ICU Medication Competency Exam

A patient with septic shock has received adequate IV fluid resuscitation. Their current assessment is:

• BP: 78/44

• MAP: 55

• HR: 104

Which medication should the nurse anticipate administering FIRST?

A. Phenylephrine

B. Vasopressin

C. Norepinephrine (Levophed)

D. Dobutamine

C. Norepinephrine

💡 Rationale

Levophed is the first-line vasopressor for septic shock after adequate fluid resuscitation because it primarily increases SVR and improves MAP.

❌ A: Phenylephrine is not first-line and may decrease cardiac output.

❌ B: Vasopressin is usually added if Levophed alone isn't enough.

❌ D: Dobutamine increases contractility but isn't first-line for septic vasodilatory shock.

The nurse is caring for a patient receiving Levophed.

Which assessments are priorities?

Select all that apply.

A. Urine output

B. Peripheral perfusion

C. Blood pressure

D. Lactate level

E. Skin temperature

A, B, C, D, E

💡 Rationale

All of these help determine whether the patient is adequately perfusing organs and whether excessive vasoconstriction is occurring.

A patient receiving Levophed develops cool fingers, delayed capillary refill, and decreasing urine output despite a MAP of 70.

What is the nurse's priority?

A. Continue monitoring because the MAP is adequate.

B. Assess tissue perfusion and notify the provider.

C. Increase the Levophed infusion.

D. Stop IV fluids.

B

💡 Rationale

A normal MAP does not guarantee adequate organ perfusion. Signs of poor perfusion require prompt assessment and provider notification.

Which statement best explains why Vasopressin is commonly added to Levophed in septic shock?

A. It increases heart rate.

B. It increases myocardial contractility.

C. It increases vascular tone through V1 receptors.

D. It dissolves microvascular clots.

C

💡 Rationale

Vasopressin acts on V1 receptors to cause vasoconstriction and support blood pressure.

Which statements about Vasopressin are correct? Select all that apply

A. It is usually the first vasopressor started.

B. It has minimal direct effect on heart rate.

C. It works on V1 receptors.

D. It may decrease blood flow to the intestines.

E. It is primarily an inotrope.

B, C, D

💡 Rationale

✔ Minimal cardiac effects

✔ V1 receptor vasoconstriction

✔ Mesenteric ischemia is a known complication

A patient is hypotensive with a heart rate of 160 bpm in atrial fibrillation.

Which medication would most likely increase blood pressure without significantly increasing the heart rate?

A. Dopamine

B. Epinephrine

C. Dobutamine

D. Phenylephrine

D

💡 Rationale

Phenylephrine is a pure alpha-1 agonist, making it useful when tachycardia is already present.

Which patient would MOST likely benefit from Dobutamine?

A. Septic shock with profound vasodilation

B. Cardiogenic shock with low cardiac output

C. Severe hypertension

D. Symptomatic bradycardia

B

💡 Rationale

Dobutamine primarily increases myocardial contractility and cardiac output.

The nurse is monitoring a patient receiving Dobutamine.

Which complications should the nurse watch for?

A. Tachyarrhythmias

B. Increased cardiac output

C. Hypotension

D. Improved contractility

E. Reflex bradycardia

A, B, C, D

💡 Rationale

Dobutamine improves contractility and cardiac output but may also cause tachyarrhythmias and hypotension due to vasodilation.

Which medication primarily increases contractility rather than systemic vascular resistance?

A. Phenylephrine

B. Levophed

C. Dobutamine

D. Vasopressin

C

A patient with pulmonary hypertension has worsening right ventricular failure.

Which medication is most appropriate?

A. Milrinone

B. Phenylephrine

C. Vasopressin

D. Levophed

A

💡 Rationale

Milrinone improves contractility while decreasing pulmonary vascular resistance, making it especially useful in right ventricular failure.

A patient receiving Milrinone develops frequent PVCs.

Which assessment should concern the nurse most?

A. Ventricular irritability

B. Hyperglycemia

C. Hypertension

D. Bradycardia

A

💡 Rationale

Milrinone increases the risk of ventricular dysrhythmias.

Which medications primarily function as vasopressors?

A. Levophed

B. Vasopressin

C. Phenylephrine

D. Dobutamine

E. Milrinone

A, B, C

💡 Rationale

Levophed, Vasopressin, and Phenylephrine primarily increase vascular tone.

Dobutamine and Milrinone are primarily inotropes.

The provider orders Dopamine for symptomatic bradycardia after Atropine fails.

Why?

A. Dopamine slows AV node conduction.

B. Dopamine increases heart rate and contractility.

C. Dopamine dissolves clots.

D. Dopamine decreases preload.

B

The nurse is caring for four patients.

Which patient should be assessed FIRST?

A. Patient receiving Levophed with new cool, mottled extremities

B. Patient receiving Dobutamine with HR 102

C. Patient receiving Vasopressin with BP 118/68

D. Patient receiving Milrinone who reports mild headache

A

💡 Rationale

Cool, mottled extremities suggest severe peripheral hypoperfusion or excessive vasoconstriction requiring immediate assessment.

Which medications primarily improve blood pressure by increasing vascular resistance rather than improving cardiac contractility?

Select all that apply.

A. Norepinephrine

B. Vasopressin

C. Phenylephrine

D. Dobutamine

E. Milrinone

A, B, C

💡 Rationale

✔ Levophed → Vasoconstriction

✔ Vasopressin → Vasoconstriction

✔ Phenylephrine → Pure alpha vasoconstriction

❌ Dobutamine → Improves contractility.

❌ Milrinone → Improves contractility and causes vasodilation.

A patient is receiving an Esmolol infusion for atrial fibrillation with RVR. Thirty minutes later, the monitor shows:

• HR: 48 bpm

• BP: 86/52

What is the nurse's priority action?

A. Increase the Esmolol infusion.

B. Assess the patient and follow the titration protocol for symptomatic bradycardia/hypotension.

C. Administer another beta-blocker.

D. Continue the infusion because the heart rate is now controlled.

B

💡 Rationale

Esmolol lowers both heart rate and blood pressure. A HR of 48 with hypotension requires immediate assessment and adjustment of therapy per protocol.

❌ A: Increasing the infusion could worsen the patient's condition.

❌ C: Giving another beta-blocker would further slow the heart.

❌ D: Heart rate control means little if the patient is unstable.

Which findings should the nurse monitor while a patient is receiving Esmolol?

A. Heart rate

B. Blood pressure

C. ECG rhythm

D. Oxygen saturation

E. Signs of heart block

A, B, C, E

💡 Rationale

Esmolol may cause bradycardia, hypotension, and AV block. ECG monitoring is essential.

A patient with an acute ischemic stroke is receiving a Cardene infusion.

Why should the nurse avoid lowering the blood pressure too quickly?

A. It can increase heart rate.

B. It can decrease cerebral perfusion.

C. It causes hyperkalemia.

D. It causes pulmonary edema.

B

💡 Rationale

Rapid blood pressure reduction can reduce blood flow to the brain, potentially worsening neurologic injury.

A patient receiving Cardene reports dizziness.

Current vital signs:

• BP: 82/46

• HR: 108

What should the nurse do FIRST?

A. Increase the infusion.

B. Reassess the blood pressure, evaluate the patient, and follow the titration protocol.

C. Encourage the patient to stand up slowly.

D. Give Atropine.

B

💡 Rationale

The patient's hypotension is likely related to the infusion. Immediate assessment and titration are indicated.

Which adverse effects are commonly associated with Nitroglycerin?

A. Headache

B. Hypotension

C. Dizziness

D. Bradycardia

E. Flushing

A, B, C, E

💡 Rationale

Nitroglycerin's vasodilatory effects commonly cause headaches, flushing, dizziness, and hypotension. Bradycardia is less common than reflex tachycardia.

Before initiating a Nitroglycerin infusion, which question is MOST important?

A. "Have you ever taken insulin?"

B. "Have you taken Viagra, Cialis, or Levitra recently?"

C. "Do you have diabetes?"

D. "Have you eaten today?"

B

💡 Rationale

PDE-5 inhibitors combined with Nitroglycerin can cause profound, life-threatening hypotension.

A patient on Nitroglycerin develops:

• BP: 76/40

• Reports feeling lightheaded

What is the priority nursing action?

A. Increase the Nitroglycerin.

B. Stop or decrease the infusion per protocol and reassess the patient.

C. Encourage deep breathing.

D. Administer Cardene.

B

💡 Rationale

The patient's hypotension is likely due to excessive vasodilation from Nitroglycerin.

Cardizem is most commonly used to treat which rhythm?

A. Ventricular fibrillation

B. Asystole

C. Atrial fibrillation with RVR

D. Sinus bradycardia

C

💡 Rationale

Cardizem slows AV node conduction, making it effective for rate control in atrial fibrillation.

Which assessments are priorities while administering Cardizem?

A. Blood pressure

B. Heart rate

C. ECG rhythm

D. Respiratory rate

E. Signs of AV block

A, B, C, E

💡 Rationale

Cardizem can cause hypotension, bradycardia, and AV block.

Which patient should NOT receive Cardizem?

A. Stable atrial fibrillation

B. Ventricular tachycardia

C. Controlled atrial flutter

D. Stable SVT

B

💡 Rationale

Cardizem is contraindicated in ventricular tachycardia because it may worsen hemodynamic instability.

A patient has been taking Amiodarone for six months.

Which new assessment finding requires immediate follow-up?

A. Mild nausea

B. Progressive shortness of breath

C. Dry mouth

D. Mild fatigue after work

B

💡 Rationale

Pulmonary toxicity is one of the most serious complications of Amiodarone.

Which organs should be monitored during long-term Amiodarone therapy?

A. Liver

B. Thyroid

C. Lungs

D. Pancreas

E. Kidneys

A, B, C

💡 Rationale

Amiodarone is associated with pulmonary fibrosis, thyroid dysfunction, and hepatotoxicity.

The nurse is preparing to administer Adenosine to a patient with stable PSVT.

How should the medication be given?

A. Slowly over 10 minutes.

B. Through a feeding tube.

C. Rapid IV push followed immediately by a saline flush.

D. Intramuscular injection.

C

💡 Rationale

Adenosine has a half-life of less than 10 seconds, so it must reach the heart quickly.

Immediately after Adenosine is administered, the cardiac monitor briefly shows asystole.

What should the nurse do?

A. Begin CPR immediately.

B. Recognize this is an expected transient effect while continuing to monitor the patient.

C. Administer another dose immediately.

D. Disconnect the monitor.

B

💡 Rationale

A brief period of asystole or AV block is expected after Adenosine before normal rhythm resumes.

Which medications can significantly lower blood pressure?

Select all that apply.

A. Cardene

B. Nitroglycerin

C. Esmolol

D. Cardizem

E. Amiodarone (IV)

A, B, C, D, E

💡 Rationale

All of these medications can contribute to hypotension, although through different mechanisms:

• ✔ Cardene → arterial vasodilation.

• ✔ Nitroglycerin → venous (and some arterial) vasodilation.

• ✔ Esmolol → decreases heart rate and contractility.

• ✔ Cardizem → decreases heart rate and causes some vasodilation.

• ✔ IV Amiodarone → may cause hypotension, especially during loading doses or rapid infusions.

An intubated patient is receiving a continuous Fentanyl infusion. Which assessment finding requires the nurse's immediate attention?

A. Pain score decreased from 8 to 3

B. Respiratory rate of 7 breaths/minute

C. Blood pressure of 132/76

D. Heart rate of 88 bpm

B. Respiratory rate of 7 breaths/minute

💡 Rationale

Respiratory depression is one of the most dangerous adverse effects of Fentanyl. A respiratory rate of 7 requires immediate assessment and intervention.

❌ A: This indicates pain relief.

❌ C: Normal BP.

❌ D: Normal HR.

A patient is receiving a Fentanyl infusion.

Which assessments are priorities?

A. Respiratory rate

B. Pain level

C. Oxygen saturation

D. Blood pressure

E. Sedation level

A, B, C, D, E

💡 Rationale

Although Fentanyl is an analgesic, it can also affect respiratory status, blood pressure, and level of consciousness.

Which medication reverses the effects of Fentanyl?

A. Flumazenil

B. Protamine

C. Naloxone

D. Adenosine

C

💡 Rationale

Naloxone reverses opioid-induced respiratory depression.

A patient is receiving Precedex. Their heart rate gradually decreases from 88 to 42 bpm while their blood pressure remains stable.

What is the nurse's priority action?

A. Stop the infusion immediately without assessment.

B. Assess the patient and follow the titration protocol.

C. Administer Epinephrine.

D. Increase the infusion.

B

💡 Rationale

Bradycardia is common with Precedex. First assess the patient, determine if they are symptomatic, and follow institutional protocols.

Which statements about Precedex are TRUE?

A. It causes minimal respiratory depression.

B. Patients may remain on it after extubation.

C. Bradycardia is common.

D. It provides pain relief.

E. Hypotension may occur.

A, B, C, E

💡 Rationale

Precedex provides sedation—not analgesia. Bradycardia and hypotension are common adverse effects.

A patient has been receiving Propofol for five days.

Which laboratory value is MOST important to monitor?

A. Troponin

B. INR

C. Triglycerides

D. Hemoglobin

C

💡 Rationale

Propofol is formulated in a lipid emulsion and prolonged infusions may significantly increase triglyceride levels.

A patient receiving Propofol suddenly develops:

• BP 74/38

• Difficult ventilation

• Metabolic acidosis

Which complication should the nurse suspect?

A. Stroke

B. Propofol Infusion Syndrome (PRIS)

C. Pneumonia

D. DKA

B

💡 Rationale

PRIS is a rare but life-threatening complication associated with prolonged high-dose Propofol infusions.

Which medications provide sedation without pain relief?

A. Propofol

B. Versed

C. Ativan

D. Fentanyl

E. Etomidate

A, B, C, E

💡 Rationale

These medications sedate the patient but do not provide analgesia.

Fentanyl is the analgesic.

Which reversal agent is used for Versed?

A. Naloxone

B. Protamine

C. Flumazenil

D. Calcium Gluconate

C

A patient receiving Versed becomes difficult to arouse.

Which assessment is the nurse's priority?

A. Blood glucose

B. Respiratory status

C. Urine output

D. Bowel sounds

💡 Rationale

Benzodiazepines can cause respiratory depression.

A patient receiving Nimbex suddenly stops moving.

The family says,

"He looks peaceful now."

Which nursing response is BEST?

A. "The medication also relieves pain."

B. "The medication makes him sleep."

C. "The medication only causes paralysis, so we continue pain medicine and sedation."

D. "He can no longer hear us."

C

💡 Rationale

🚨 This is one of the MOST tested ICU concepts.

Nimbex ONLY paralyzes skeletal muscles.

It does NOT:

• relieve pain

• reduce anxiety

• cause unconsciousness

Before starting a Nimbex infusion, which actions should the nurse perform?

A. Verify adequate sedation.

B. Verify adequate pain control.

C. Apply Train-of-Four monitoring when indicated.

D. Explain the procedure if the patient is awake.

E. Remove oxygen.

A, B, C, D

💡 Rationale

Paralyzed patients require sedation, analgesia, TOF monitoring, and communication whenever possible.

Why is Etomidate commonly chosen during rapid sequence intubation?

A. It lowers potassium.

B. It provides long-term sedation.

C. It causes minimal cardiovascular depression.

D. It treats pain.

C

💡 Rationale

Etomidate is commonly selected because it usually maintains blood pressure better than many other induction agents.

A patient with a potassium level of 6.4 mEq/L is scheduled for emergency intubation.

Which medication should the nurse question?

A. Propofol

B. Rocuronium

C. Succinylcholine

D. Fentanyl

C

💡 Rationale

Succinylcholine may further increase potassium and precipitate fatal dysrhythmias.

Which medications DO NOT provide pain relief?

Select all that apply.

A. Propofol

B. Precedex

C. Versed

D. Rocuronium

E. Etomidate

F. Fentanyl

A, B, C, D, E

💡 Rationale

None of these medications treat pain.

✔ Propofol → Sedation only

✔ Precedex → Sedation only

✔ Versed → Sedation & amnesia only

✔ Rocuronium → Paralysis only

✔ Etomidate → Sedation only

❌ Fentanyl is the only medication listed that provides analgesia.

Your patient is receiving:

• Propofol

• Fentanyl

• Nimbex

Suddenly they stop moving.

Which medication is responsible?

A. Propofol

B. Fentanyl

C. Nimbex

D. All three

C

Which medication in the above combination is actually treating the patient's pain?

A. Propofol

B. Fentanyl

C. Nimbex

D. Versed

B

Which medication would you expect to continue after extubation?

A. Nimbex

B. Propofol

C. Precedex

D. Rocuronium

C

A patient receiving a Heparin infusion has a platelet count that drops from 245,000 to 68,000 over several days.

Which complication should the nurse suspect?

A. Iron deficiency anemia

B. Disseminated intravascular coagulation (DIC)

C. Heparin-Induced Thrombocytopenia (HIT)

D. Normal therapeutic response

C. Heparin-Induced Thrombocytopenia (HIT)

💡 Rationale

A significant drop in platelets while receiving Heparin is concerning for HIT, which is a pro-thrombotic immune reaction. Even though platelets are low, patients are actually at higher risk for forming dangerous clots, not just bleeding.

❌ A: Iron deficiency doesn't cause an abrupt platelet drop after starting Heparin.

❌ B: DIC has a different clinical picture and isn't the expected complication from Heparin therapy.

❌ D: This is not a normal response and requires immediate evaluation.

The nurse is caring for a patient receiving a continuous Heparin infusion.

Which assessments are priorities?

A. aPTT (or Anti-Xa per protocol)

B. Signs of bleeding

C. Platelet count

D. Urine output

E. Stool for occult blood if indicated

A, B, C, E

💡 Rationale

Heparin requires close monitoring for therapeutic anticoagulation, bleeding, and HIT. Stool may be checked for occult GI bleeding when clinically indicated.

A patient develops HIT.

Which medication should the nurse anticipate administering?

A. Alteplase

B. Argatroban

C. More Heparin

D. Aspirin

B

💡 Rationale

Argatroban is a direct thrombin inhibitor commonly used when HIT is suspected or confirmed.

Which medication is the antidote for Heparin?

A. Vitamin K

B. Naloxone

C. Protamine Sulfate

D. Flumazenil

C

A patient receiving Alteplase (tPA) suddenly reports "the worst headache of my life."

What is the nurse's priority action?

A. Give acetaminophen.

B. Continue the infusion.

C. Stop the infusion per protocol, perform a rapid neurologic assessment, and notify the provider immediately.

D. Encourage the patient to rest.

C

💡 Rationale

A sudden severe headache during thrombolytic therapy is concerning for intracranial hemorrhage, one of the most serious complications of tPA.

Which medications prevent clot formation rather than dissolve existing clots?

A. Heparin

B. Eliquis

C. Alteplase

D. Argatroban

E. tPA

A, B, D

💡 Rationale

Heparin, Eliquis, and Argatroban are anticoagulants.

Alteplase (tPA) breaks down existing clots.

A patient is receiving EKOS therapy.

Which medications are commonly infused as part of the treatment?

A. Nitroglycerin and Dopamine

B. Alteplase, Heparin, and Normal Saline

C. Albumin and Fentanyl

D. Dobutamine and Cardizem

B

💡 Rationale

EKOS combines ultrasound-assisted thrombolysis with Alteplase, low-dose Heparin, and saline coolant.

A kidney transplant patient taking Tacrolimus has:

• Creatinine rising

• New hand tremors

What complication should the nurse suspect?

A. Pneumonia

B. Tacrolimus toxicity

C. Hyperthyroidism

D. GI bleed

B

💡 Rationale

Tacrolimus commonly causes nephrotoxicity and neurotoxicity, especially when drug levels become elevated.

Which findings should the nurse monitor in a patient taking CellCept?

A. Fever

B. White blood cell count

C. Signs of infection

D. CBC

E. Blood glucose only

A, B, C, D

💡 Rationale

CellCept suppresses the immune system, increasing infection risk and potentially causing leukopenia.

A patient is receiving 3% Hypertonic Saline for symptomatic hyponatremia.

Which laboratory result requires immediate attention?

A. Sodium increased from 118 to 132 mEq/L in four hours

B. Potassium 4.1

C. Glucose 120

D. Magnesium 2.0

A

💡 Rationale

Correcting sodium too quickly increases the risk of osmotic demyelination syndrome (ODS).

Which patient should the nurse question receiving Albumin?

A. A patient with hypovolemia

B. A patient with pulmonary edema and severe fluid overload

C. A patient after a large-volume paracentesis

D. A patient with hypoalbuminemia

B

💡 Rationale

Albumin pulls fluid into the bloodstream, which can worsen pulmonary edema and fluid overload.

A mechanically ventilated ICU patient is receiving Protonix.

Why is this medication commonly prescribed?

A. Stress ulcer prophylaxis

B. GI bleed treatment

C. GERD

D. Pain control

E. Reduce stomach acid

A, B, C, E

💡 Rationale

Protonix decreases gastric acid production and helps prevent or treat acid-related GI complications.

A patient with cirrhosis develops active bleeding from esophageal varices.

Which medication should the nurse anticipate?

A. Octreotide

B. Levophed

C. Cardene

D. Milrinone

A

💡 Rationale

Octreotide decreases portal venous pressure and helps control variceal bleeding.

The nurse notices a patient's Veletri infusion has accidentally stopped.

What is the priority action?

A. Restart the infusion immediately and notify the provider per protocol.

B. Wait until the next scheduled dose.

C. Discontinue therapy.

D. Flush the IV and observe.

A

💡 Rationale

Abrupt interruption of Veletri can cause life-threatening rebound pulmonary hypertension.

A patient with potassium 7.2 mEq/L receives the hyperkalemia cocktail.

Which statements are TRUE?

A. Calcium gluconate stabilizes the heart.

B. Regular insulin shifts potassium into the cells.

C. D50 prevents hypoglycemia.

D. Regular insulin removes potassium from the body.

E. Lantus is the preferred insulin for emergency hyperkalemia.

A, B, C

💡 Rationale

✔ A: Calcium protects the myocardium.

✔ B: Regular insulin temporarily shifts potassium intracellularly.

✔ C: D50 prevents insulin-induced hypoglycemia.

❌ D: Insulin does not remove potassium; it only shifts it into cells temporarily.

❌ E: Regular insulin, not Lantus, is used IV for emergency hyperkalemia.

Your patient is receiving:

• Levophed

• Vasopressin

• Propofol

• Heparin

Their BP improves, but their urine output drops to 10 mL/hr.

What is your biggest concern?

A. The BP is fine, so no action is needed.

B. Poor organ perfusion despite an adequate MAP.

C. The Propofol is causing kidney failure.

D. The patient needs more sedation.

B

💡 Rationale: An adequate MAP does not always mean adequate tissue perfusion. Decreased urine output may indicate worsening shock or excessive vasoconstriction.

Your patient is receiving:

• Fentanyl

• Propofol

• Nimbex

The family asks, "Which medication is helping with his pain?"

A. Propofol

B. Nimbex

C. Fentanyl

D. All of them

C

💡 Rationale: Fentanyl is the analgesic. Propofol provides sedation, and Nimbex causes paralysis only.

A patient receiving a Heparin infusion develops suspected HIT.

Which medication from your ICU medication packet is the best replacement?

A. Eliquis

B. Argatroban

C. Alteplase

D. Protamine Sulfate

Answer: B

💡 Rationale: Argatroban is a direct thrombin inhibitor commonly used as an alternative anticoagulant in patients with HIT.

🎓 One Last Piece of Advice

Looking over your medication packet and the questions we've built, if I had to bet on what your hospital educator will emphasize, I'd rank these topics:

1. ⭐ Levophed vs. Vasopressin vs. Phenylephrine vs. Dobutamine (knowing when each is used)

2. ⭐ Paralytics do NOT sedate or relieve pain (Nimbex/Rocuronium)

3. ⭐ Hyperkalemia treatment (Calcium vs. Regular insulin vs. D50)

4. ⭐ Heparin → HIT → Argatroban

5. ⭐ Adenosine administration (rapid IV push + flush)

6. ⭐ Propofol monitoring (triglycerides, hypotension, PRIS)

7. ⭐ Never abruptly stop Veletri or Remodulin

8. ⭐ 3% saline—don't correct sodium too quickly

9. ⭐ Tacrolimus—monitor trough levels and kidney function

10. ⭐ Octreotide for variceal bleeding