PASS the CCRN! Questions

A 56 yr-old male is admitted to the ICU with a blood pressure of 225/135 and complains of a headache and nausea. He reports he ran out of blood pressure meds three days ago, but also appears to be confused to the date and situation. What is the most appropriate treatment approach?

Rapidly lower the diastolic pressure to 100 with IV antihypertensive meds, then continue to gradually reduce the diastolic pressure to 85 with oral antihypertensive meds.

The maximum initial decrease should be no more than 25% reduction from initial presenting value. Reducing the blood pressure too quickly can lead to cerebral edema or renal failure.

A patient has sepsis, receives Lactated ringers 500ml IV bolus. Which finding indicate that this intervention is having it's intended effect?

ScvO2 of 72%

Early goal directed therapy for sepsis includes early fluid resuscitation at 30 ml/kg to maintain a CVP of 8-12 or 12-15 if mechanically ventilated, MAP greater than 65, ScvO2 greater than 70%, and urine output greater than 0.5 kg/hr

72 male patient in ICU for 6 days on the ventilator for treatment of a COPD exacerbation. He has been receiving VTE prophylaxis and subcutaneous Heparin since admission. Today his platelet count decreased significantly to 43,000 and was found to have new DVT on his right upper extremity. What do you suspect is the most likely cause of these findings?

HIT

The hallmark sign of HIT is a significant decrease in platelet count over a 24 hours period (>50%) within 5-10 days of administering Heparin. The other hallmark sign is a new development of DVT despite being on VTE prophylaxis.

TRALI:

is a complication from a blood transfusion reaction, which causes acute lung injury typically within 6 hours of a blood transfusion.

2 Hallmark signs of HIT:

Decrease in platelet count over a 24 hr period.

New development of DVT despite being on VTE prophylaxis.

Values in Early compensated Hypovolemic shock?

CO 4.0 L/min, HR 135, SV 65, SVR 1700, MAP 65

In hypovolemic states, circulating volume is depleted therefore preload and contractility are decreased which leads to a decrease in SV and CO. HR and SV increase as compensatory measure to preserve CO, MAP and cerebral perfusion.

Post-renal failure values:

Urine output < 200; urine sodium 30; BUN: Creatinine ratio 15:1; urine specific gravity 1.010

BUN: Creatinine ratio is 15:1, but both the BUN & creatinine are elevated. Urine sodium is typically 1-40 mEq/L.

What to do in the event of HIT:

Stop Heparin and administer an alternative direct thrombin inhibitor.

Warfarin is contraindicated in HIT? T/F

True - there is also no evidence that shows protamine, corticosteroids, and benadryl are effective treatments for HIT

Patients with right ventricular infarctions become preload dependent. Meds that decrease preload should be avoided - which meds are these?

Morphine, Nitro, Beta blockers and diuretics.

Polymorphic ventricular tachycardia aka Torsades is treated by?

Magnesium

Myocardial contusions generally impact which parts of the heart? and what would the values be?

Atria & right ventricle because of the position of the heart in the chest.

PAOP 6, PA Pressure 40/24, RA Pressure 16

Neurogenic shock signs?

CVP: 3, CI: 2.5, SVR: 650, SBP: 88

Neuro shock is associated with a loss of sympathetic tone causing extensive peripheral vasodilation. Clinical signs and symptoms include hypotension, a low SVR, low CVP and low normal CI

What causes a larger than normal A wave on a PAOP?

Mitral stenosis - causes increased left atrial pressure during atrial contraction.

Pulmonary HTN will result in what?

Elevated PA pressures but have no impact on PAOP.

Infective Endocarditis can cause what kind of impairment?

Neurologic impairment. One of the risks of infective endocarditis is the bacterial strand breaking in the heart and throwing bacterial emboli forward into the lungs from the right side of the heart or to the brain/body from the left side of the heart.

Neurologic impairment could be a sign?

Embolic ischemic stroke.

Post bariatric surgery should avoid what kind of meds?

Extended release meds due to absorption concerns post-operatively

Chlorpropamide is a what?

sulfonylurea drug that is used in DI as an antidiuretic. It is primarily a glucose lowering agent. (hypoglycemia)

Will a cardiac transplant patient respond to atropine?

No - pacing is the best instrument for symptomatic bradycardia.

Elevated urine osmolality; decreased serum osmolality; and decreased serum sodium is what symptom?

SIADH - causes retention of water. Urine production is minimal and concentrated & leads to an increased urine osmolality.

What does Neo drug increase?

SVR - Peripheral constriction

Treatment for narrow complex, regular rhythm?

Administer 6mg adenosine rapidly IVP

Half life of metformin?

6 hours - close monitoring is required to ensure the blood glucose level does not climb too quickly while dextrose is being administered.

Most accurate reflection of daily fluid balance?

Record a daily weight at the same time each day.

Wide mediastinum on chest x-ray, narrow pulse pressure, and hypotension are signs of what?

Cardiac tamponade

A patient with hyponatremia would need what?

Help maintaining a safe environment. HypoNa impairs judgment, and causes confusion.

Peritoneal dialysis works on the principles of both?

Diffusion and osmosis.

HHNS leads to what?

Large fluid deficits and may require multiple liters of fluid, which is determined by the patient's level of dehydration and hyperosmolality.

What parameters are consistent with Pulsus Paradoxes?

Decrease in SBP>10 during inspiration.

Before administering rtPA what must happen?

Lower the BP to at least 185/110. An elevated BP prior to rtPA can cause hemorrhage.

Ibutilide can cause what?

Torsades

A person with disecting AAA would receive what drug?

PRN IV narcotic analgesia - BP management is a priority in the care of a patient with a dissecting AAA. Pain is the primary driver of HTN.

Autonomic hyperreflexia is what?

This disorder is seen with spinal injuries occurring above the T6 spine.

Cause of autonomic hyperreflexia?

Bladder obstruction, constipation, pressure ulcers, and pain. Usually when the noxious stimulus is identified and removed, the symptoms resolve. Checking urinary catheter for obstruction is the most appropriate next action.

MEDS for asymptomatic left ventricular systolic dysfunction?

ACE or (ARB), beta-blockers and statins for all patients with a history of MI and for all patients with a reduced ejection fraction.

What is the Z point technique?

is a method used to estimate ventricular end diastolic pressure. It is taken just before the closure of the mitral valve and is especially useful when an A wave does not exist on the PAOP tracing such as in atrial fib.

Ascites position for relief?

Place pt on left side.

DIC lab values?

Fibrinogen decreased

FSP elevated

Platelets decreased

D-dimer elevated

Decreased Albumin is an indicator of what?

Protein deficiency and poor nutrition, which are major contributors to poor wound healing.

A continous infusion of Lorazepam for greater than 3 days can lead to an accumulation of?

Propylene glycol.

Inability to communicate in full sentences may be a sign of what?

Severity of asthma (high risk)

Management of high ICP includes?

Osmotic diuretics, hypertonic saline & antihypertensives.

Causes increased left atrial pressure during atrial contraction - results in a larger than normal A wave on the PAOP tracing?

Mitral Stenosis

Pulmonary htn will result in elevated PA pressures but have no impact on?

PAOP

Elevated urine osmolality; decreased serum osmolality; decreased serum sodium?

SIADH

Absolute contraindication for thrombolytic therapy?

Aortic dissection

Crackles in bilateral lower lobes and a s3 heart sounds are indicative of what? Tx?

Fluid overload

Furosemide 40 mg IV x 1 now

Narrow pulse pressure - CO 3L/min, HR 135, SV 30, SVR 2100 are all signs of what?

Cardiogenic shock

HUS is marked by what?

Renal failure

Thrombocytopenia & hemolytic anemia

DIC lab values?

Decreased Fibrinogen

FSP elevated

Platelets decreased

D-dimer elevated

HOB position for ICP?

Other tx?

45 degrees

Increase sedation or mannitol as prescribed.

Opening the Ventriculostomy drain requires specific orders?

True

Brain death criteria?

Positive Apnea test

Absent Oculovestibular and Oculocephalic reflex

Respiratory acidosis

ST elevation is indicative of what?

Cardiac ischemia and should be treated as myocardial infarction

CDC indications for urinary catheter include:

end-of-life care, strict I&O, immobility, select surgical procedures, sacral wounds, urinary retention/obstruction

A saddle embolus is life threatening and requires which immediate intervention?

IV thrombolytic for clot lysis.

Subcutaneous and IV heparin inhibit thrombus growth and promote resolution of the formed clot, but will treat the a saddle pulmonary embolus.

Indiscrimate pacing spikes indicate that the pacer is not what?

Not sensing or seeing the cardiac activity present. Sensitivity should be decreased.

A sudden increase in left atrial diastolic pressure will result in?

Mitral regurgitation

Late stages of shock results in what lab values?

Increased Potassium

Decreased Bicarbonate

Increased Lactic acid

Juxtaglomerular cells secrete what?

Renin in response to reduced glomerular filtration pressure.

Secondary adrenal insufficiency is caused by:

Long term steroid use, additional stress can overwhelm the hypothalamic -pitutary-adrenal system.

Neosynephrine stimulates what?

Side effects would include:

alpha receptors - causes vasoconstriction, resulting in increase BP

Reflexive bradycardia

Heptojugular Reflex is suggestive of which following condition?

Right sided heart failure

Fever is associated with what?

Worse neuro outcomes.

This is secondary to the increase in cerebral metabolism and oxygen consumption

Low volume ventilation, less than 10 mL/kg to minimize what?

Pneumothorax - over inflation can cause volutrauma, which can lead to a spontaneous pneumothorax.

Decreased right atrial pressure (RAP/CVP) could be caused by?

Sepsis

High pressure alarm on ventilator is commonly caused by?

secretions or increased resistance in the airways.

Major abdominal surgery may cause which pulmonary complication?

Atelectasis - tx would be pulmonary hygiene and chest x-ray

What would minimize pancreatic stimulation?

Begin feedings via jejunal route - enteral feedings are preferred. Utilization of jejunal feedings maintain gut integrity and minimize pancreatic stimulation.

QRS complex is upright in both leads?

Negative deflection in both leads depicts an extreme?

Negative QRS deflection in Lead 1 and positive deflection in Lead aVF are associated with?

Axis is normal

Extreme Right axis deviation

Right axis deviation

Priority data to collect for delirium and changes in QTc?

CAM-ICU and 12 lead ECG

Pacemaker setting in A-fib?

VVI

Atria cannot be paced when in atrial fibrillation

Alpha cells produce?

Beta cells?

Delta cells?

Glucagon

Insulin

Somatostatin

Serum Osmolality of 320 is indicative of:

DI - profound dehydration will lead to an elevated serum osmolality because of water loss.

Contraindications of rtPA include:

Gastro or other bleeding complications (within 3 months)

First sign of problems from a shunt include:

change in LOC or mental status

Ominous sign of acute asthma exacerbation:

Hypercapnia or elevated PaCO2 indicates patient is becoming fatigued and going into acute respiratory failure.

Nephrogenic DI would cause what?

the kidneys not respond to ADH

Lactated ringers at 100ml hr before and after procedure is often prescribed to prevent what?

Contrast induced nephropathy

Keeping the TV (tidal volume) low is the best way to decrease pressures and avoid what?

Barometric trauma in ARDS

Which of the following parameters most accurately estimates end-organ perfusion?

Urinary output, lactate, ScvO2

Aortic stenosis cause increased noise during systole and impaired outflow, leading to:

Pulmonary edema and crackles.

Tx for neurogenic shock?

Vasoconstrictor (phenylephrine) over large volume of fluid resuscitation

Liver failure labs:

Elevated bilirubin

Decreased albumin

elevated PTT, PT & INR

When the liver fails:

ammonia levels build causing encephalopathy. Bilirubin levels rise causing jaundice and coagulation times often prolong putting patient at risk for bleeding.

Patients with HIT may develop:

Thrombosis, DVT, PE, STROKE, MI, Renal impairment

Vancomycin has a risk of nephrotoxicity and RN should monitor which lab value:

Elevated serum creatinine

Cerebral insults include:

ipsilateral pupil changes and contralateral motor extremity changes.

Diuretic phase of ATN would include which lab value:

Decreased urine osmolality

Kernig's sign is indicative of:

Meningitis - pt cannot extend the knee when the hip is flexed.

DKA patients have a profound decrease in what:

Fluids

Pancreatitis leads to what?

ARDS, DIC, hypovolemic shock

Glycopyrrolate is part of medical mgmnt for:

Respiratory failure in patient with chronic pulmonary dz.

Thrombolytic therapy using rtPA is most common tx for:

ischemic stroke

Inclusion criteria for thrombolytic therapy:

over the age of 18

less than 3 hours of onset

CT scan verifying ischemic stroke

Exclusion criteria for thrombolytic therapy:

Seizure activity with onset stroke symptoms

major surgery or trauma past 3months

Adverse effects of Increasing PEEP causes:

Hypotension

Inattention, alterations in perception, disorganized thinking and memory impairment:

Delirium

An elevated Lactate level would include which tx:

Central line and additional IV fluids