MSICU Interview

A patient on the unit becomes suddenly tachypneic, hypoxic, and anxious — what do you do first?

Rapid assessment — call for help, apply high-flow oxygen, check airway patency, connect to continuous monitoring, look for causes (pulmonary edema, pneumothorax, mucus plug, PE, aspiration).

Auscultate lungs, check ventilator settings if on ventilator, obtain focused vitals and bedside ABG/oximetry.

If on ventilator, check high-pressure alarm causes and suction.

Notify the provider with SBAR and escalate to respiratory therapy/MD immediately.

How do you recognize & manage acute deterioration from sepsis?

Look for hypotension, tachycardia, altered mental status, oliguria, elevated lactate.

Immediate steps:

1) call provider/rapid response;

2) measure lactate and obtain blood cultures;

3) start broad-spectrum antibiotics within facility protocol (after cultures) and begin fluid resuscitation guided by response;

4) prepare/monitor for vasopressors if hypotension persists despite fluids;

5) source control and frequent reassessment.

Communicate changes to team and document interventions/timing.

A ventilated patient develops sudden hypotension and desaturation with absent breath sounds on one side — diagnosis and actions?

Suspect tension pneumothorax.

Immediate actions: call for help, disconnect ventilator briefly to relieve pressure if tension suspected, prepare for emergent needle decompression or chest tube placement per provider/RT, bag with 100% O₂ if necessary, set up suction and chest tube tray, notify provider and document.

How do you approach a patient with possible ARDS?

Recognize hypoxemia with bilateral infiltrates not explained by cardiac failure.

Initiate lung-protective strategy: low tidal volume ventilation, limit plateau pressure, consider higher PEEP per ARDSnet protocols, prone positioning in severe cases if available, conservative fluid strategy, and treat underlying cause (e.g., sepsis).

Engage multidisciplinary team (RT, MD, pharmacists).

How do you titrate vasoactive drips?

Titration is guided by hemodynamics and protocol/MD orders:

Choose endpoint (MAP goal, urine output, mental status).

Start with single agent per sepsis/vasogenic shock algorithm, monitor for side effects (ischemia, arrhythmias), check peripheral perfusion and lactate trends, and escalate to additional agents or advanced support if refractory.

Communicate titration and rationale at bedside handoffs

What’s your approach to a new atrial fibrillation with RVR in ICU?

Rapid assessment for reversible causes (hypoxia, electrolyte disturbances, pain, sepsis).

If hemodynamically unstable (hypotension, ischemia), prepare for synchronized cardioversion.

If stable, consider rate control (IV agents as per facility policy) and address underlying cause;

consider anticoagulation risk vs bleeding risk, consult cardiology

How do you manage acute hyperkalemia with peaked T waves?

Recognize ECG changes,

call for emergent meds per protocol (stabilize membrane potential, shift K+ intracellularly, remove total body K+),

obtain repeat labs and continuous cardiac monitoring,

and notify MD to arrange definitive therapy (diuretics, RRT).

(Follow your facility algorithms — never improvise).

How do you respond to a ventilator high-pressure alarm?

Assess patient first (breath sounds, agitation, coughing, biting tube),

check for obstruction (suction secretions),

check equipment (kinks, filters, water in tubing),

evaluate for decreased compliance causes (pulmonary edema, pneumothorax, bronchospasm).

Notify RT/MD early if unresolved.

What’s your role during a code blue?

Know your assigned role beforehand (compressions, airway, medication nurse, recorder).

Maintain closed-loop communication, follow ACLS algorithms, ensure meds and IV/IO access ready, document events/times, and participate in post-code debrief and documentation.

A patient on CRRT is alarmed for low blood flow — what do you do?

Check vascular access patency, look for kinks or clots in circuit, assess for hypotension, check for machine/line disconnection, notify renal team/MD, consider heparinization per protocol, and prepare for circuit change if clot suspected.

What are the 5 rapid assessment priorities?

1	Airway: open, patent? Intubate if not protected or inadequate oxygenation/ventilation
2	Breathing: O₂, ventilator check, breath sounds, chest rise
3	Circulation: IV/IO access, compressions if pulseless, hemodynamic monitoring
4	Disability: neuro status (GCS), glucose, pupils
5	Exposure: look for bleeding, rashes, lines, monitor temperature

What is the mechanism & primary monitoring/adverse effects of Vasopressors (e.g. norepinephrine)?

Agent type	Mechanism	Primary monitoring / adverse effects
Vasopressors (e.g., norepinephrine)	Increase systemic vascular resistance	Tissue ischemia, arrhythmias; monitor perfusion, lactate

What is the mechanism & primary monitoring/adverse effects of Inotropes (e.g. dobutamine)?

Agent type	Mechanism	Primary monitoring / adverse effects
Inotropes (e.g., dobutamine)	Increase cardiac contractility	Tachycardia, arrhythmias; monitor MAP, cardiac output

What is the mechanism & primary monitoring/adverse effects of Vasodilators?

Agent type	Mechanism	Primary monitoring / adverse effects
Vasodilators	Reduce afterload	Hypotension; monitor BP closely

In Ventilator alarm triage, with a High Pressure alarm, what is the likely cause? What is the immediate action of the RN?

High pressure

Obstruction, secretions, bronchospasm, pneumothorax

Check patient, suction, disconnect briefly if needed, call RT

In Ventilator alarm triage, with a Low Pressure alarm, what is the likely cause? What is the immediate action of the RN?

Low pressure

Disconnection, cuff leak, tube displacement

Inspect circuit, reconnect, assess breath sounds

In Ventilator alarm triage, with a Apnea alarm, what is the likely cause? What is the immediate action of the RN?

Apnea

Patient apnea, disconnect

Check patient, ventilator, call for help

As an electrolyte emergency, what is the immediate priority for Hyperkalemia with ECG changes?

Hyperkalemia with ECG changes →

stabilize (membrane stabilization),

shift K+ (insulin/glucose)

remove K+ (diuretics/CRRT/sodium polystyrene).

Monitor cardiac rhythm.

As an electrolyte emergency, what is the immediate priority for Hypokalemia with arrythmias?

Hypokalemia with arrhythmias →

replace K+, monitor Mg2+ concurrently.

As an electrolyte emergency, what is the immediate priority for Severe hyponatremia with Seizures?

Severe hyponatremia with seizures →

hypertonic saline per MD orders (watch correction rate).

What does STEMI stand for?

ST-Elevation Myocardial Infarction — complete occlusion of a coronary artery causing full-thickness damage to the heart muscle.

What does NSTEMI stand for?

Non-ST-Elevation Myocardial Infarction — partial occlusion of a coronary artery causing partial (subendocardial) heart muscle damage.

What are key ECG findings in STEMI vs NSTEMI?

STEMI → ST elevation in ≥2 contiguous leads.
NSTEMI → ST depression or T-wave inversion.

What cardiac markers are elevated in both STEMI and NSTEMI?

Troponin I/T and CK-MB

What are common signs and symptoms of acute coronary syndrome (STEMI/NSTEMI)?

Chest pain or pressure radiating to left arm, jaw, neck, or back; SOB; diaphoresis; nausea; anxiety; hypotension or arrhythmias.

What is the priority diagnostic test for chest pain in the ICU/ED?

12-lead ECG within 10 minutes of arrival

What does MONA-BASH stand for in MI management?

Morphine, Oxygen, Nitrates, Aspirin, Beta-blockers, ACE inhibitors, Statins, Heparin

Why is aspirin given immediately during suspected MI?

It inhibits platelet aggregation and prevents further clot formation

What is the definitive treatment for STEMI?

Immediate reperfusion therapy via PCI (percutaneous coronary intervention) within 90 minutes, or thrombolytics if PCI is unavailable

What is the general treatment approach for NSTEMI?

Stabilize medically (antiplatelets, heparin, beta-blockers, statins), then consider cardiac cath once patient is stable

As a nurse, what are your immediate actions for a patient with suspected STEMI?

Place on cardiac monitor, obtain ECG, administer aspirin, oxygen, and nitro, establish IV access, monitor vitals, and prepare for emergent PCI

What are key nursing priorities post-PCI?

Monitor for bleeding or hematoma at puncture site, check distal pulses, keep limb straight, assess for chest pain recurrence, monitor for arrhythmias

What complications should you monitor for after an MI?

Arrhythmias (VT/VF), cardiogenic shock, heart failure, pericarditis, or reinfarction.

What education should you give post-MI patient?

Medication adherence (antiplatelet, beta-blocker, statin), cardiac rehab, smoking cessation, diet changes, and when to seek emergency help

In an interview, how can you summarize your nursing approach to an MI patient?

“I’d assess, monitor, stabilize, and prepare the patient for reperfusion while ensuring clear communication and coordinated care with the provider and cath lab.”

What is cardiogenic shock?

A state of inadequate tissue perfusion due to the heart’s inability to pump effectively, leading to low cardiac output.

What are the most common causes of cardiogenic shock?

Acute MI, severe heart failure, arrhythmias, mechanical valve dysfunction, or papillary muscle rupture.

What are hallmark signs of cardiogenic shock?

Hypotension, tachycardia, cool clammy skin, low urine output, pulmonary congestion, altered mental status.

What are the hemodynamic findings in cardiogenic shock?

↓ CO/CI (Cardiac Output/Cardiac Index), ↑ PCWP (Pulmonary Capillary Wedge Pressure), ↑ SVR (Systemic Vascular Resistance)

What medications increase cardiac contractility?

Inotropes: Dobutamine, Dopamine, Milrinone.

What medication supports BP in severe hypotension?

Vasopressors — Norepinephrine or Epinephrine

Why should fluids be used cautiously in cardiogenic shock?

The failing heart can’t handle volume — excess fluid can worsen pulmonary edema.

What is the purpose of an IABP (Intra-Aortic Balloon Pump)?

It decreases afterload and improves coronary perfusion to support the failing heart.

What lab trends are expected in cardiogenic shock?

↑ Troponin, ↑ BNP, ↑ lactate, metabolic acidosis on ABG

What are key nursing priorities for cardiogenic shock?

Monitor perfusion, titrate vasoactive drips, assess lung sounds, track urine output, maintain MAP > 65, prevent complications

What are possible complications of cardiogenic shock?

Multi-organ failure, arrhythmias, cardiac arrest, death.

In an interview, how can you describe your nursing approach to cardiogenic shock?

“Early recognition, rapid intervention, continuous monitoring, and strong teamwork to stabilize perfusion and prevent organ damage.”

What is sepsis?

Life-threatening organ dysfunction caused by a dysregulated response to infection.

What defines septic shock?

Sepsis with persistent hypotension requiring vasopressors to maintain MAP ≥65 mmHg and lactate >2 mmol/L despite fluids.

What is the most common cause of septic shock?

Bacterial infection (often pneumonia, urinary tract infection, or intra-abdominal infection).

What is the initial fluid resuscitation goal in septic shock?

30 mL/kg IV crystalloids within 3 hours of recognition.

What is the first-line vasopressor for septic shock?

Norepinephrine (Levophed).

Why should blood cultures be drawn before starting antibiotics?

To identify the causative organism and guide targeted therapy.

What lab is used to monitor tissue perfusion in sepsis?

Lactate.

What is the purpose of the Surviving Sepsis Campaign “1-hour bundle”?

To ensure early recognition and treatment (lactate, cultures, antibiotics, fluids, vasopressors).

What are common complications of septic shock?

Multi-organ failure, acute kidney injury, disseminated intravascular coagulation (DIC), and death.

What are nursing priorities for septic shock?

Early recognition, fluids, antibiotics, vasopressors, and ongoing monitoring of perfusion and urine output.

What ABG finding is common in septic shock?

Metabolic acidosis due to lactic acid buildup from tissue hypoxia

What are early vs late skin findings in septic shock?

Early: warm, flushed skin (due to vasodilation).
Late: cool, mottled skin (due to poor perfusion).

What are indicators that sepsis is worsening?

MAP <65 mmHg, lactate rising, low urine output, altered LOC, and persistent tachycardia despite fluids.

How would you summarize your nursing approach to a septic shock patient in an interview?

“Recognize early, act fast — initiate fluids, antibiotics, and vasopressors while continuously reassessing perfusion and collaborating with the care team.”

What is the hallmark sign of pulmonary edema?

Pink, frothy sputum and crackles in the lungs.

What is the primary goal in acute decompensated heart failure?

Improve oxygenation, reduce preload and afterload, and enhance cardiac output.

What lab value indicates heart failure?

Elevated B-type natriuretic peptide (BNP) >100 pg/mL.

What position should the patient be placed in during pulmonary edema?

High Fowler’s with legs dangling to decrease venous return.

What is the first-line medication to relieve pulmonary congestion?

IV loop diuretic (e.g., furosemide/Lasix).

Why is morphine used in pulmonary edema?

It reduces preload and anxiety, decreasing cardiac workload (use cautiously)

What should be monitored closely when giving diuretics?

Potassium (K⁺) and magnesium (Mg²⁺) levels, urine output, and blood pressure

What is the normal ejection fraction (EF)?

55–70%. <40% indicates systolic heart failure

What rhythm is described as “irregularly irregular” with no visible P waves?

Atrial Fibrillation (AFib).

What is the first-line medication for symptomatic bradycardia?

Atropine 0.5 mg IV push every 3–5 minutes (max 3 mg).

How is pulseless VTach or VFib treated?

CPR + Defibrillation + Epinephrine + Amiodarone.

What rhythm is NOT shockable?

Asystole and Pulseless Electrical Activity (PEA).

What is the drug of choice for stable SVT?

Adenosine 6 mg rapid IV push (followed by 20 mL saline flush).

What is the normal PR interval?

0.12–0.20 seconds.

What are the “H’s and T’s” in cardiac arrest?

Hypoxia, Hypovolemia, Hydrogen ions, Hypo-/Hyperkalemia, Hypothermia,

Tension pneumothorax, Tamponade, Toxins, Thrombosis (MI/PE).

What electrolyte imbalances increase risk of ventricular arrhythmias?

Low potassium (hypokalemia) and low magnesium (hypomagnesemia)

What rhythm shows a “sawtooth” pattern on ECG?

Atrial Flutter.

What’s the difference between cardioversion and defibrillation?

Cardioversion is synchronized (for unstable rhythms with pulse); defibrillation is unsynchronized (for pulseless VT/VF).

What are the key post-cath vascular assessments?

Check distal pulses, color, temperature, sensation; monitor for bleeding or hematoma.

What is a TR Band used for?

Radial artery hemostasis device to prevent bleeding and allow controlled compression.

What are signs of retroperitoneal bleed?

Hypotension, tachycardia, back/flank/abdominal pain, decreased hemoglobin/hematocrit.

When should you notify the provider post-cath?

Any bleeding, hematoma, hypotension, chest pain, arrhythmia, or neurological changes.

What labs are monitored after heparin during cath?

Activated partial thromboplastin time (aPTT) or Activated clotting time (ACT)

How do you prevent contrast-induced nephropathy?

Maintain adequate hydration, monitor urine output, check BUN/creatinine

What is the priority action if a patient has active bleeding at the femoral site?

Apply direct pressure, call provider, prepare for fluids/blood products, monitor vitals.

What should be monitored if a patient is on post-cath anticoagulation therapy?

Signs of bleeding, hemoglobin/hematocrit, aPTT/ACT, and vital signs.

What is the first-line vasopressor for septic shock?

Norepinephrine.

What is the purpose of Dobutamine?

Increases cardiac contractility and cardiac output.

Which antiarrhythmic is given as a rapid IV push for SVT?

Adenosine.

What is the antidote for Heparin?

Protamine sulfate.

What monitoring is required for Amiodarone infusion?

Continuous ECG, blood pressure, heart rate, watch for hypotension and bradycardia.

Which vasopressor can cause bradycardia due to pure alpha stimulation?

Phenylephrine.

What labs are essential for monitoring warfarin therapy?

INR (goal 2–3 for most indications).

Name two common side effects of Milrinone.

Hypotension and arrhythmias.

What is a key nursing priority for patients on IV anticoagulants?

Monitor for signs of bleeding and check lab values (aPTT, INR, CBC).

Why must Adenosine be pushed rapidly?

Because it has a very short half-life (<10 seconds) to effectively terminate SVT.

What is refractory hypoxemia, and what condition is it associated with?

Refractory hypoxemia is low oxygen levels that do not improve with supplemental O₂, seen in ARDS.

What are the main ventilator settings to monitor?

Rate, FiO₂, PEEP, and tidal volume.

High-pressure alarm on the ventilator means what?

Possible obstruction (secretions, kink, biting, coughing).