positive inotrope and increases contractility in the heart.

B. Milrinone is an alpha-2 agonist.

C. Milrinone is a vasodilator.

D. Milrinone is administered IV only.

E. Monitor BP, HR, renal function and ECG (for arrhythmias) when using this agent.

Everything except B

A. Milrinone is a positive inotrope and increases contractility in the heart.

C. Milrinone is a vasodilator.

D. Milrinone is administered IV only.

E. Monitor BP, HR, renal function and ECG (for arrhythmias) when using this agent.

Which of the following are IV hemostatic agents? (Select ALL that apply.)

A. Aminocaproic acid

B. Kcentra

C. Praxbind

D. NovoSeven

E. Gammagard

Everything except E

A. Aminocaproic acid

B. Kcentra

C. Praxbind

D. NovoSeven

A patient in the ICU is receiving a dopamine drip at 44 mL/hr. The patient weighs 200 lbs and is receiving the hospital’s standard dopamine drip (400 mg/250 mL). What receptor effect should be expected from this dose?

A. Alpha-1 receptor antagonism

B. Alpha-1 receptor agonism

C. Beta-1 receptor antagonism

D. Beta-1 receptor agonism

E. Dopamine-1 receptor agonism

B. Alpha-1 receptor agonism

Which of the following medications is a vasopressor?

A. Remifentanil

B. Phenylephrine

C. NovoSeven

D. Nitroprusside

E. Adenosine

B. Phenylephrine

A patient has been receiving 4 days worth of propofol for sedation posttraumatic brain injury. Which of the following statements regarding propofol is/are correct? (Select ALL that apply.)

A. Hypotension, apnea and elevated triglycerides are likely side effects.

B. This patient may be at risk for developing infections.

C. This medication can cause orange/red urine in rare cases.

D. This agent is generally shorter-acting than lorazepam.

E. Propofol contains calories that must be accounted for in the daily nutrition plan for the patient.

Everything except C

A. Hypotension, apnea and elevated triglycerides are likely side effects.

B. This patient may be at risk for developing infections.

D. This agent is generally shorter-acting than lorazepam.

E. Propofol contains calories that must be accounted for in the daily nutrition plan for the patient.

Select the correct generic name for Levophed:

A. Nitroprusside

B. Nebivolol

C. Eplerenone

D. Naloxone

E. Norepinephrine

E. Norepinephrine

Which medication is an anesthetic?

A. Bupivacaine

B. Tranexamic acid

C. Cisatracurium

D. Tolvaptan

E. Dexmedetomidine

A. Bupivacaine

A patient in the ICU is receiving a phenylephrine infusion. What is the mechanism of action of phenylephrine and the clinical effect?

A. Dopamine-1 agonist - increased renal perfusion

B. Phosphodiesterase-3 inhibitor - decreased blood pressure

C. Beta-2 agonist - increased cardiac contractility

D. Alpha-1 agonist - increased blood pressure

E. Beta-1 agonist - increased heart rate

D. Alpha-1 agonist - increased blood pressure

LS is an 84-year-old Hispanic female admitted directly to the medical ICU on 12/15 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation and decreased oral intake. Her past medical history includes hypertension, diabetes and dementia.

Allergies: NKDA

Medications: Norvasc 10 mg PO daily Lasix 40 mg PO daily (started 12/1 for lower extremity swelling) Exelon patch 9.5 mg/24 hr Namenda 5 mg BID Lantus 10 units at HS Novolin R sliding scale PRN (scale not documented on transfer records) Calcium supplement (dose not documented on transfer records)

Vitals: Height: 5’2” Weight: 136 pounds BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10

Labs from Nursing Home on 10/2: Na (mEq/L) = 138 (135 – 145) K (mEq/L) = 3.6 (3.5 – 5) Cl (mEq/L) = 100 (95 – 103) HCO3 (mEq/L) = 27 (24 – 30) BUN (mg/dL) = 20 (7 – 20) SCr (mg/dL) = 1.1 (0.6 – 1.3) Glucose (mg/dL) = 187 (100 – 125) Ca (mg/dL) = 8.7 (8.5 – 10.5) Mg (mEq/L) = 1.3 (1.3 – 2.1) PO4 (mg/dL) = 2.2 (2.3 – 4.7) A1C (%) = 8.9 Albumin (g/dL) = 3.6 (3.5 – 5) Labs on Hospital Admission 12/15: Na (mEq/L) = 135 (135 – 145) K (mEq/L) = 3.1 (3.5 – 5) Cl (mEq/L) = 99 (95 – 103) HCO3 (mEq/L) = 27 (24 – 30) BUN (mg/dL) = 42 (7 – 20) SCr (mg/dL) = 1.4 (0.6 – 1.3) Glucose (mg/dL) = 169 (100 – 125) Ca (mg/dL) = 8.8 (8.5 – 10.5) Mg (mEq/L) = 1.0 (1.3 – 2.1) PO4 (mg/dL) = 1.9 (2.3 – 4.7) A1C (%) = 8.8 Albumin (g/dL) = 2.9 (3.5 – 5)

Tests: EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval

Urinalysis and blood cultures are ordered and results are pending. LS requires fluid resuscitation.

Which of the following is the best recommendation?

A. Hydroxyethyl starch

B. Dextrose 5%

C. NaCl 0.9%

D. Albumin 25%

E. Dextran

C. NaCl 0.9%

LS is an 84-year-old Hispanic female admitted directly to the medical ICU on 12/15 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation and decreased oral intake. Her past medical history includes hypertension, diabetes and dementia.

Allergies: NKDA

Medications: Norvasc 10 mg PO daily Lasix 40 mg PO daily (started 12/1 for lower extremity swelling) Exelon patch 9.5 mg/24 hr Namenda 5 mg BID Lantus 10 units at HS Novolin R sliding scale PRN (scale not documented on transfer records) Calcium supplement (dose not documented on transfer records)

Vitals: Height: 5’2” Weight: 136 pounds BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10

Labs from Nursing Home on 10/2: Na (mEq/L) = 138 (135 – 145) K (mEq/L) = 3.6 (3.5 – 5) Cl (mEq/L) = 100 (95 – 103) HCO3 (mEq/L) = 27 (24 – 30) BUN (mg/dL) = 20 (7 – 20) SCr (mg/dL) = 1.1 (0.6 – 1.3) Glucose (mg/dL) = 187 (100 – 125) Ca (mg/dL) = 8.7 (8.5 – 10.5) Mg (mEq/L) = 1.3 (1.3 – 2.1) PO4 (mg/dL) = 2.2 (2.3 – 4.7) A1C (%) = 8.9 Albumin (g/dL) = 3.6 (3.5 – 5) Labs on Hospital Admission 12/15: Na (mEq/L) = 135 (135 – 145) K (mEq/L) = 3.1 (3.5 – 5) Cl (mEq/L) = 99 (95 – 103) HCO3 (mEq/L) = 27 (24 – 30) BUN (mg/dL) = 42 (7 – 20) SCr (mg/dL) = 1.4 (0.6 – 1.3) Glucose (mg/dL) = 169 (100 – 125) Ca (mg/dL) = 8.8 (8.5 – 10.5) Mg (mEq/L) = 1.0 (1.3 – 2.1) PO4 (mg/dL) = 1.9 (2.3 – 4.7) A1C (%) = 8.8 Albumin (g/dL) = 2.9 (3.5 – 5)

Tests: EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval

Urinalysis and blood cultures are ordered and results are pending. LS requires fluid resuscitation.

A dopamine drip is ordered for LS. Which of the following represents the correct combination of dose-effect relationships for dopamine?

A. Low dose → vasopressor effects, medium dose → positive inotropic effect, and high dose → renal vasodilation

B. Low dose → positive inotropic effect, medium dose → renal vasodilation, and high dose → vasopressor effects

C. Low dose → vasopressor effects, medium dose → renal vasodilation, and high dose → positive inotropic effect

D. Low dose → positive inotropic effect, medium dose → vasopressor effects, and high dose → renal vasodilation

E. Low dose → renal vasodilation, medium dose → positive inotropic effect, and high dose → vasopressor effects

E. Low dose → renal vasodilation, medium dose → positive inotropic effect, and high dose → vasopressor effects

LS is an 84-year-old Hispanic female admitted directly to the medical ICU on 12/15 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation and decreased oral intake. Her past medical history includes hypertension, diabetes and dementia.

Allergies: NKDA

Medications: Norvasc 10 mg PO daily Lasix 40 mg PO daily (started 12/1 for lower extremity swelling) Exelon patch 9.5 mg/24 hr Namenda 5 mg BID Lantus 10 units at HS Novolin R sliding scale PRN (scale not documented on transfer records) Calcium supplement (dose not documented on transfer records)

Vitals: Height: 5’2” Weight: 136 pounds BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10

Labs from Nursing Home on 10/2: Na (mEq/L) = 138 (135 – 145) K (mEq/L) = 3.6 (3.5 – 5) Cl (mEq/L) = 100 (95 – 103) HCO3 (mEq/L) = 27 (24 – 30) BUN (mg/dL) = 20 (7 – 20) SCr (mg/dL) = 1.1 (0.6 – 1.3) Glucose (mg/dL) = 187 (100 – 125) Ca (mg/dL) = 8.7 (8.5 – 10.5) Mg (mEq/L) = 1.3 (1.3 – 2.1) PO4 (mg/dL) = 2.2 (2.3 – 4.7) A1C (%) = 8.9 Albumin (g/dL) = 3.6 (3.5 – 5) Labs on Hospital Admission 12/15: Na (mEq/L) = 135 (135 – 145) K (mEq/L) = 3.1 (3.5 – 5) Cl (mEq/L) = 99 (95 – 103) HCO3 (mEq/L) = 27 (24 – 30) BUN (mg/dL) = 42 (7 – 20) SCr (mg/dL) = 1.4 (0.6 – 1.3) Glucose (mg/dL) = 169 (100 – 125) Ca (mg/dL) = 8.8 (8.5 – 10.5) Mg (mEq/L) = 1.0 (1.3 – 2.1) PO4 (mg/dL) = 1.9 (2.3 – 4.7) A1C (%) = 8.8 Albumin (g/dL) = 2.9 (3.5 – 5)

Tests: EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval

Urinalysis and blood cultures are ordered and results are pending. LS requires fluid resuscitation.

The ICU staff will monitor LS for delirium during her stay. Which statement is correct regarding ICU delirium?

A. Delirium is rare in ventilated ICU patients.

B. Haloperidol is recommended for prophylaxis and treatment of ICU delirium.

C. Providing sedation with Ativan as opposed to Precedex may reduce the incidence of delirium.

D. Seroquel may increase the duration of delirium.

E. Early mobilization and environmental control are recommended to prevent delirium.

E. Early mobilization and environmental control are recommended to prevent delirium.

LS is an 84-year-old Hispanic female admitted directly to the medical ICU on 12/15 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation and decreased oral intake. Her past medical history includes hypertension, diabetes and dementia.

Allergies: NKDA

Medications: Norvasc 10 mg PO daily Lasix 40 mg PO daily (started 12/1 for lower extremity swelling) Exelon patch 9.5 mg/24 hr Namenda 5 mg BID Lantus 10 units at HS Novolin R sliding scale PRN (scale not documented on transfer records) Calcium supplement (dose not documented on transfer records)

Vitals: Height: 5’2” Weight: 136 pounds BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10

Labs from Nursing Home on 10/2: Na (mEq/L) = 138 (135 – 145) K (mEq/L) = 3.6 (3.5 – 5) Cl (mEq/L) = 100 (95 – 103) HCO3 (mEq/L) = 27 (24 – 30) BUN (mg/dL) = 20 (7 – 20) SCr (mg/dL) = 1.1 (0.6 – 1.3) Glucose (mg/dL) = 187 (100 – 125) Ca (mg/dL) = 8.7 (8.5 – 10.5) Mg (mEq/L) = 1.3 (1.3 – 2.1) PO4 (mg/dL) = 2.2 (2.3 – 4.7) A1C (%) = 8.9 Albumin (g/dL) = 3.6 (3.5 – 5) Labs on Hospital Admission 12/15: Na (mEq/L) = 135 (135 – 145) K (mEq/L) = 3.1 (3.5 – 5) Cl (mEq/L) = 99 (95 – 103) HCO3 (mEq/L) = 27 (24 – 30) BUN (mg/dL) = 42 (7 – 20) SCr (mg/dL) = 1.4 (0.6 – 1.3) Glucose (mg/dL) = 169 (100 – 125) Ca (mg/dL) = 8.8 (8.5 – 10.5) Mg (mEq/L) = 1.0 (1.3 – 2.1) PO4 (mg/dL) = 1.9 (2.3 – 4.7) A1C (%) = 8.8 Albumin (g/dL) = 2.9 (3.5 – 5)

Tests: EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval

Urinalysis and blood cultures are ordered and results are pending. LS requires fluid resuscitation.

Which statement is correct regarding LS's electrolyte abnormalities on 12/15? (Select ALL that apply.)

A. Lasix may have caused the hypokalemia and hypomagnesemia.

B. Replacement of the patient’s body stores of magnesium will be complete after one dose of IV magnesium sulfate.

C. Hypophosphatemia is considered severe and usually symptomatic when the serum phosphorus level is < 2 mg/dL.

D. Hypomagnesemia should be treated with IV replacement therapy when the serum magnesium level is < 1 mEq/L and seizures or an arrhythmia is present.

E. The patient's serum potassium suggests a total body deficit of 400 – 1600 mEq.

A. Lasix may have caused the hypokalemia and hypomagnesemia.

D. Hypomagnesemia should be treated with IV replacement therapy when the serum magnesium level is < 1 mEq/L and seizures or an arrhythmia is present.

LS is an 84-year-old Hispanic female admitted directly to the medical ICU on 12/15 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation and decreased oral intake. Her past medical history includes hypertension, diabetes and dementia.

Allergies: NKDA

Medications: Norvasc 10 mg PO daily Lasix 40 mg PO daily (started 12/1 for lower extremity swelling) Exelon patch 9.5 mg/24 hr Namenda 5 mg BID Lantus 10 units at HS Novolin R sliding scale PRN (scale not documented on transfer records) Calcium supplement (dose not documented on transfer records)

Vitals: Height: 5’2” Weight: 136 pounds BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10

Labs from Nursing Home on 10/2: Na (mEq/L) = 138 (135 – 145) K (mEq/L) = 3.6 (3.5 – 5) Cl (mEq/L) = 100 (95 – 103) HCO3 (mEq/L) = 27 (24 – 30) BUN (mg/dL) = 20 (7 – 20) SCr (mg/dL) = 1.1 (0.6 – 1.3) Glucose (mg/dL) = 187 (100 – 125) Ca (mg/dL) = 8.7 (8.5 – 10.5) Mg (mEq/L) = 1.3 (1.3 – 2.1) PO4 (mg/dL) = 2.2 (2.3 – 4.7) A1C (%) = 8.9 Albumin (g/dL) = 3.6 (3.5 – 5) Labs on Hospital Admission 12/15: Na (mEq/L) = 135 (135 – 145) K (mEq/L) = 3.1 (3.5 – 5) Cl (mEq/L) = 99 (95 – 103) HCO3 (mEq/L) = 27 (24 – 30) BUN (mg/dL) = 42 (7 – 20) SCr (mg/dL) = 1.4 (0.6 – 1.3) Glucose (mg/dL) = 169 (100 – 125) Ca (mg/dL) = 8.8 (8.5 – 10.5) Mg (mEq/L) = 1.0 (1.3 – 2.1) PO4 (mg/dL) = 1.9 (2.3 – 4.7) A1C (%) = 8.8 Albumin (g/dL) = 2.9 (3.5 – 5)

Tests: EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval

Urinalysis and blood cultures are ordered and results are pending. LS requires fluid resuscitation.

An order is placed for LS to receive 40 mEq of KCl IV with continuous EKG monitoring. She only has a peripheral IV line at this point. The hospital stocks premixed bags of 10 mEq KCl/100 mL 0.9% NaCl. The pharmacist modifies the order to read “10 mEq KCl/100 mL 0.9% NaCl x 4 doses.” What is the shortest recommended infusion time for each 10 mEq KCl bag?

A. 1-2 minutes

B. 30 minutes

C. 1 hour

D. 4 hours

E. 12 hours

C. 1 hour

A pharmacist receives an order for Diprivan. Which of the following is an appropriate generic substitution for Diprivan?

A. Propofol

B. Diltiazem

C. Oxycodone

D. Lorazepam

E. Propantheline

A. Propofol

A patient in the OR received succinylcholine for intubation and is currently receiving inhaled isoflurane during surgery. Which rare, but serious, side effect is this patient potentially at risk for?

A. Neuroleptic malignant syndrome

B. Central pontine myelinolysis

C. Serotonin syndrome

D. Malignant hyperthermia

E. Acute quadriplegic myopathy syndrome

D. Malignant hyperthermia

Which of the following methods reduce the risk of adverse renal events in a patient with kidney disease that requires intravenous immunoglobulin (IVIG)? (Select ALL that apply.)

A. Pretreat for infusion reactions

B. Avoid IVIG products with sucrose

C. Avoid IV gentamicin therapy, if possible

D. Avoid IV vancomycin therapy, if possible

E. Use a slower infusion rate

Everything except A

B. Avoid IVIG products with sucrose

C. Avoid IV gentamicin therapy, if possible

D. Avoid IV vancomycin therapy, if possible

E. Use a slower infusion rate

A patient in the ICU with shock is receiving a norepinephrine infusion. What is the purpose of using norepinephrine in this setting?

A. To decrease cardiac output, increase blood flow to vital organs and increase blood pressure.

B. To increase cardiac output, increase blood flow to vital organs and increase blood pressure.

C. To increase cardiac output, decrease blood flow to vital organs and increase blood pressure.

D. To increase cardiac output, increase blood flow to vital organs and decrease blood pressure.

E. To vasodilate in the kidney for nephroprotection and decrease blood pressure.

B. To increase cardiac output, increase blood flow to vital organs and increase blood pressure.

A hospitalized patient requires fluid resuscitation. Which of the following best describes the difference between Lactated Ringer's and AlbuRx? (Select ALL that apply.)

A. AlbuRx is less expensive.

B. Lactated Ringer's have fewer adverse reactions.

C. AlbuRx is better at increasing oncotic pressure.

D. Lactated Ringer's are more expensive.

E. AlbuRx is associated with improved clinical outcomes.

B. Lactated Ringer's have fewer adverse reactions.

C. AlbuRx is better at increasing oncotic pressure.

MS is an elderly patient admitted for altered mental status. His admission serum sodium is 115 mEq/L. MS is started on Vaprisol (loading dose and continuous infusion). The next day his serum sodium is 129 mEq/L. MS is at risk for which of the following adverse effects?

A. Progressive multifocal leukoencephalopathy (PML)

B. Acute quadriplegic myopathy syndrome (AQMS)

C. Diabetes insipidus (DI)

D. Osmotic demyelination syndrome (ODS)

E. Disseminated intravascular coagulation (DIC)

D. Osmotic demyelination syndrome (ODS)

Which of the following are crystalloids? (Select ALL that apply.)

A. Sodium chloride

B. 5% Albumin

C. Lactated Ringers

D. Dextrose

E. Dextran

A. Sodium chloride

C. Lactated Ringers

D. Dextrose

GS is a 72-year-old male with heart failure. He is admitted to the hospital, and tolvaptan 15 mg PO daily is ordered. What is tolvaptan used for?

A. Anesthesia

B. Life-threatening hypokalemia

C. Hypervolemic hyponatremia

D. Neuromuscular blockade

E. Hemostasis

C. Hypervolemic hyponatremia

AB has recently been admitted to the intensive care unit after an acute asthma exacerbation. She has been intubated and requires adequate sedation. She has normal renal and liver function. The medical team wants to use the shortest acting benzodiazepine available intravenously for sedation. Which of the following medications would be the best recommendation?

A. Temazepam

B. Lorazepam

C. Diazepam

D. Clonazepam

E. Midazolam

E. Midazolam

A patient is admitted with significant hyponatremia (Na = 125). The provider would like to use tolvaptan. Which of the following statements is correct?

A. Tolvaptan is available IV only.

B. Tolvaptan is a first-line agent for the treatment of hyponatremia.

C. Sodium should be corrected at a rate of 12 mEq/hr while on tolvaptan.

D. The brand name for tolvaptan is Vaprisol.

E. Tolvaptan use should be limited to 30 days due to the potential for hepatotoxicity.

E. Tolvaptan use should be limited to 30 days due to the potential for hepatotoxicity.

Which of the following statements concerning IVIG is correct?

A. It has a risk for thrombosis.

B. IVIG is a form of active immunity.

C. IVIG should be infused quickly in patients with CV disease.

D. It takes 10 human donors to make one dose.

E. IVIG is nearly all IgM.

A. It has a risk for thrombosis.

The pharmacist receives an order for Precedex. Which of the following is an appropriate generic substitution for Precedex?

A. Cisatracurium

B. Ketamine

C. Dexmedetomidine

D. Propofol

E. Dexamethasone

C. Dexmedetomidine

KC is a 56-year-old male (85 kg) with a past medical history of COPD, hyperlipidemia and hypertension. He presented to the emergency room with shortness of breath, increased purulent sputum and fever of 102.1°F. His blood pressure did not respond to an initial fluid bolus and is now 78/50 mmHg. Broad-spectrum antibiotics are started. The physician decides to start a norepinephrine 4 mg/250 mL infusion to maintain a mean arterial pressure (MAP) above 65 mmHg. The nurse starts the infusion at a rate of 0.1 mcg/kg/minute. After 20 minutes, the patient’s blood pressure is 88/56 mmHg. How should the infusion be adjusted based on the patient’s target MAP?

A. Stop the infusion

B. Decrease the infusion rate

C. Maintain the current infusion rate

D. Increase the infusion rate

E. Add on vasopressin

C. Maintain the current infusion rate

Which of the following statements is true of colloids and crystalloids?

A. Crystalloids cause more adverse reactions than colloids.

B. Colloids improve mortality in shock when compared to crystalloids.

C. Colloids are commonly used for maintenance hydration and to replace fluid losses.

D. Colloids are more expensive than crystalloids.

E. Crystalloids are large molecules that primarily remain in the intravascular space.

D. Colloids are more expensive than crystalloids.

A male patient weighing 82 kg is receiving dopamine 400 mg/250 mL D5W at a rate of 22 mL/hr. What is the primary receptor effect of this dose?

A. Dopamine-1 agonist

B. Beta-1 agonist

C. Beta-2 agonist

D. Alpha-1 agonist

E. Alpha-2 agonist

B. Beta-1 agonist

Which of the following fluids would be expected to remain in the intravascular space and increase oncotic pressure? (Select ALL that apply.)

A. Normal saline

B. Hydroxyethyl starch

C. Lactated Ringer's

D. Dextran

E. Albumin

B. Hydroxyethyl starch

D. Dextran

E. Albumin

A patient presents to the hospital with hypernatremia and a "free water" deficit. The physician determines that the patient needs more intracellular water. Which fluid replacement strategy would be preferred?

A. Normal saline

B. Sodium chloride 0.45%

C. Lactated ringers

D. Dextrose 5%

E. Albumin

D. Dextrose 5%

Which of the following agents is a depolarizing neuromuscular blocking agent?

A. Succinylcholine

B. Cisatracurium

C. Pancuronium
D. Vecuronium

E. Atracurium

A. Succinylcholine

What are the risks associated with providing proton pump inhibitors to patients who do not require stress ulcer prophylaxis? (Select ALL that apply.)

A. Increased infection risk by increasing gastric pH and allowing bacteria overgrowth in the GI tract and airways.

B. Increased risk of contracting hospital-acquired pneumonia.

C. Increased risk of developing Clostridioides difficile diarrhea.

D. Increased risk of GI bleeding.

E. Increased risk of VTE.

A. Increased infection risk by increasing gastric pH and allowing bacteria overgrowth in the GI tract and airways.

B. Increased risk of contracting hospital-acquired pneumonia.

C. Increased risk of developing Clostridioides difficile diarrhea.

History of Present Illness: DR, a 58-year-old male, presents to the hospital with septic shock and a severe left foot infection.

Allergies: NKDA

Past Medical History: type 2 diabetes x 10 years (poorly controlled), hypertension, heart failure, obesity, sleep apnea Home Medications: Glucophage XR 1,000 mg daily, lisinopril 20 mg daily, Toprol XL 100 mg daily, torsemide 30 mg daily, aspirin 81 mg daily

Physical Exam / Vitals: Height: 5’10” Weight: 265 pounds BP: 88/62 mmHg HR: 108 BPM RR: 16 BPM Temp: 102.2°F Pain: 7/10

Inpatient Stat Medication Orders Normal saline continuous infusion at 150 mL/hr Norepinephrine (8 mg/250 mL) at 18 mL/hr Zosyn 4.5 g/100 mL NS IV Q6H Vancomycin pharmacy to dose Tobramycin pharmacy to dose

Diagnostic Tests: X-ray (left foot): soft tissue swelling, unable to rule out osteomyelitis. Recommend MRI. Blood cultures: pending

Consults: Wound management for I&D. Surgery consult to evaluate viability of lateral toes and possible need for foot amputation.

What is the primary mechanism of action of the vasopressor being used to maintain DR's blood pressure?

A. Vasopressin agonist

B. Venous vasodilator

C. Alpha-1 agonist

D. Beta-1 antagonist

E. Phosphodiesterase-3 inhibitor

C. Alpha-1 agonist

History of Present Illness: DR, a 58-year-old male, presents to the hospital with septic shock and a severe left foot infection.

Allergies: NKDA

Past Medical History: type 2 diabetes x 10 years (poorly controlled), hypertension, heart failure, obesity, sleep apnea Home Medications: Glucophage XR 1,000 mg daily, lisinopril 20 mg daily, Toprol XL 100 mg daily, torsemide 30 mg daily, aspirin 81 mg daily

Physical Exam / Vitals: Height: 5’10” Weight: 265 pounds BP: 88/62 mmHg HR: 108 BPM RR: 16 BPM Temp: 102.2°F Pain: 7/10

Inpatient Stat Medication Orders Normal saline continuous infusion at 150 mL/hr Norepinephrine (8 mg/250 mL) at 18 mL/hr Zosyn 4.5 g/100 mL NS IV Q6H Vancomycin pharmacy to dose Tobramycin pharmacy to dose

Diagnostic Tests: X-ray (left foot): soft tissue swelling, unable to rule out osteomyelitis. Recommend MRI. Blood cultures: pending

Consults: Wound management for I&D. Surgery consult to evaluate viability of lateral toes and possible need for foot amputation.

During his hospitalization, DR receives phentolamine. What is the most likely reason this medication was administered to DR?

A. Hypotension

B. Extravasation

C. Hyperglycemia

D. Acidosis

E. Leukopenia

B. Extravasation

Which of the following agents are used as ICU sedatives? (Select ALL that apply.)

A. Precedex

B. Midazolam

C. Ativan

D. Diprivan

E. Levophed

Everything except E

A. Precedex

B. Midazolam

C. Ativan

D. Diprivan

A patient picks up a prescription for an EpiPen for her son. Which of the following ratio strengths is used for epinephrine given by intramuscular administration?

A. 1:500

B. 1:1,000

C. 1:10,000

D. 1:100,000

E. 1:1,000,000

B. 1:1,000

A pharmacist is checking the ICU drips before her shift ends so she can let the midnight pharmacist know what drips will need to be made overnight. A 210 pound patient is receiving Precedex (200 mcg/50 mL NS) at 0.2 mcg/kg/hr. There is 25 mL remaining in the bag. Assuming a constant rate of infusion, how many more hours will the bag last? (Answer must be numeric; no units or commas; round the final answer to the nearest WHOLE number.)

5

A patient's norepinephrine intravenous line extravasated into the surrounding tissue. The nurse quickly starts to give phentolamine to reverse any skin necrosis. What is the mechanism of action of phentolamine?

A. Alpha-adrenergic antagonist

B. Alpha-adrenergic agonist

C. Beta-adrenergic antagonist

D. Beta-adrenergic agonist

E. Calcium channel antagonist

A. Alpha-adrenergic antagonist

A patient presents to the hospital with increasing shortness of breath, fatigue and lower extremity edema. The patient is diagnosed with acute decompensated heart failure. His blood pressure is 109/60 mmHg, and his heart rate is 80 BPM. His serum creatinine is 1.4 mg/dL. In addition to furosemide, the cardiologist recommends an IV vasodilator. Which of the following medications is appropriate for this patient?

A. Nitroglycerin

B. Tolvaptan

C. Vasopressin

D. Dopamine

E. Phenylephrine

A. Nitroglycerin

Which of the following positive inotropes acts via phosphodiesterase-3 inhibition?

A. Digoxin

B. Dobutamine

C. Dopamine

D. Epinephrine

E. Milrinone

E. Milrinone

What is the correct rationale for using an inotropic agent in a patient with shock syndrome?

A. To increase cardiac contraction in order to increase cardiac output.

B. To decrease cardiac contraction in order to provide rest to a failing heart.

C. To increase preload and improve mean arterial pressure.

D. To decrease heart rate in order to reverse tachycardia.

E. To increase systemic vascular resistance in order to decrease or reverse tachypnea.

A. To increase cardiac contraction in order to increase cardiac output.

A patient in the ICU has been receiving a continuous infusion of vecuronium for 3 days. On rounds, the nurse comments that the patient requires constant suctioning of his mouth secretions. Which medication can be recommended to reduce secretions?

A. Aminocaproic acid

B. Phentolamine

C. Neostigmine

D. Sugammadex

E. Glycopyrrolate

E. Glycopyrrolate

Which of the following best describes the mechanism of action of nitroprusside?

A. Beta-1 agonist

B. Recombinant B-type natriuretic peptide
C. Phosphodiesterase-3 inhibitor

D. Mixed venous and arterial vasodilator

E. Alpha-1 agonist

D. Mixed venous and arterial vasodilator

Which of the following drugs is formulated in a lipid emulsion?

A. Precedex

B. Valium

C. Fentanyl

D. Diprivan

E. Ativan

D. Diprivan

JH is a 55-year-old male who will be receiving his third IVIG treatment for autoimmune encephalopathy. He reports that he had been receiving steroid therapy for many years, but was changed to IVIG the previous fall when his symptoms worsened. He has presented to the infusion room. The pharmacist cannot locate the referring physician's paperwork and will attempt to conduct a pre-screening before the treatment. Which of the following screening questions should the pharmacist ask? (Select ALL that apply.)

A. Did the patient use any medications prior to the treatment to help lessen the side effects?

B. What is the name of the IVIG medication received previously, and is the patient aware of the dose?

C. Is anyone in the house presently immunocompromised (e.g., family members with cancer or HIV)?

D. Are there any small infants in the house?

E. Did the patient develop any reactions to the medication, either during the infusion, or afterward?

A. Did the patient use any medications prior to the treatment to help lessen the side effects?

B. What is the name of the IVIG medication received previously, and is the patient aware of the dose?

E. Did the patient develop any reactions to the medication, either during the infusion, or afterward?

Which medication is matched with the correct indication?

A. Precedex - paralysis

B. Seroquel - delirium

C. Diprivan - analgesia

D. Nimbex - sedation

E. Dilaudid - hemostasis

B. Seroquel - delirium

Hemostatic agents prevent blood loss. Which of the following statements concerning hemostatic agents are correct? (Select ALL that apply.)

A. Hemostatic agents can increase risk of thrombosis.

B. The most common adverse events from the use of hemostatic agents are a drop in hemoglobin and anemia.

C. Patients receiving hemostatic agents are at low risk of clotting.
D. Recombinant thrombin (Recothrom) is a topical hemostatic agent.

E. Tranexamic acid is a hemostatic agent that can be used for heavy menstrual bleeding.

A. Hemostatic agents can increase risk of thrombosis.

D. Recombinant thrombin (Recothrom) is a topical hemostatic agent.

E. Tranexamic acid is a hemostatic agent that can be used for heavy menstrual bleeding.

A pharmacist is checking several ICU drips that were made by a technician. The first is a dexmedetomidine drip labeled with a final concentration of 2 mcg/mL. In reviewing the technician's notes and IV room waste, the technician used 2 mL from a dexmedetomidine vial (100 mcg/mL) and added this to 48 mL of NS to prepare a final volume of 50 mL. What is the correct final concentration of this drip in mcg/mL? (Answer must be numeric; no units or commas.)

4

Which of the following statements concerning rocuronium, vecuronium and cisatracurium is incorrect?

A. According to ISMP, these are all classified as "HIGH-RISK" medications.

B. These drugs are paralytics or neuromuscular blocking agents (NMBAs).

C. These drugs provide a high degree of sedation.

D. These drugs should have a warning applied to the bag, such as: "WARNING: PARALYZING AGENT."

E. They are non-depolarizing neuromuscular blockers that bind to the acetylcholine receptor and block the action of acetylcholine.

C. These drugs provide a high degree of sedation.

An ICU patient is mechanically ventilated. Which medication is preferred for sedation according to critical care guidelines?

A. Propofol

B. Cisatracurium

C. Midazolam

D. Ketamine

E. Haloperidol

A. Propofol