NRNP6566 Advanced Care of Adults in Acute Settings I
Week 3 Knowledge Check
Question 1What is your interpretation of this 12-lead EKG?
Question 2 A 66-year-old female complains of dizziness, fatigue, and shortness of breath. Her EKG is below. What is your working diagnosis? What immediate treatment is indicated?
Question 3A 59-year-old male complains of dizziness, palpitations, weakness, and chest tightness. These symptoms have occurred a couple times a day for the last seven days. EKG shows atrial fibrillation with rapid ventricular response. His blood pressure varies with readings of 90/42 to 120/66. Heart rate ranges from 150—210. The decision is made to cardiovert the patient. Prior to the procedure, what testing is essential to complete?
Question 4 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?
Question 5What is your interpretation of this 12-lead EKG?
NRNP6566 Advanced Care of Adults in Acute Settings I
Week 4 Knowledge Check
Question 1 A 56 year old man is thought to be in hypovolemic shock. What physical assessment findings would you expect to find to confirm this type of shock?
Question 2 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 ?
Question 3 A 44 year old man is thought to be in cardiogenic shock. What are the initial interventions needed for a patient in cardiogenic shock?
Question 4 What is the mechanism of action and common side effects of dobutamine, norepinephrine, labetalol, and amiodarone?
Question 5 What is the difference between dopamine and dobutamine?
NRNP6566 Advanced Care of Adults in Acute Settings I
Week 5 Knowledge Check
Question 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?
Question 2 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?
Question 3 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?
Question 4 Renee is a 56-year-old female that fell about a week ago and sprained her R ankle. She states she 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)?
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?
NRNP6566 Advanced Care of Adults in Acute Settings I
Week 7 Knowledge Check 1
Question 1 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
ABG Result
pH pCO2 pO2 HCO3
7.08 54 54 15
Question 2 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?
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
ABG Result
pH pCO2 pO2 HCO3
7.51 39.4 77.3 31.3
Question 4 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
ABG Result
pH pCO2 pO2 HCO3
7.36 30 80 15
Question 5 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?
NRNP6566 Advanced Care of Adults in Acute Settings I
Week 7 Knowledge Check 2
Question 1 A patient with respiratory failure has hemodynamic monitoring and is receiving mechanical ventilation 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.
Question 2 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?
Question 3 A patient is admitted to the ICU with severe necrotizing pancreatitis. Three hours after admission his oxygen saturations decreased and he was intubated for hypoxia. Initially his oxygen saturation improved to 94% on FiO2 of 50% but over the past two hours his FiO2 has been increased to 70% and his saturation is 89%. The patient is on 5 cm H2O of PEEP.
His current ABG shows pH 7.34, pCO2 36, PO2 61, HCO3 21 on an FIO2 of 80%. The patient’s repeat chest x-ray shows diffuse bilateral opacities in a pattern consistent with pulmonary edema. An echo earlier today was read as normal.
What can you do to improve his oxygenation?
Question 4 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?
Question 5 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 do static and peek pressures represent on the ventilator?
NRNP6566 Advanced Care of Adults in Acute Settings I
Week 8 Knowledge Check
Question 1 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?
Question 2 A 13 year old girl is evaluated in urgent care for a large wound on her left forearm. She complains of severe pain, is crying, and is rocking on the bed due to pain. The APRN is planning on how to repair the laceration and is considering utilizing ketamine for procedural sedation. What are the benefits and risks of this drug? What monitoring would be indicated if utilized?
Question 3 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?
Question 4 What type of ICU sedation would be appropriate for a 32 year old male patient who is intubated with bilateral chest tube following a motor vehicle crash.
Question 5 A 77 year old man fell and suffered a laceration across his upper right lip. The APRN decides to utilize a block for pain control which suturing the laceration. What type of block and what medication would be appropriate for this patient?
NRNP6566 Advanced Care of Adults in Acute Settings I
Week 9 Knowledge Check
Question 1 A 16 year old male is admitted to the step down unit following laparotomy for appendici-tis. It was determined during surgery that the appendix had ruptured causing a perito-nitis. What antibiotics would be indicated to treat the peritonitis?
Question 2This is a sensitivity report for a 45 year old male. What antibiotic would you not order to treat this infection? Would ciprofloxin with a MIC of 1 be more effective than aztreonam with a MIC of 8?
Question 3 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?
Question 4 A 42 year old man is evaluated for redness, pain, swelling, and tenderness on the anterior right thigh. His symptoms started about 4 days ago with a small 1 cm blister on his thigh. The area has gotten bigger over the past 4 days and is now 4 cm x 6 cm. He indicates that has been having fever and chills over the past couple of days. The NP diagnoses him with cellulitis. What would your treatment for this be?
Question 5 A 52 year old female is 7 days post lumbar laminectomy complaining of abdominal pain and severe diarrhea. She is afebrile with stable vital signs. Lab results show a positive C-diff culture. How should you treat this patient?
NRNP6566 Advanced Care of Adults in Acute Settings I
Week 10 Knowledge Check
Question 1 An 87 year male is brought to the emergency department from a nursing home by his family with concerns about his functional status. They state that over the past week he is very somnolent and not participating in his own care very much. The family is worried that he has had a stroke or is overmedicated by the nursing home staff. Medical record from the nursing home shows that he is disruptive and has daily wrist restraints ordered.
The patient is arousable but somnolent when no one is speaking with him. His past medical history is unremarkable. He was placed in the nursing home due to his age and inability to care for himself at home. His family states that he is usually quite alert and interactive. The patient is widowed and has been at the nursing home for about 2 months.
He has no routine medications but several PRN mediations including haloperidol, valium, and milk of magnesia.
BP 100/53 T 98.3 HR 88 RR 14
Mucous membranes are dry. Pulmonary, cardiovascular, abdominal, and extremity examinations are normal. Chest x-ray shows no infiltrate and voided urine shows no evidenced of UTI.
LAB DATA:
-Sodium 162
-Potassium 3.4
-Chloride 130
-Bicarbonate 23
-BUN 38
-Creatinine 1.8
-Glucose 97
-Calcium 10.3
What is your working diagnosis for this patient? How would you treat it?
Question 2 A 70 year old man is 4 hours post right heme-colectomy for a tumor. The NP is called due to falling urine output since surgery.
Past medical history - hypertension, type 2 diabetes, gout
Medications - lisinopril, allopurinol, and spironolactone (all last given this morning).
Physical exam - BP 100/60. HR 110 regular weight 60 kg
Lungs are clear, abdominal wound is clean with no drainage, No JVD
Urine output
1700 hr. 35 ml
1800 hr 22 ml
1900 hr 15 ml
2000 hr. 8 ml
Urine dipstick is normal
How would you classify his renal status? How would you treat it?
Question 3 A 25 year old man with schizophrenia is admitted to the psych unit for medication stabilization. The patient is responsive but sleepy. Vital signs are within normal limits and muscle tone is normal. The patient has a large container of sweet iced tea which is nearly empty.
His admission labs include:
-Sodium 122
-Potassium 4.0
-Chloride 101
-Bicarbonate 21
-BUN 67
-Creatinine 0.9
-Glucose 91
What is our working diagnosis? How would you treat it?
Question 4 A 44 year old female is NPO following surgery for a bowel obstruction. She weighs 166 pounds. How would you calculate her daily maintenance IV fluid need while she is NPO?
Question 5 A 57 year old female is admitted to the oncology unit for chemotherapy related to her to acute leukemia. Her initial dose of chemo was 2 days ago. While rounding today, the patients tells the NP that she feels so weak. The NP notes her heart rate is 44 today (down from 68 2 days ago). She has had less than 100 cc of urine out over the last 24 hours.
Labs from this morning include:
LAB DATA:
-Sodium 131
-Potassium 7.8
-Chloride 105
-Bicarbonate 17
-BUN 67
-Creatinine 5.8
-Glucose 83
-Calcium 7.6
-Phosphorus 6.8
-Uric acid 16.3
What is your working diagnosis for this patient? How would you treat her?
NRNP6566 Advanced Care of Adults in Acute Settings I
Week 11 Knowledge Check
Question 1 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?
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 patient education would be important to provided related to sick day management of his diabetes (include management of insulin) ?
Question 3 A 44 year old female with history of type 2 diabetes taking metformin is admitted to the ICU following percutaneous placement of two coronary stents. Her chest pain is completely resolved. Twelve hours after the procedure the NP is contacted by the ICU nurse. The patient is experiencing shortness of breath, severe muscles pain, chilled, and a slow irregular heart beat. The patients ankles are swollen. The most recent labs show a Bun of 44 and Cr of 3.1. What do you suspect is happening with this patient?
Question 4 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:
0300 0700 1200 1700 2100
62 196 109 90 146
64 203 82 100 150
What is your working diagnosis for this patient?
Question 5 How would you differentiate between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS)?
