NURSING 6560 francisstudyguide_(2)/COMPLETE SOLUTION TO SCORE A

NURSING 6560 francisstudyguide_(2)/COMPLETE SOLUTION TO SCORE A 1. You want to get more funding for your hospital’s Rapid Response Team. How should you present this issue to the committee? 2. What is the best way f ...

NURSING 6560 francisstudyguide_(2)/COMPLETE SOLUTION TO SCORE A 1. You want to get more funding for your hospital’s Rapid Response Team. How should you present this issue to the committee? 2. What is the best way for the AGACNP to get involved in policy making? 3. What is the best way for the AGACNP to demonstrate and advocate for full scope of practice? 4. Which of the following is considered a high acuity role for the AGACNP? 5. What is the best way to advocate for gay and lesbian population in your area? 6. Which of the following is most important to evaluate statistical significance when reviewing the literature? 7. When closing a practice, the NP is required to do all of the following except 8. Which of the following components of an evidenced based research process is the most important for NP to participate in? 9. A former pt of an NP is writing blog posts, sending emails, and distributing false, accusatory statements about the NP’s practice. Which of the following forms of defamation is this? 10. Can you tell the pt’s wife, for her protection, that her husband has HIV? 11. How can the ANCP prepare to get involved in future mass casualty event? 12. An 80-year-old male patient with dementia requires long-term care placement. To which funding agency does the patient apply after "spending down" to qualify? 13. Your pt is worried about insurance coverage and asks you for advice on Medicaid. You instruct the patient that Medicaid: 14. You are giving a dinner presentation to a group. The pharmaceutical rep calls you the night before and wants you to say that their drug is the only one that works. What ethical principles does this challenge? Veracity and Fidelity • Health Literacy: Average American-8th grade education level • Know your QA/QI/CPI basic definitions and goals: verbatim from Barkley’s Book • One question had Quality Assurance as one answer, then CPI as another option! It sounded more like CPI to me. • Quality assurance-a process for evaluating the care of pts using established standards of care to ensure quality • CPI measures what 3 measures to improve nursing? Structure, processes, and outcomes • A root cause analysis of a crisis situation in the ICU identified a lack of clinician-family communication as the basis for the resulting adverse outcome. As part of the performance improvement plan, the NP is asked to develop evidence-based polices to establish clinician-family communication standards in the unit. These policies should include: guidelines for having discussions with family members that are geared toward establishing treatment goals. • Which clinical scenario does the NP evaluate for a quality improvement process change? An increased incidence of postoperative sternal wound infections • Goals set forth in "Healthy People 2020" by the United States Department of Health and Human Services include: elimination of health disparities. (and ↑QOL/LOL) • Based on the individual's culture, ethnicity, and personal choices, the NP can optimize the therapeutic partnership w/the patient by: Tailoring his or her communication style to the patient’s preference. • A 70-year-old pt with a hx of DM, HTN, OAs, and a new diagnosis of coronary artery disease, is being discharged. The adult- gerontology acute care nurse practitioner teaches the patient that the first point of contact for health care needs is the: primary care provider • The NP is asked to provide evidence to the hospital administration about the safety of NP placing central lines. Which resource provides the strongest level of evidence? A systematic review (meta-analysis is even stronger) • What legislation allowed nurse practitioners to be recognized Medicare providers in all geographical areas with their own provider number? Balanced Budget Act • True/False: restraining an unwilling patient is grounds for malpractice? False, if they are a danger you can restrain • Pt presents to the clinic for routine f/u and passes out. You revive the pt and admit overnight. Which of the following would qualify as incident-to-billing? Temperature and weight recording • The NP program initiated, primarily, because of what issue in healthcare at the time? Pediatric physician shortage • Elderly F pt takes a turn for the worse. The husband is crying when you enter the room and begins telling you what end-of-life care he prefers. What do you do? Ask him to speak candidly with you • Pt calls to complain about bills and states he has Medicare, which should cover all costs. You explain: Since you are healthy, exams are not covered. HIPPA • Doc calls from another center asking if you can tell him what kind of orders he should give for maintenance of patient… HIPPA. • Pt in ER not doing well, primary md calls: Give him info • NP working on ESRD research project . A colleague renal specialist asks for pt info on your patients: HIPPA breach. • Who enforces HIPPA- Office of Civil Rights /Dept. Health and Human Services • Who ISN'T covered by HIPPA? Law enforcement/Municipal Offices, CPS/Schools, Employers/Workman’s Comp, Life insurance • Question about an insurance company calling to verify some patient appointments. You have to pick out that there is already a medical release signed by the patient. The answer is to give the requested information to them. Definitions • Root Cause Analysis – very basic question where RCA is the answer and the question is the definition • Benchmarking-how institution compares with similar organizations • Managed Care: know what this is and how it has improved costs. Something about putting caps on payments… • Peer review-timely, not anonymous, and NP knows how peer review will impact yearly evaluation • Sensitivity vs specificity… sensitivity is positive and specificity is negative. Know this backwards and forwards—like what would a high sensitivity say versus a low sensitivity, in about 3-4 of Phil’s questions There was a question where a patient had a multinodular goiter and wanted to know why the NP was not going to do periodic U/S and Fine needle biopsy in montoring for some kind of cancer or complication. The answer I picked was that these tests were not very specific to detect the cancer. Another option was specificity. • Reliability: When implementing a new study… tested over and over. The consistency of a measurement, or the degree to which an instrument measures the same way over time • Validity of results in an article: P-value. Probability of falsely rejecting the null hypothesis. Want it to be low • Statistical significance: look at sample size & p value. • Medical futility- unlikely to produce any significant good for the pt • Privileging – may be granted in full or part by the hospital. Credentialing committee is made of physicians. • Institutional bylaws may further restrict practice (Facility limited scope of practice) • Informed Consent: a state indicating pt has received adequate instruction/information regarding aspects of care to make a prudent, personal choice regarding such Tx. Includes benefits and risks. Includes competence: pt. ability to CURD: communicate, understand, reason, differentiate good and bad • Case management- Mobilize, monitor, and control resources that a pt uses during course of an illness while balancing quality and cost (“move pts thru the system appropriately”). There was a 50-60’s year old patient with a new diagnosis of cancer. To appropriately plan for discharge, what should the NP do? Options were to consult CM, consult SW, refer to Oncology, or I think refer to hospice • Nondisclosure: not disclosing patient PHI without their permission (confidentiality) • Negligence: failure of individual to do what any reasonable person would do, resulting in injury to the patient • When serving as a nurse researcher, the NP is guided by which ethical principle to ensure that research participants are protected from harm or exploitation? Nonmaleficence • Quantitative and Qualitative…. Quantitative is amount/numbers… qualitative is descriptive, like case studies • Know difference between advanced directive and living will: Living will provides "POA/healthcare proxy” There was a patient who wasn’t doing well and family was at patient bedside. Answer was to address decision making with the healthcare proxy. • Billing: NP sees a pt for HF and performs an H & P. What % is expected to be paid? Medicare pays 80% of the total bill, Pt pays 20%. NP is reimbursed 85% of what the MD is reimbursed for physician services, and for procedure is paid 80% of that 85% General Tips • Several questions on d/c planning • A lot of health policy/sw/cm/pt. rights • Palliative care, end of life and advance directives There was a question on the focus of palliative care. Answer was basic improvement in QOL of anyone with an illness at any stage. Another answer was <6 months to live, that one’s wrong bc its hospice • Types of research, lots of EBP, research terms, Ethical terms • LOTS of therapeutic communication- know this whole section of Barkley • Scope of practice: integration of care across the acute illness continuum with: o Collaboration* o Coordination of care o Researched based clinical practice o Clinical leadership o Family assessment o Discharge planning • Collaboration*: “true partnership” in which all players have and desire power, share common goals, and recognize/accept separate areas of responsibility/activity • 4 Roles of a Nurse Practitioner: Education, Research, Clinician, Consultant/Collaborator • Pt is getting dc and needs wound care, pulmonary, and follow up: NP’s role is: to coordinate services • Government is moving towards being cost effective. What is the best way? Allow NP to treat a wider variety of pts. • Question about cutting costs by the gov’t and my answer was something primary-preventative related • Protected health information: Conversation between the ACNP and a consultant on the case: considered clinical relevance • How should the ACNP stay up to date with current information? Evidence based guidelines • “Incident to” billing rules • Medicare levels and what they cover. Hospice is Medicare A • A pt presents to the ER with c/o CP and SOB. The NP misinterprets the EKG and admits the pt for further monitoring without consulting Cardio. Later in the shift, the pt decompensates and goes into cardiac arrest. The pt. was resuscitated but sustained permanent brain damage. What grounds of malpractice is the NP accountable for? Lack of skill • Healthcare exchange: = health insurance marketplaces = orgs. in each state thru which pple can purchase health insurance, DECISION MAKING 1. You notice there have been less favorable outcomes and satisfaction surveys in patients treated for sickle cell anemia. How do you approach this problem? a. Ask the patients treated how care can be improved b. Look back at prior treatment given to see how outcomes can be improved c. Form a standardized Tx plans for all pts that can be used by all healthcare staf d. Form individualized Tx plans that can be used by all healthcare staff . 2. You have transferred a pt to the SNF. The MD in charge at that facility calls for info about the pt’s medical care. What do you do? a. Direct him to look it up in the EMR b. Refuse to share protected health information c. Instruct him to call the department head d. Share the information he requests 3. Your patient has refused human blood products based on religious beliefs. He is now rapidly destabilizing. What do you do? a. Administer PRBCs as needed b. Call the ethics committee c. Continue to research alternative treatments d. Ask the family to give permission now that he’s unconscious 4. What is the best way to make sure a patient will follow up as instructed? a. Instruct the patient to schedule the appointment b. Ask the patient the best time they can go to an appointment c. Have the office manager to schedule the appointment d. Schedule the appointment for the patient 5. Your patient is brain dead on the ventilator. The family wants all possible treatment measures done to preserve life, but states that the patient would not want to be on a ventilator. What should you do? a. Consult neurology to come interview the family b. Document the situation carefully in the chart c. Call a clergy member to offer support d. Call the Ethics Committee 6. A patient visits your clinic for sinusitis. She requests a PAP smear since she has not had one in “years.” You: a. Refer her to a gynecologist b. Schedule her to come back next week for the PAP at another appt. c. Perform the PAP today d. Do a vaginal exam only, and refer the PAP to a gyno 7. A patient visits your cardiology clinic. She requests a PAP smear since she has not had one in “years.” You: a. Refer her to a gynecologist b. Schedule her to come back next week for the PAP at another appt. c. Perform the PAP today d. Do a vaginal exam only, and refer the PAP to a gyno 8. Discharge planning is underway for a pt who has been very debilitated after treatment for end-stage liver cancer. His wife is also debilitated and the children live out of state. What is the best choice? a. Hospice b. Home Health care c. SNF d. Private Duty RN 9. Your patient presents to ED w/R wrist pain. She states, “It’s my fault; I should have had dinner ready on time.” What do you do? a. Tell her not to go home bc it’s not safe b. XR the wrist c. Call the police d. Consult psych 10. Now the husband presents to ED with drug overdose. What is your action? a. Hand him off to another practitioner b. Call the police c. Consult psych d. Treat him without prejudice 11. The medical resident obtained consent for an operative procedure. On your visit, the pt is confused/refusing the procedure. a. Cancel the surgery b. Have the wife sign another consent c. Call the resident to clarify the patient was not confused when he signed the first consent d. Consult neurology 12. Your HIV positive patient is preparing to discharge when he tells you not only that he has passed the virus to his wife, but also that he plans to kill her when he gets home. How do you respond? a. call the police b. consult psych c. consult social work d. document his statements 13. Your clinical student breaks the sterile field. How do you handle this situation? a. Discuss it with the student b. report it to the charge nurse c. report it to the unit manager d. inform the faculty in charge of the student 14. You are the NP on call for the night. The nurse calls you to report the patient is decompensating. Who do you direct her to call? a. the ER physician b. anesthesia c. an NP present on another unit currently d. the attending MD who is at home 15. A code you are in does not go well, and staff members afterwards are criticizing each other. How do you deal with the situation? a. Schedule an in-service to discuss common code mistakes b. Meet with each team member individually c. set up exercises to increase collaboration during a code d. Meet with all who participated in the code and have a one-time briefing 16. Your patient is not doing well and family/wife is at bedside crying. You are preparing to talk to the family. What do you do first? a. Place a social work consult b. Explicitly explain the situation, the outcomes, and care involved. c. Ask if the patient has an advanced directive d. Set up a family meeting in a room with a specific time and date 17. Your patient is not conscious. His advance directive states he wants to be a DNR, but his family says they want him to be a full code. How do you respond? a. Tell her the decision goes to the next of kin b. Call the ethics committee c. Comply with her wishes and make him a full code d. Tell her you can’t go against the advanced directives 18. A patient comes to the ED at a community hospital who is 29 weeks pregnant. She says her water has broken. Her VS are stable. What do you do? a. Transfer her to a tertiary facility b. Contact her OB/GYN for treatment advice c. Admit to labor and delivery d. Consult the nurse midwife. 19. Your 51F patient is getting ready to discharge when she tells you she hasn’t had a mammogram in 3 years. What do you do? Refer to PCP for outpatient discharge 20. Your patient’s imaging reveals he has metastatic cancer. The family, in accordance with their culture, request that you not share the test results to spare him distress. How do you respond? Ask the patient what he wants to know about his prognosis 21. 35 yo F presents with c/o bilateral wrist pain. You suspect spouse abuse. You notice a handgun in her purse. What would be your next action? Call security to ensure safety 22. Adult child of a pt reports that her father has expressed desire to commit suicide and has a hx of EOTH and depression. The best response would be to? Hospitalize the pt and start psychotherapy 23. You notice that another NP in your group is frequently contacted by pharmacy for prescription errors. How do you handle the situation? Address it directly with the NP 24. Your patient voices concerns because he has lost his insurance and worries his children will no longer have coverage for medical expenses. What do you do? Consult case management 25. 80-year-old patient has macular degeneration and is seen on the surgical unit for postoperative care after repair of a hip fracture. To prepare the patient for discharge, the NP: provides verbal reinforcement to the patient on how to keep proper body alignment following hip surgery. 26. A 40-year-old female patient w/no PMH is admitted with bilateral pulmonary emboli. W/U reveals a positive result for lupus anticoagulant, and anticoagulant therapy is planned. The patient verbalizes concern about her ability to manage the appointments and the follow-up care. The NPs most effective intervention is to: arrange follow-up appointments for the patient at the warfarin (Coumadin) clinic and PCP after discharge. 27. What procedure does the AGACNP perform to evaluate cytology, only, in the tumor? Fine needle biopsy 28. A patient has fully recovered from septic shock due to bacteremia and has been accepted to a LTC facility for continuation of abx. ID has not seen the patient in two days. The NP: contacts the ID MD to determine the appropriate abx duration 29. 32 yo M presented with a gunshot wound (GSW) to the FA. Injuries are negligible and pt is stable. Pt. reports the shot was an accident during hunting. What should the NP do? Report to the police. ALL GSW must be reported • ASSESS the pt before you order tests • What is most important when assessing status? Level of alertness or hx of symptoms • A woman of child-bearing age c/o abdominal pain. What level of exam do you document? Detailed • A diabetic pt complains of abd pain. Which type of exam do you conduct? Comprehensive • What qualifies pt for HHC: is home bound, has a prescription, requires care services, wound care, select care • Pt is refusing care: let them refuse, educate, and search for alternatives • Guy in ER needs refill on Ritalin: research alternatives • Knowledge deficit in ICU, what would you for nurses: In-service • A patient has advanced dementia, ESRD, and HF, what do you do for him? Transfer from acute to palliative care COMMON PROBS/CULTURE/RISK 1. Your 24M patient has been out hiking on vacation. He shows you the following rash, and thinks he has Rocky Mountain Spotted Fever. What is his diagnosis? Lyme Disease (Erythema Migrans/Bullseye rash) (both are treated with Doxycycline) 2. Your patient is a Chinese female immigrant living in the US. You notice she is avoiding eye contact. What is this due to? a. Shame because she feels the illness is her fault b. Embarrassment from the examination c. A sign of respect d. A normal response 3. Your patient speaks only Spanish and you need to evaluate his pain. What do you do? a. Ask a family member to translate for you b. Utilize the hospital’s interpreter service c. Call over the Hispanic housekeeper and ask her to translate d. Use a visual pain scale (less $$ than interpreter) Question where the patient spoke a foreign language and you wanted to get consent from him. The options were to give him the consent form in his own language, use the hospital’s telephone interpreter service, have a family member translate, and then an obviously wrong option. 4. 58yo Japanese M with CP 4/10 for 3 hours, reluctant to answer questions. Which of the following in the ED warrant admission? a. Age b. Gender c. Pain level d. Ethnicity (underestimates pain, taught to be stoic. Pain is probably much more severe) 5. A 77M patient’s wife cares for him at home. Which statement by the wife indicates a need for a SNF? a. My husband needs more help with his ADLs b. I can’t lift him out of bed anymore c. He has lost 20 pounds d. He has trouble swallowing and I’m worried he will choke on his food. 6. Which psychiatric disorder is most commonly diagnosed, yet least commonly treated? a. Bipolar disorder b. Alzheimer disease c. Depression d. Dementia 7. Your pt w/PNA is noted to have a heavy drinking habit. 2 days p admit he becomes combative/agitated. What is Tx? a. IV valium b. IV Ativan c. po Librium d. Lasix 8. Your patient has developed a fever of unknown origin. What is the next step? a. PO abx b. IV abx c. Do nothing until diagnosis is confirmed d. Tylenol 9. How long will it take to begin to see healing in a pressure ulcer that has a clean, well-vascularized bed? a. 7 days b. 2-4 weeks c. 2 days d. 4-6 weeks 10. The patient has been in a bar fight and has a human bite on his hand. What should you do next? a. Order PO abx b. Order wound culture c. Order IV abx d. Measure the wound depth and width 11. Your patient has a chronic, nonhealing decubitus ulcer. He c/o pain when he moves his leg. What is a potential complication? a. Compartment syndrome b. Decrease in ROM ability c. Septic shock d. Osteomyelitis 12. What is the strongest predictor of functional impairment prior to discharge of the elderly pt? a. Advanced age b. Incontinence c. Cognitive impairment d. Poor balance 13. Your pt has been taking Thorazine and now has fever, sweating, lethargy, and a temp of 39.4 (102.92): a. Give IVF (flush it out. This is neuroleptic malignant syndrome) b. Antipyretic c. Abx d. Ice packs to groin and axilla 14. You suspect your patient on TPN with a PICC has a CLABSI. What is the first intervention? a. Stop the TPN, Remove the line, and place a new line for TPN b. Start abx c. Send Cx d. Change the guidewire 15. Your patient has a fever 3 days post op, WBC are 15,000, Blood Cx (-), and Eos 9%. What is the dx? a) Viral infxn b) Bacterial infxn c) Malignant hyperthermia d) Drug fever (eos – allergic rxn. Normal is 1-4%) 16. What are protein supplements best used for? a. Eliminate the need for lipids b. Prevent anasarca (peripheral edema) c. Aid in post-op healing 17. Which macronutrient of TPN significantly increases the osmolality of the solution? a. Lipids b. Dextrose c. MV’s d. Potassium There was a question about Xg/kg/day of protein being in the nutrition for what reason? And the answer was to ‘maintain nitrogen balance along with metabolic needs’ or something similar. • TF/TPN nitrogen balance: per UptoDate, Adjust protein weekly by measuring urinary urea nitrogen (use to calculate nitrogen balance) 18. Which electrolyte are you most concerned about monitoring in a cachexic patient? a. Mag b. Ca c. Na d. K (refeeding syndrome. hypokalemia. also hypophosphatemia) There was a question about what electrolyte to monitor in Refeeding Syndrome. The answer is Phosphorus. 19. Which lab do you monitor daily in a patient on nutritional supplements? a. BMP (And monitor LFTs weekly) The answer had some other things in it, but it was the only one with BMP. b. CBC c. ABG d. Blood Cx 20. What alternative therapy can you order to relax the pt prior to a procedure? a. Massage b. Aromatherapy c. Music d. Muscle relaxant There was a question about what to do for the patient to help/distract their pain during a procedure, and the answer was guided imagery. 21. Which helps a Parkinson’s pt. with coordination a. Acupuncture b. Tai Chi (also helps prevent falls in elderly) c. Relaxation techniques d. Hypnotherapy There was another question about a patient after a CVA who continued to have fear of falls even after therapy. The answer I picked was Tango Dance Therapy, because the others did not address balance. 22. Which 2 headaches can be treated with triptans? Migraines and cluster. 23. What kind of dressing do you use on a decubitus ulcer with necrotic tissue? Hydrocolloid 24. 45 yo s/p double mastectomy 2 months ago. Now is c/o pain at the incision site. Neuropathic pain • What does the leg /foot look like in a hip fracture? Internally rotated or externally rotated? • Pt has a post-op fever: give fluids • WHO pain ladder: fentanyl patch for breakthrough cancer pain • Best pain indicator: pt self report • Best alternative therapy to decrease pain in clavicle fracture: therapeutic touch/reiki (Reiki: hand or palm-healing that transfers ‘universal energy’, has been used for cancer, emotional, or physical healing) • Picture of Gunshot wound to the R lung area: you purpose of dressing. The answer is to allow the dressing to be sucked to the chest wall during the negative pressure of expiration. Another answer was to let air blow out during inhalation. • Cocaine induced psychosis: s/s: paranoia, delusions, hallucinations ‘cocaine bugs’ under skin, mydriasis • Pt comes in tachycardic, hallucinating, all kinds of other crazy symptoms w/dilated pupils: Sympathomimetic (which is cocaine or meth) wrong answers included Cholinergic and two others • Antidepressant OD: s/s hallucinations, confusion, tachy/dysrhythmias, hypothermia, blurred vision, urinary retention, hypotension, (can’t see, can’t pee, can’t spit, can’t shit), TX: ICU if CNS or cardio toxic, activated charcoal, NaHCO3 for dysrhythmias and maintain PH, Benzos (valium) for Sz (if serotonin syndrome: dantrium/dantrolene sodium) • ASA overdose: s/s: n/v, tinnitus, dehydration, hyperthermia, apnea, cyanosis, metabolic acidosis. Tx: activated charcoal, NaHCO3 for severe acidosis of <7.1. MONITOR ABGs • How do you treat group A strep on skin: TMP/SMX or Doxy/Mino + beta lactam (1st gen ceph, PCN or Amoxil) • Pt has cellulitis of lower extremity with a wound, what do you treat with? Based on the hospital sensitivity • Mallampati grades for visualization of oral cavity: (I complete soft palate, II complete uvula, III uvula base only, IV none) • Osteomalacia = softening of bones (PEDS: rickets) Most common cause = Deficient VitD (also Phos, Ca, UV-B light) • Hospice vs palliative care: Palliative are still receiving Tx. Hospice is no curative treatment, has death dx, and ≤6mos to live • Venous stasis ulcer: use compression stocking • The patient has had a dog bite and 3 doses of Tetanus in the past. The NP knows the recommendation for tetanus is that the: patient gets a booster if they have a dirty wound and haven’t had a tetanus shot in five years. • Tdap vaccine is an example of what type of immunity? Active immunity • How often should a woman between the ages of 20-39 have a PAP with HPV? Q5 years, PAP with cytology Q3 years • If born on or after what year is it indicated to receive 2 doses of mumps vaccine? 1957 • What age does an individual receive Zostavax? 50, one time dose • At what age do males start colonoscopy every 10 years? 50 • When should PSA levels be initiated and how often? PSA levels every year >50 (and DRE) • Annual PSA and DRE are indicated in what group? African-American >40 and family hx of prostate CA • Pt has normal PAP smear and reports that she has not had an abnormal PAP for past 10 years. What is the appropriate age to DC? 65-70 • 35 yo Asian-american is in good health. He is worried about life-prolonging measures. What is the most likely cause of death for a man like him? Unintentional injury (if he’s African American, it’s Homicide < 35 and heart dz at 35) • What is the leading cause of death in African Americans M ages 40-59? CAD • What is the leading cause of deaths in Hispanics in the US? Heart disease • Pt has massive trauma and splenic rupture , Hb 6.8, INR 1.2 and some other labs, what to do ?—“Transfuse PRBC “ • Wife TBI and on vent , husband comes to shows the Advance directive to NP and wants to remove vent, --” review the advance directive with the husband” • Leap frog and some other IOM goal—” medical entry of pt prescriptions “ • Pt has some cancer and needs lymphocele drainage, when to talk to him about it—” recovering and time of discharge” • Best way to ask drug seeker ---” do you use street drugs..( be direct ) “ • Woman not having safe sex with partners and misuse alcohol , --- many options were there “Express concern her alcoholic problem and advise her behaviour change “ • 83 yr old man misusing alcohol , NP sends him to psych consult .Pysch consult suggests that he has age related misusing of alcohol , no treatment require , what NP do ?== do vitamin B regimen ( basic therapy) • Closed angle glaucoma NP gives timolol , what will she see—” pain reduced” • Immigrant has TB and lives in family of 10 other ppl—” report to health deptmt and get family tested” • Why do u need tracheostomy in TBI pt who is on vent for a month?—“ for delayed wean and discharge from ICU” • NP worked in one state she can put central lines, moves to a new state Dr doesnot want her to do central lines? “ It is the employer decision “ Qn asks if it it state law or employee law • DR rude to NP on phone—” talk to dr and tell him not acceptable” • New nurse wants to learn a new practice on some cathter, NP teaches her and gathers allnurses for inservce with the help of the department manager what is her role—” collaborates the practice “ • Pt weak and tired, BS 658, NA 148, K 6.6, WHAT is it—” insulin shock “ • ST john wort—effects serotonin and digoxin • Who needs western blot and elisa tested from the list of pts –1. Man with pneumocystis ( didn’t pick this one has he already had the disease, opportunitisc infection ), 2. Lady with osterprois,3. Man with trauma . 4. Sex worker with HPV • UC wat meds—” steroids( prednisone) and sulfasalazine” • Ur trauma NP which to refer—” maxillofacial tauma “ , other choices were gunshot wound to stomach etc • Burn referaal criteria • Central line lab calls it is infected what will u do—” stop TPN, remove central line and start antibx”. No guidewire exchange since it causes the orgranism to travel thro the tract. CDC does not recommend guidewire exchanges , but wants it done only when no IV access is obtained or difficult veins” • Which wound needs proper wound mgmt. and dressing when pt does some dressing at home—” eschar” , as it is obscured and tunneling may be seen • ALI –decrease tidal volume • ARDS- increase peep 10 • FLUID VOLUME AND ELECTROLYTES 1. The most common cause of hyponatremic hyperosmolality? a. Hyperglycemia b. Hyperthyroidism c. Adrenal insufficiency d. K-sparing diuretics 2. What method should you use to treat hyponatremia related to SIADH? a. Bolus 500 mL NS b. Bolus 3% hypertonic saline c. NS at 200 ml/hr d. 3% hypertonic saline, calculated 3. What is a potential cause of hyperkalemia? a. Carafate b. NSAIDS c. Centrally acting HTN meds 4. Your patient has a Na of 128 and was treated with colloids 3 days ago. What is the treatment? Restrict free water 5. A 68-year-old pt had Sx three days ago to repair an AAA. The patient remains intubated, is neurologically intact, and has active bowel sounds. LFTS are normal, no s/s CHF. The patient's laboratory values are: blood urea nitrogen of 12 mg/dL, creatinine of 0.8 mg/dL, PaCO2 of 37 mmHg. Which is the most appropriate method to deliver nutrition? a. Central line b. PIV c. G tube d. enteral feeding to the duodenum via a nasogastric small-bore tube (NG tube) Similar question where the patient was placed on the vent 2 days ago, and it wanted to know the best nutrition. The answers were to let the patient remain NPO, do TPN via peripheral line, do TPN via central line, or do “enteric nutrition via a feeding tube”. It did not say what kind of feeding tube but I picked that option. 6. Your patient has a serum osmolality of 268 mOsm/kg and a serum sodium of 134 mEq/L. His urine has Na+ less than 10 mEq/L. You know that all of the following are possible explanations except: a. Diarrhea b. Diuretics (Na<10 is nonrenal cause. Diuretics are associated with renal cause, Urine Na >20) c. Dehydration d. Vomiting 7. A 61 yr old F c/o fatigue, muscle weakness, and constipation. She adds that she had felt her heart beating “abnormally” and she has been experiencing muscle spasms on occasion. You order and EKG and find decreased amplitude and broad T waves. Occasionally you also note prominent U waves. Of the following, which is the most likely Dx? a. Hypokalemia b. Hyperkalemia c. Hypocalcemia d. Hypermagnesemia 8. Your patient has complications from parenteral nutritional support. All of the following are plausible explanations except: a. Hypernatremia b. Pneumothorax c. HHNK d. GI Bleed (this is enteral complication) • Know your basic labs including Mag and Phos • 65 yo M with c/o N/V/constipation x several days and a 6 # wt loss. Pt s/p TKR several weeks ago and reports not getting off the couch. What electrolyte is altered? Hypercalcemia secondary to immobility • Pt with s/s of ABD distention, weakness and occasional diarrhea. Hx indicates renal failure. You conclude that the pt has a fluid and electrolyte problem. Which of the following is he most likely experiencing? Hyperkalemia • ABG reads high HC03 and pCO2 55mmhg. What electrolyte abnormality is most likely associated with these values? Hypokalemia r/t metabolic alkalosis • Pt has a fever and tachycardia, and Hx of CHF. There is a box with lab values, and the Na is high. What does it say about their hydration status: extracellular dehydration deficit • Low serum Na and high serum osmolality: hyperglycemia (Probably HHNK) • A patient with hypovolemic, hypotonic, hyponatremia and what fluids to give: NS • Low protein =low BUN=hypoosmolar hyponatremia (probably edematous, expect edema in Albumin < 2.7) • A pt. who has been in ICU for 17 days develops hypernatremic hyperosmolality. The patient weighs 132 lb (59.9 kg), is intubated, and is receiving mechanical ventilation. The serum osmolality is 320 mOsm/L kg H2O. Clinical signs include tachycardia and hypotension. The initial treatment is to: replenish volume by infusing a 0.9% sodium chloride solution. • Which electrolyte imbalance leads to confusion and lethargy in the ETOH abuse pt? Hyponatremia • What electrolyte should be monitored prior to administering succinylcholine? K+ • Hypercalcemia: Question with patient who had metastatic cancer to her bones. Symptoms of hypercal were listed in stem • ASA overdose- which electrolyte to monitor: K (if low, will prevent the alkalinization of urine, which is the mainstay of Tx) • What sx is associated with hepatotoxicity s/p acetaminophen toxicity? Delirium • Pt at highest risk for hyperkalemia: NSAIDs then ACEi • TF S/E: Diarrhea: Decrease the osmolality of the Tube feeding! • What pt requires labs to be monitored closely after initiating TF? Alcoholic with decreased intake over the past 2-3 weeks ENDOCRINE 1. What disorder can be ruled out using the Cosyntropin stimulation test? a. Cushings b. Diabetes Insipidus c. Adrenal insufficiency d. SIADH. 2. What side effect of levothyroxine is most likely to lead to non-compliance when first initiated? a. Alopecia b. dyspepsia c. weight loss d. nervousness 3. You are treating a patient for hypothyroidism. Which lab value is monitored for treatment/synthroid effectiveness? a. T3 b. T4 c. TSH d. Thyroxin index 4. What method should you use to treat hyponatremia related to SIADH? a. Bolus 500 mL NS b. Bolus 3% hypertonic saline c. NS at 200 ml/hr d. 3% hypertonic saline, calculated 5. For the past few months, 29 year old Janine has been gaining weight while experiencing amenorrhea and increasingly severe acne. She has gained more than 20 pounds, and you note that she is carrying her weight around the midline, w/BL purplish striae across both flanks. You suspect Cushing’s syndrome. Which of the following findings would not contribute to a Dx? a. Urine free cortisol = 360 μg/day (>50 is abnormal) b. Glycosuria c. WBC 19 d. After a high dose of dexamethasone, there is a 90% reduction in urinary free cortisol (In Cushings, pituitary does not respond to dexamethasone) 6. Which of the following is not a criteria of Metabolic Syndrome? a. BP > 140/90 (it’s ≥130/85) b. Waist >40 inches c. TG >150 d. HDL < 40 • Cushing labs, symptoms: ↑ BG, ↑Na, ↓K. S/S: central obesity, moon face with buffalo hump. • Addison’s disease labs & Tx: : ↓BG, ↓Na, ↑K. Tx: florinef, hydrocortisone, Steroid bolus. Test: Cosyntropin, + if serum cortisol < 18 mcg/dL in the morning. • Pt is hypotensive + Addison’s. Tx?: dopamine/pressors don’t work, so choose IVF (D5NS). • SIADH- inappropriate water retention, CNS d/o, retain water, hypothermia, hyponatremia, ↓sOSm, ↑ urine osmolality (concentrated), urine sodium >20meq (kidneys trying to excrete water via salt), need 3% hypertonic fluids calculated • Urine Na 28, serum osmo 250, urine osmo 115. What is the suspected cause? SIADH • 23 yo F presents with DKA. ABD pH 7.3, glucose 520, BP 90/65, HR 120 and confused. Which of the following are not included in the initial management of DKA? Isotonic fluids, insulin infusion, sodium bicarb, or supportive care? Sodium bicarb is only indicated for DKA if pH <7.1 • 24 yo M presents with DKA. Now confused and irritable. ABG Ph 7.29/33/22. Received isotonic fulids x 1 hour, BP 110/70, HR 90. Blood glucose 550. What is the best IV fluid indicated ½ NS (d/t BG >500) • HHNK: fluids to use: NS for massive fluid volume deficit, then ½ NS to hydrate the cell, then D5 ½ NS if on insulin gtt • Understand hypothyroidism, hyperthyroidism signs and symptoms and treatment. • Thyroid labs: Hyperthyroid: high T3, T4, resin uptake TSH >5; Hypothyroid: low T4, low resin uptake (T3 not reliable test) • S/S of thyroid storm/crisis: fever, goiter, tachycardia, low TSH • Myxedema coma treatment: loading synthroid followed by maintenance dose • Pt w/BP 210/110 + HA, then BP ↓ 160’s, what is 1st Tx: pheochromocytoma: alpha blockers preop Regitine/Phentolamine • What is the first test you run when you see s/s of pheochromocytoma? TSH • Diagnostic test confirmative for pheochromocytoma: CT • DKA pt: IVF first (1L in 1st hr, then 500 ml/hr, use ½ NS if BG >500) • Somogyi Effect: Low at 3am and rebounds to high at 7am • 15-year-old pt with DM1 reports ↑BG in am. The ACNP determines hyperglycemia is d/t dawn phenomenon: increases the insulin dosage at bedtime. CARDIOVASCULAR 1. Your patient has a history of coagulopathy and is about to go to surgery. Which order is appropriate for DVT/Bleeding prophylaxis? a. Heparin gtt b. Lovenox c. Coumadin d. Pneumatic stockings 2. Which of the following is least likely to experience a DVT? a. 24Y F on OCP b. 74 M post hip replacement c. 58 Y M liver patient d. Paraplegic 3. The nurse calls you to report low BP in a CHF patient on the unit. You have IVF ordered, and the cardiologist has ordered Lasix. a. D/C the Lasix b. Leave the orders as they are c. Call the cardiologist to discuss d. Call the Ethics Committee. 4. You are assessing heart sounds pre-operatively and hear a classic “aortic stenosis” type murmur, as well as a carotid bruit. There are no neurological symptoms. What should you order first? a. Carotid U/S b. Consultation to cardiology c. Cancellation of surgery until next week d. Echocardiogram 5. Which of the following is contraindicated for a patient receiving a renal angiogram? a. Beta blocker b. Alpha blocker c. Calcium channel blocker d. Ace Inhibitor 6. Your 45M patient has new onset Atrial Fibrillation, but no other past medical history. What should you prescribe? a. Tylenol b. ASA (young with no risk factors/history) c. Coumadin (would be used in old-65 with + RF/Hx) d. Plavix 7. Which is best used to diagnose pulmonary HTN? a. Bubble study b. Presence of peripheral edema c. Cardiac catheterization d. 2D ECHO (confirmed by cardiac cath) 8. Your patient has overdosed on Lopressor. It has been 5-6 hours. What do you order? a. Glucagon and Atropine b. Narcan c. activated charcoal d. flumazenil 9. Your pt is pre-operative for an elective surgery. You notice a pulsating mass in the mid abdomen (AAA). What is next action? a. Cancel the surgery b. Order abdominal U/S c. Order abdominal CT d. Document the mass carefully and send to surgery 10. Your patient is post-op after an aneurysm clipping. Which intervention is used? a. Maintain SBP 140-160 b. Place pt in a quiet room c. Encourage visitors d. Start Decadron 11. Your 67 yr old pt has a BP of 168/92. On her second visit her BP is 158/88. What is your initial Tx plan? a. Prescribe an ACEi b. Prescribe a mild diuretic c. Teach lifestyle changes d. Schedule a stress test 12. Which of the following lipid panels shows 3 out of 4 abnormal values? a. TC 205, LDL 150, HDL 30, TG 300 b. TC 150, LDL 99, HDL 35, TG 145 c. TC 102, LDL 50, HDL 60, TG 102 d. TC 180, LDL 136, HDL 25, TG 160 13. Your patient is an obese 38 F with the following fasting lipid panel: TC 270, LDL 168, HDL 28. What is your action? a. Start a statin (key word is obese) b. Teach lifestyle changes c. Prescribe metformin d. Prescribe Niacin 14. Which med must be on the d/c list of a patient admitted for CHF? a. Sotalol b. Norvasc c. Lisinopril d. Losartan. There was a similar question that listed lots of random information/details in the stem, along with the pt. having CHF. You have to pick out the CHF from all of the stem distractors, and the answer is an ace inhibitor of some sort. 15. 31 yo M with a blowing murmur occurring during S1 and galloping addition heart sound. Murmur is heard best at the base of the heart. What is the MM? Mitral Regurgitation 16. When d/c an 85F pt w/stasis dermatitis, the NP includes instructions to: keep legs elevated while seated. There was a question with an older man who had been a smoker for years and had shiny hairless legs (PAD). You have to pick which diagnostic to order. The options were ABI, arterial Doppler, venous Doppler, D-dimer or something. I picked ABI 17. 20. A 70-year-old patient with acute systolic HF denies any functional limitations, is able to walk five blocks before tiring, and is euvolemic. Which medication is the first-line therapy for this patient? Lisinopril (Zestril). 18. A patient with HF has DOE and sleeps all night while using 3 pillows. What is her NYHA HF stage? Stage III • Identify: 2nd type 2 or Complete/3rd degree block: Tx transcutaneous pacing, venous if can’t capture, atropine if very symptomatic, plan for pacemaker. d/c AV-nodal blocking drugs 2nd type 2- “P’s go marching along.” Mine was 3rd degree block but the answer was “complete AV block” P's 'go marching along' • 2nd type 1-Wenckebach monitoring, pacing if symptomatic (longer longer drop) • Pt had an EF of 20 and bronchospasm-what med caused it? Beta Blocker (look up Beta Blocker overdose in UptoDate) • Hypertensive Emergency - 220/120 (Urgency is 180/110) • Afib: check TSH (for hyperthyroid), Tx with beta blocker • What grade murmur do /you first hear a thrill: 4 (listed on test as IV) • On physical exam, you note a mod. Loud MM with no thrill. What grade? 3 • Pt has low diastolic rumble murmur in the left lateral position with no radiation: Mitral stenosis • Pt presents with suspected mitral regurg. What physical findings would confirm? S3 systolic MM • Blood flow thru heart: tricuspid regurgitation occurs in RA • Stages of heart failure – NYHA • Pt w/Hx of HF or PRBCs, wet LS, LE edema, dyspnea- cause of edema: increased hydrostatic capillary pressure. • What is the purpose of cardiac stress testing? Diferentiate ischemia vs infarction • STEMI guidelines “door to needle” 30 minutes “door to balloon” 90 minutes There was a really busy question in a pt with hx of smoking and atherosclerosis. You have to pick out that he has chest pain radiating to the back. It wants to know what test you would order. Options are kind of all over the place, I picked electrocardiogram/ECG • Pt is post-MI, on a beta blocker and statin. What do they need? ACE-I • HTN + DM: ACEi • Which drug prevents cardiac remodeling: ACEi (double checked this. Beta blockers also possibly prevent remodeling) • Pt w/ 14 hrs of CP presents to the ED. next step of action? Take to cath lab (fibrinolytic therapy 6° window is closed) • Pericarditis- pt with normal CXR, low grade temp, elevation in all leads- best diagnostic test- echo, send home on NSAIDS -risk for what: tamponade • A pt post CABG with abd distention, labs provided, Dx = mesenteric infarct (one RF is cardiac surgery) • Gerontology and cardiac…. Cardiomegaly • PAD/PVD: pt w/ PVD needs to quit smoking. “Tell me how I can help you, what do you need?” • CVI: Venous status ulcer use compression stocking • How pt w/ DM and ♥dz decrease LDL non-pharm? Diet and exercise, lifestyle changes • Temporal arteritis requires immediate Tx in order to prevent: blindness in the afected eye. • Pt in the ER with sudden LOC and motor function. The ER dx TIA. The pt has right-handed weakness and numbness. Carotid studies are completed and revel 92-95% occlusion bilaterally. What is next step? Patient to have left carotid explored first followed by the right one at a later date • 62 yo M presents with angina after his daily walk. Lipid panel reveals LDL 250, HDL 25, chol 350 and triglycerides 250. You prescribe niacin. How would you explain the mechanism of action to the pt? Niacin lowers LDL and increases HDL GI 1. What among the following is a common cause of pancreatitis? a. Moderate ETOH use b. medications c. abdominal trauma d. cholelithiasis A question wanted to know the most common complication of ERCP. I picked pancreatitis. 2. Your pat is s/p liver transplant. He develops fever and his bile production decreases to 20 from 300. What should you do next? a. Consider liver bx b. Run a C&S on the bile c. Call the surgeon to recommend an operation d. Consult GI to rule out pancreatitis 3. Which of the following displays a current or recent Hepatitis A infection? a. Antibody-specific to IgG b. Anitbody-specific to IgM c. Hepatitis A core Antibody d. Hepatitis A Surface antigen 4. Your patient is post-op cardiothoracic surgery. She develops nausea, periumbilical abdominal pain, moderate Lipase, LDH, ALT, ↓BS. What is the diagnosis? Mesenteric Infarct 5. Your patient complains of tarry stools, change in stool caliper, and constipation. What intervention is appropriate? a. Order more testing b. Consult surgery for possible colon cancer c. Give PRBCs d. Consult oncology for chemotherapy 6. Your pt has been on peritoneal dialysis long term, and develops a fever and cloudy peritoneal fluid. What do you order first? a. Blood culture b. Antibiotics c. Culture of the dialysis tube 7. Most critical symptom for diagnosing peritonitis/bowel perforation? a. Guarding b. Rigidity c. Distention d. Rebound tenderness 8. What is GI angioplasty used to diagnose? a. Hemorrhage of unknown cause b. Uncontrolled bleeding c. Cholelithiasis d. Bleeding due to PVD A similar question presents a patient case with GI bleeding. The answer of angioplasty is in the options below. 9. Your pt with Sickle Cell Anemia is complaining of nausea and lack of sleep. What med is best? a. Reglan b. Zofran c. Phenergan d. Ativan 10. Pt presents with RLQ pain, 1-2 episodes of vomiting, and + Psoas sign. What dx are confirmatory of appendicitis? a. ABD US and WBC 10-20 (key is WBC. A CT would also work) b. CT ABD and elevated amylase c. ABD US and elevated amylase d. CT ABD and elevated amylase and lipase 11. 36 yo with h/o Crohn’s disease arrives in the ER with c/o ABD pain, freq. vomiting and water bowel movements. You notice high-pitched, tinkling bowel sounds and transabdominal US reveals partial SBO. Which is not necessary? a. NPO and IVFs, b. NG tube for LWS, c. immediate surgical consult d. monitor for spontaneous resolution 12. A Nurse experiences a needle stick from a patient who has Non-A, Non-B hepatitis. She has already had the HepB vaccine series. What is the next step? Obtain blood samples from the pt and the RN. 13. 42 y M with epigastric pain that is better after he eats: duodenal ulcer 14. 65 yr ETOH use + 25 yr smoking. S/s: dysphagia and epigastric pain. What is Dx: GERD 15. XR identification: Pneumoperitoneum. Note air under the diaphragm (d/t perforated bowel) • Avoid Diverticulitis flare ups: quit smoking (also increased risk for perf/abcess) • Tx for diverticulitis: NPO dependent upon condition, IVF, IV abx (flagyl,Cipro, ceftazidime, clinda, ampicillin), Tx GI bleed My question wanted treatment for diverticulitis. • True/False: Barium enema is indicated in the conservative management of diverticulitis? False • Lab values and acute pancreatitis: GWGLA HBCABE • Which disorder worsens epistaxis? Cirrhosis, HIV • Bowel obstruction – zosyn (piperacillin-tazobactam) • 49 yo M presents with c/o abdominal swelling that progressed over 2 days. Patient also reports mucous-filled diarrhea and ABD pain. Exam is significant for profound ABD distention. You suspect an SBO. What type of bowel sounds are associated? High pitched, tinkling bowel sounds • Profuse vomiting and variable epigastric pain are 2 symptoms of what diagnosis? Proximal SBO • Lots of UC and crohns. • Know the tx and presentation for Crohns. (diarrhea, abd p, abscess/fistulas, abx: flagyl/Cipro) • Who is at risk for Toxic megacolon: both crohns and UC • 48 yo with fever, ABD pain and bloody diarrhea with h/o chronic sinusitis, arthritis and recent DVT Which represents the most likely dx and test to order? Ulcerative colitis, sigmoidoscopy • 17 year old with UC, what is the worst complication? Toxic megacolon • Question on a young male with UC, what would be a probable finding? Rectosigmoid stricture • Ulcerative colitis meds… Canasa (mesalamine) suppositories or enemas for 3-12 weeks, hydrocortisone suppositories and enemas. • What abx do you use for UC? “IV ciprofloxacin and metronidazole in severe colitis and high grade fever, leukocytosis with extreme numbers of immature neutrophils (bands > 700/microL), and peritoneal signs or megacolon. There is no role of antibiotics in patients with severe colitis without signs of systemic toxicity Similar question wanted to know treatment for fulminant UC. I picked IV steroids. • When would you find “thumb printing sign” on abd XRAY? Mesenteric ischemia (ischemic colitis), pseudomembranous colitis, and IBD (ulceratve colitis) = radiologic sign of thickening of the bowel wall • Woman ETOH has liver dz but husband does not: Women are likely to get liver disease while drinking less than men (something like this, it was option d) • What causes GI bleed in elderly? Thin gastric membranes (However, per Medscape: PUD in UGIB. Diverticulosis and colitis in LGIB. Both exacerbated by NSAID/ASA/Anticoag use) • Do not use protonix (PPI) LT: due to increased risk of hip fx. Increase vitamin D • Why would you pick a PPI over phenergan for treatment: PPI Can be used in combo with other drugs to control symptoms • Patient on PD Dialysis has an infected dialysis catheter: Remove the catheter • Hepatitis: You are a preceptor who is mentoring student. The patient s/s are broad and variable and include mild icteric symptoms. How should you educate your student? One option was to have the student review the clinical symptoms and query differential diagnoses (I picked this one) A second option was to inform the student that because of their complex presentation, they need a hepatologist referral (icteric is the phase of hepatitis after pre-icteric: WL, jaundice, RUQ pain, clay stool, dark urine, etc) NEURO 1. What is the most important assessment finding in determining patient’s mental status? a. orientation level b. attention c. memory d. affect 2. Your patient has a severe closed head injury. VS are listed. Which value is it crucial in evaluating him for brain death? a. Pt had a gag & cough reflex b. Pt is not normothermic c. Pt is not normotensive d. Documenting family opinion on whether pt is brain dead 3. Your patient has a closed head injury and is ventilated. His ABGs are: pH 7.48, pCO2 35, FiO2 40%, pO2 60. What is the recommended action? a. Increase the FiO2 to 60% b. Decrease the Tidal Volume c. Decrease the Respiratory Rate d. Leave the setting as it is (CO2 in head trauma = 35 goal. Permissive hypocapnea) 4. Your patient has suffered a spinal cord injury. What sign indicates recovery has begun? a. Increase in DTRs b. Bradycardia c. Edema d. Moderating respiratory rate 5. Your patient presents to ED with ischemic stroke-like symptoms. Her BP is 160/90 and she is on Norvasc. Symptom onset was 4 hours ago. Which of the following is a contraindication to fibrinolytic therapy? a. Time b. PMH c. Age d. BP 6. Your patient is s/p craniotomy and is about to d/c home. You notice ataxic gait and holding the wall while walking. What is your action? a. Consult PT b. Discharge home c. Make outpatient PT appt d. 2nd guess the RN assessment 7. Patient has a hip fracture, carotid bruit, weakness, and confusion. What do you order? Carotid US 8. A patient was diagnosed with cauda equina syndrome and neurosurgery has been consulted. What is the NP responsibility in anticipation of surgery? a) discuss the MRI results and how the nerves are afected b) discuss rehab after surgery c) order small frequent meals to prevent nausea. d) explain the surgery to the patient 9. Your patient has had a CVA and is now having trouble feeding himself. Who do you consult? a. OT b. PT c. Social Work d. Case management 10. A patient has hyperactive reflexes of the lower extremities. The adult-gerontology acute care nurse practitioner assesses for ankle clonus by: sharply dorsiflexing and maintaining the foot in this position, while supporting the knee 11. Which muscle moves the eye from center, to side, and back? Rectus • There is a patient with a TBI and increasing hypercapnia/lethargy. The NP is worried about ICP, what should she consider? The answer is intubation (to control CO2) • Change in LOC: CT wo contrast • MS: Tx for a flare-up: steroids Patho: autoimmune dz, immune system attacking myelin. flare up • Myasthenia gravis patho, s/s, Tx, - Patho: reduction of the number of acetylcholine receptor sites at neuromuscular junction. S/s: ptosis, diplopia, extremity weakness worse w/exercise, respiratory difficulty. Meds/tx: anticholinesterase drugs like prostigmin, plasmapheresis, and immunosuppressives. Vent may be needed in crisis. • MMSE: have wife leave the room • MSE on older pt: test is reliable • Dementia vs delirium: Delirium: sudden transient clouded sensorium, Dementia: gradual, permanent memory/intellectual • What is the number one cause of death in dementia patients? Pneumonia (think aspiration) • Pt with a 50% R-sided carotid artery occlusion r-sided weakness that went away (TIA)ASA or Plavix. My version had Plavix. • CVA tPA contraindication: CVA 2 months ago • Chronic subdural hematoma: may present with the insidious onset of HA, light-headedness, cognitive impairment, apathy, somnolence, and occasionally Sz. Management: surgical evacuation of in pts w/potential for recovery if there is evidence of mod-sev cognitive impairment, if progressive neurologic deterioration, or if clot thickness ≥10 mm or midline shift ≥5 mm • Latest sign that you missed a herniation? Pupil change and positive babinski (toes fan UP/out) • Homonymous hemaniopia: know definition. Basic question and this is the answer • Left middle cerebral artery infarct- aphasia • CN sensory only: CN I, II, VIII • CN both motor and sensory? V Trigeminal, VII Facial, IX Glossopharyngeal, X Vagus • CN nerve: hands on the side of pt face and ask them to chew: CN V, trigeminal nerve • Status epilepticus-meds not working, low SaO2/desating, family can’t decide: intubate • Cauda Equina Syndrome: Medical emergency. 18 nerve roots of the cauda equine at base of spine. S/S : Pain, numbness, tingling & LBP radiating into leg(s), S1-S2: weak plantar flexion w/loss of ankle jerks, foot drop. S3-S5: Loss of bowel/bladder. Muscle weakness, sensory loss in the dermatomal distribution of the affected nerve roots. Cause: tumor, spinal stenosis, herniated disc, CA, infxn, inflammation. • What is the pathology of Parkinson’s disease? imbalance between ACH and dopamine in the corpus striatum • You are examining a pt with PMH of seizures. Pt sustains a seizure lasting around 1 minutes. What is the most appropriate intervention? Valium 5-10 mg IV • Initial action in a patient with new onset seizures? CT scan • 60 yo M presents to ER and his child reports he passed out in the care while driving, regained consciousness and was drooling and out of it. Pts HR and BP are decreased. You give Nimodipine. What is the rationale for administering Nimodipine to this patient? Calcium channel blocker, counters vasospasm s/p CVA • What CSF values are characteristic of bacterial meningitis? ↑ opening pressure, ↑ protein, WBC, ↓ glucose PULMONARY 1. Your patient has swallowed a foreign object (coin) and it is lodged in the c-spine area according to XR. How to get it out? a) a bronchoscope (pic will be side view of CXR) b) surgery with forceps 2. Your patient has a Gunshot chest wound. What kind of dressing does he need? 3-sided dressing Allows air to escape, but not enter (and thus be trapped) in the lungs, so as not to cause a tension pneumothorax. When the pt exhales, air tries to enter the hole. This is why we have the pt take a deep breath and hold hit when we pull a chest tube. Air won’t enter chest cavity when the lungs are full of air.) 3. Your pt is 3d post appendectomy and develops dysphagia, drooling, and expiratory stridor. What is going on (there will be lots of distracting information): Epiglottitis 4. Your patient is ventilated and becomes confused with arm edema. What low cost test do you order? (Pt could also have HIV) a) D-dimer b) Ultrasound c) VQ scan 5. Your patient with VAP is on broad spectrum coverage including Levaquin, Cefipime, & Vancomycin. Your culture comes pack growing Pseudomonas. What do you do now? Narrow the spectrum (you don’t need the vanc) 6. Which of the following does not cause hypoxemia? a) Hyperventilation b) Hypoventilation c) Decreased in atmospheric O2 d) Right to left shunt 7. What is the initial finding in a pulmonary embolism? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis 8. Your 32M patient has a history of MVR (distractor) and c/o wheezing with exercise. What is your order? a) PFTs b) Pulmonary consult c) PO steroids d) SABA 9. The mother of 19-yr old Alice calls you with concerns about her dtr’s asthma attack. She tells you that Alice has SOB and difficulty speaking in sentences. She adds that Alice’s usual medicine, Alupent (Albuterol), is not working. Which of the following should the mother administer to treat Alice’s asthma attack? a) Ipratropium bromide (anticholinergic) b) Aqueous epinephrine (only if pt cant cooperate) c) Albuterol (already had) d) Metaproterenol (already had) 10. A 36-yr old pt who has a hx of asthma comes to the ED in a fatigued state. She has difficulty speaking d/t respiratory distress. but able to explain she is recovering from a cold, but her s/s are so severe that she came to the ED. HR is 118, FVC WDL, FEV1 45% of expected value. You order metaproterenol (albuterol) 0.3 mL in 5% solution, but the pt does not respond. Now what? a) Aqueous epinephrine b) Albuterol c) Methylprednisolone d) Montekulast 11. Your patient with asthma has decreased breath sounds on presentation. You give a nebulizer treatment. Now, the SaO2 is decreased to 86% and there are no breath sounds. What do you do? a) Stat Nebulizer b) ABGs c) Epinephrine d) Intubate 12. A 51 yr-old male is admitted to the ED w/severe dyspnea. The pts’ Hx indicates emphysema. The NP orders O2, since the pt SaO2 dropped from 96% to 90%. However, the NP also advises the attending RN to continue monitoring the pt because a) He has lost his hypoxemic respiratory drive b) He has lost his hypercapnic respiratory drive 13. What is the earliest sign of PNA in the elderly patient? a) Dyspnea/SOB b) Tachypnea c) Fever d) Hypoxia 14. Your patient is a 79 M Japanese immigrant. What TB induration measurement is diagnostic? a) 3 mm b) 7 mm c) 11 mm 15. Your asthmatic patient is on a SABA and ICS. She has no secretions but her symptoms are still not well controlled. What do you order next? a) Salmeterol (LABA) b) Ipratropium bromide c) Montekulast d) Metaproterenol My version had the patient on a SABA only with multiple trips to the ER in the past 3 months. You add an ICS: FLovent 16. What is paradoxical abdominal and diaphragmatic movement? a) Symptoms of Anxiety disorder b) Asthma ominous sign c) Respiratory bacterial infxn 17. Which of the following is reason to intubate in an asthmatic patient? a) RR in the 30s b) Bad ABGs c) SaO2 in the 80s d) Change in behavior 18. What history do you ask about before you prescribe a sleep aid to your 69 yr old patient? a) Sz b) Depression c) Heart Dz d) OSA 19. Your patient is an RN with a positive PPD. Her CXR comes back negative/WDL. What do you do now? Ofer 6 mos INH 20. Which national measure is more important to prevent VAP, ↑HOB or frequent oral care? ↑HOB 30° My version had this question and then a second question where frequent oral disinfection was an answer. 21. XR identification: Pneumonitis. Pt with SOB and dry cough CXR reveals generalized inflammation throughout. • numerous poorly defined small (<5 mm) opacities throughout both lungs, sometimes with sparing of the apices and bases • airspace dz: usu seen as ground-glass opacities (patchy or diffuse, resemble pulmonary edema) or rarely, as consolidation • a pattern of fine reticulation may also occur • XRay: Blunting of costophrenic angle: Pleural efusion Tx: thoracentesis • XRay: Kerley B lines: pulmonary edema • Exudative effusion: higher ratio of pleural protein and LDH to serum levels o Protein: Pleural fluid: serum ratio > 0.5 o LDH: Pleural fluid : serum ratio > 0.6 o Pleural fluid LDH > 2/3 upper limit of serum LDH • When is the greatest risk for a mechanically ventilated pt to contract VAP? 48-72 hours • VAP: Pseudomonas: (zosyn, cefepime, or imipenem/meropenem) + (fluoroquinolone or azithromycin) ± gentamycin • 37 yp s/p endotracheal intubation 2 days ago has fever, chills and purulent sputum. CXR = lung infiltrates. Which of the following is the best regimen for the pts condition? Cefepime and Cipro (Pseudomonas for VAP) • PE: causes respiratory alkalosis (breathing off all their acids) • Spontaneous pneumothorax common in what disorder: Marphan syndrome • Most important HPI questions in pt w/hemoptysis: amount of blood, previous episodes, dyspnea • Patho of PE: Failure of right ventricle • What is the best non-pharmacologic tx in a pt with end stage COPD: Bipap (NIPPV) I had this question plus another where an acute COPD patient was described. His ABGs looks like he needs to be intubated, but that’s not an option so you pick NIPPV • Which med decreases mortality in COPD: LABA-ICS combo…Advair (Salmeterol + Fluticasone) (O2 also)…Scott said ipratropium bromide but UptoDate does not support this • Example of a patient most likely to have emphysema? 59 yo with increased AP diameter • Mainstay COPD Tx: Sympathomimetics (Albuterol) • What PFTs show asthma: Obstructive: decreases in FEV1, FEV25-75, PEFR, FVC • Most important in a status asthmatic patient who was extubated: follow up w/ asthma specialist in 3-5 days • A patient has TB and lives with 6 other people. Do you treat the 6 other people, or test them? Test them • A patient who has HIV or some comorbidity tests positive for TB. It wants you to select Tx: answer is 4 drug regimen • Pt presents with night sweats and dry cough with wt loss. You suspect TB. Which of the following is diagnostic? Culture X 3 • 38 yo F immobilized for 4 months. Examining her before releasing you note dyspnea and tachycardia. You suspect PE, but V/Q scan does not confirm. What is the next diagnostic test? Pulmonary angiography • What confirms the dx of PNA? Consolidation in the lungs (CXR) • Which of the following is recommend for asthmatics or smokers ages 19-64? PNA vaccine • Elderly women who has a hx of lung dysfunctions comes to our office. She presents with a number of respiratory symptoms. Most severe c/o HA. Which is the most likely respiratory dx based on HA? Acute bronchitis IMMUNOLOGIC/MISC 1. Your patient needs to start treatment with a DMARD for RA. Which is the least expensive? a. hydroxychloroquine b. sulfasalazine c. methotrexate d. leflunomide 2. Where are Bouchards Nodes located? a. DIPs b. PIPs c. MCP d. Wrists 3. Which of the following is NOT an early sign of HIV/AIDS? a. Fatigue/vague abdominal pain b. Fever c. Weight loss d. Night sweats 4. Which of the following patients is most likely to get HIV? a. Sex worker who doesn’t use condoms b. MSM who doesn’t sue condoms c. IVDU My version had an option with a 57 year old male hemophiliac with pneumocystis pneumonia, and I picked that one. PRBCs weren’t tested for HIV until 1985, so he could have had contaminated transfusions earlier in life. 5. Which of the following demonstrates the appearance of normal veins on a funduscopic examination? a. Pale gray compared to arteries b. Wider than arteries (arteries are brighter red and narrower than veins) c. Brighter red than arteries d. Thinner than arteries 6. Your HIV patient has CMV. What is the appropriate treatment? a. Cefazolin b. Ciprofloxacin c. Fluconazole d. Gemcyclovir (pick the ‘vir’) 7. Your patient has RA and her corticosteroids are not working. What is your next step? Methotrexate 8. Your patient stepped on a nail and does not know his tetanus status. Do you give Td or Tdap? Tdap 9. In which pt would sarcopenia be the most expected finding? Elderly pt 10. Why are so many HIV pts noncompliant? ↓Access to care • Know HIV testing: ELISA confirmed with Western Blot. AIDS = CD4 <200 (800 is WDL) or <20%. Ideal viral load (by PCR) < 5000 • HIV pt with petechiae on legs (bone marrow suppression) and leg weakness (malaise) What should you test for?: CMV • HIV Meds S/E: GI probs, N/V, skin rash, anemia • ESR (sed rate) elevated: RA, SLE, temporal arteritis, inflammation • In addition to a positive serum ANA, what dx is supportive of dx. A patient with SLE ? Leukopenia • 28 yo F presents with fever, malaise, rash across the back and splinter hemorrhages. Hgb 10, positive ANA, UA proteinuria and elevated ESR. What is the suspected diagnosis? SLE (endocarditis was one of the wrong answers) • Which of the following drugs can cause lupus-like symptoms? Procainamide • RA: methotrexate, DMARDS, corticosteroids, hydrochloroquine, gold salts. most cost effective: methotrexate (monitor LFTs) • Felty’s syndrome: RA + joint swelling + enlarged spleen + leukopenia (complication of RA) • Pt c/o wrist /hand, swollen redness & pain worse in a.m and resolves as the day goes on. What dx would support RA? ↑ ESR • OA: ASA, APAP (1st line), NSAIDS, Cox2 inhibitors (Celebrex). Swimming for non-pharm. Cane goes on opposite side. • 57 yo M with PMH of cardiovascular disease presents with c/o of pain in both knees that is progressively worse throughout the day. You suspect OA. What medication is contraindicated? Celebrex r/t ARF, MI and pts PMH + for cardiac disease • What is associated with HA, fever, and elevated ESR? Temporal Arteritis • EYES: Best way to verify your treatment is working for open angle glaucoma? Tonometry (normal IOP is 10-20 mmHg) • Which of the following meds is not indicated in the management of closed angle glaucoma? Alpha 2 adrenergic agonist (this is for open angle.) I had a difficult question in which a patient with open angle glaucoma had a hx of CHF and HTN and something else, and it wanted me to pick his regimen based on that. Xalatan, ALphagan, Timolol, and Pilocarpine were listed. I don’t know the answer but I picked pilocarpine. • 47 yo M comes in complaining of intense right eye pain which has worsened since he woke up. Eye exam: copious tearing/redness. Which of the following do you complete to confirm suspected dx? Sodium fluorescein stain for corneal abrasion • Picture of an elderly persons arm with a skin tear… dermis thins in old age • Older lady with iron deficiency anemia is opening a jar and sustains a spiral fx of her arm. Why? Osteoporosis CRITICAL CARE/TRAUMA 2. Your patient ABGs come back as follows: pH 7.37, HCO3 19, pCO2 24. What is the diagnosis? a. Metabolic acidosis with resulting respiratory alkalosis 3. Your anaphylactic patient is wheezing and states she feels like her throat is closing. What is the priority action? a. IV steroids b. Give Epinephrine c. Intubate d. IV Benadryl Question of prioritization where an NP rounds on the unit and the RN gives her 4 patients, you have to pick the one that is most urgent. One is a pancreatitis patient with decreased urine output, the other is a facial cellulitis with increasing dysphagia. I picked the cellulitis d/t proximity of swelling to airway. 4. Your patient has tachycardia, anxiety, urticaria in recovery from a cardiac catheterization. What is the treatment? IV methylprednisolone, H2 Blocker, and IV Benadryl (Epi was one incorrect option) 5. What kind of shock is exhibited by the following values? PCWP 18, CI 2.0, SVR 1800 a. Distributive b. Cardiogenic (only one with high wedge) c. Obstructive d. Hypovolemic This question also gives you some readings from the pulmonary artery catheter, you don’t need them. 6. Your patient has had treatment for a hematoma. He is confused and combative. It is necessary that he lie still for several hours. What do you do? a. Order Paralytic b. Order Bedside sitter c. Insist the family remain at bedside d. Order sedation with holidays for neuro checks 7. Your ventilated pt has these settings: SIMV, FiO2 60%, PEEP 5. You notice pulmonary shunting. What is your action? a. Increase PEEP to 10 (shunting d/t atelectasis) b. Order a Beta agonist nebulizer c. Increase FIO2 to 70% d. Add +5 Pressure Support 8. Your intubated pt has sounds coming out from around the tube. What is the cause? a. Mucous plug b. Bronchospasm c. Tracheoesophageal fistula d. Cuf insufficiency (air leak) 9. The NP correctly identifies the expected hemodynamic profile of a pt in hypovolemic shock as being most closely represented by which of the following? a. CO 3.5 L/min, CVP 1 mmHg, PCWP 4 mmHg, SVR 700 b. CO 3.0 L/min, CVP 1 mmHg, PCWP 3 mmHg, SVR 1400 (everything is low except SVR) c. CO 3.5 L/min, CVP 1 mmHg, PCWP 14 mmHg, SVR 1300 d. CO 8.5 L/min, CVP 9 mmHg, PCWP 4 mmHg, SVR 700 10. A pt presents to the ED with intense abdominal pain that worsens when she coughs. A physical exam indicates abdominal tenderness, abd guarding. During the PE, the NP elicits RLQ pain when pressure is applied to LLQ. Her labs are: HR 140, SV 70ml/min, CVP 8 mm Hg, PCWP 4 mm Hg, SVR 600 dyn sec/cm3. Which of the following should be initiated for this pt? a. Norepinephrine b. Hydrocortisone suppositories c. Epinephrine d. PRBC transfusion Had a similar question with hemodynamic values and hypotension but had to pick between dopamine and levophed. 11. A 42 yr old F is brought to ED after spilling a pot of boiling water on her arms and chest. On exam you see that burned skin is broken, swollen with edema, and covered in blisters. She rates pain as “extremely painful.” You determine that the pt has burns over 20% of her TBSA. Which of the following most accurately describes the pts burn? a. 1st degree burn b. Full thickness burn c. Partial thickness burn d. 3rd degree burn • Early septic shock:↑CO/CI (>8/4) • First priority in a septic shock hypotensive patient? ABC, then IVF • Hemodynamic parameters all types of shock • How would you know cardiogenic shock: only shock with initially high wedge PCWP • Pt was stung by a bee and is in respiratory distress what do you do first? Administer Epinephrine • 54 yo M s/p acute MI on levophed, epi, vasopression and nitro. BP 160/75, now 81/50. Which med would you decrease? Nitro • What pathological finding can cause both cardiogenic and obstructive shock? Cardiac tamponade • Hypovolemic Shock: Tx – IVF, transfuse PRBCS as needed • Cardiogenic Shock:– Acute pump failures, MI, dysrhythmia, pulmonary edema, tamponade Tx – IVF then vasopressors ie. NE, dopamine, dobutamine, nitro IV if ischemia • Obstructive shock: – Massive PE, Tension pneumo, tamponade. SWAN catheter = obstructive shock Tx – IVF, maintain BP, tx underlying cause, vasopressors Norepi, dopamine • Anaphylactic Shock (distributive): Tx – Airway, Epi IM, Benadryl IV/IM, IVF, consider ranitidine (H2 antagonist), inhaled beta agonist • Neurogenic Shock (distributive)– Spinal cord injury, regional anesthesia Tx – Airway, IVF, vasopressors (dopamine, noepi, ephedrine • Septic shock (distributive) Tx – Bld Cx, IVF, vasopressors Norepi, dopamine, dobutamine; Abxs should be initiated in 1 hour • Basic vent settings: RR 12, PEEP 5-8, Vt 6-8 ml/kg • Lung protective vent settings: for ARDS. Low tidal volume ventilation 4 to 8 mL/kg predicted BW. Can also Adjust Vt to goal inspiratory plateau pressure ≤30 cm H2O. ↓ Vt = ↓r/o alveolar over-distension, VALI (ventilator-associated lung injury) • Pain scale to use in ventilated or unconscious patient: CPOT • There is also a question about CAM-ICU to identify ICU delirium. You have to know what the CAM-ICU scores or measures to answer the question • Pt is 2 days post extubation, is now stable but failed a swallow eval in ICU: needs step down unit • Pt decompensating and family not sure if they want to intubate right now what do you do? Intubate • Sepsis Quality measure: treat w/abx within 1 hour • What acid-base imbalance indication for CRRT? Metabolic acidosis • Resp acidosis: increase RR on vent to blow of acids • Know anion gap: (Na + K) – (HCO3 + Cl-) normal is 7-17 • Central line is placed, pain develops, in respiratory distress + absent breath sounds.: Needle decompression • Which valve condition is a contraindication for intra-arterial balloon pump? Significant aortic regurgitation (regurgitation ↑’ed by counter-pulsation. Also: aortic dissection & big aortic aneurysm) • Lab for Rhabdo – CK (creatine kinase) • When to transfer burns: facial involvement • Pt was burned in explosion. Burns feature moisture on the skin w/ blisters and redness (2nd degree burns). He was burned on each arm, his face, and his neck. The pt wants to know how much of his body was burned. The NP states? 28 % (each arm 9% = 18%, head 9%, neck 1%) • A bedside parasternal ultrasound reveals fluid in the pericardial sac. What is the initial action in managing this patient? Emergent percicardiocentesis • Cervical spine xray of guy who hung himself: leave collar on • Testicular torsion: treatment is emergency surgery • A pt dx with compartment syndrome should immediately receive what? Referral for surgery Had a question with a pt that had a tib/fib fx and started having s/s of compartment syndrome. Answer was to measure intracompartmental pressure. • To check for other sources of bleeding in a pelvic fracture: CXR and FAST scan • There is a trauma hypotensive pt. distractor is blood transfusion: answer is ATN (causes: ischemia-↓ perfusion, sepsis, nephrotoxins-drugs, IV contrast) Similar question: Identify the cause of ischemic ATN. The answer was a pt. who had hemorrhaged and received a blood transfusion. The other options were all nephrotoxic causes and thus wrong. • LeForte Criteria: Malocclusion and x-ray: trauma referral, stabilize and ship if community hospital. Mine had an xray of the patient’s mouth. I think the patient was a victim of domestic violence • Leforte: Your patient has Mx Facial fractures, malocclusion, broken palate & teeth. What do you do? Stabilize and ship! DRUGS 1. Which antiemetic blocks the 5-HTS serotonin receptor and can cause extrapyramidal symptoms? a. odansetron b. metoclopramide (another one is listed with it that is same class of drug) 2. What can contribute to Dilantin toxicity in a patient with diabetes mellitus? Hypoalbuminemia (as in any pt) 3. Which of the following anti-epileptic drugs is the LT drug of choice for treating pts dx with convulsive status epilepticus? a. Phosyfentoin b. Diazepam c. Phenytoin d. Phenobarbital • There is a question asking ‘which of the following factors puts the patient at risk for drug toxicity’? Answer is CrCl <30 (the correct answer) Albumin of 4 is a distractor, this value is WDL • 52 yo F is concerned with hormonal replacement therapy. What are the associated SE? Gallstones, blood clots and CVA • Hormonal replacement therapy has been shown to improve what dx? Osteoporosis • 57 yo M with PMH of cardiovascular disease presents with c/o of pain in both knees that is progressively worse throughout the day. You suspect OA. What medication is contraindicated? Celebrex r/t ARF, MI, and CV dz • Dantroline sodium/Dantrium. Tx: Serotonin syndrome, malignant hyperthermia, neuroleptic malignant syndrome • Detrol LA– anticholinergic efects (drying: xerostomia, constipation, dyspepsia, dry eyes, dysuria, HA) • Ginseng – increases the risk of bleeding • Hypoalbuminemia: risk of drug toxicity (decreased binding  more free substance in blood) • Metformin: causes lactic acidosis • Methotrexate: monitor LFTs • Metoclopramide (Reglan) S/E: tardive dyskinesia, EPS • NSAIDS: monitor creatinine, hyperkalemia • Opiate naïve, how long do you monitor? 3 hours • PPI: r/o hip fractures, increase vitamin d • Coumadin, how do you know pts understands instructions: Getting INR checked • Renal angiogram: no ACEi • Tamoxifen S/E: (estrogen modulator) Hot flashes, menopausal symptoms, vag dryness, hair thinning/loss, menstrual irregularities, pancytopenia, ↑risk of DVT/CVA. • St John’s wort: decreases the efectiveness of dig, ↑r/o SSRI syndrome • Succinylcholine: (relaxes airway for RSI) r/o malignant hyperthermia. C.I.: ↑K , intubation for Methamphetamine OD • Synthroid: Risk of MI. Ensure adequate treatment by checking TSH. S/E: alopecia • Transplant questions: what types of meds • TCA overdose expected finding? Prolonged QT • What would you monitor post-op with serotonin HT3? Nausea (Zofran is a serotonin 5HT3 antagonist) • What 2 herbs are associated with relieving premenstrual symptoms? Evening primrose and black cohosh • Elderly pt takes an herbal root to help fight colds, however has a history of renal insufficiency. Which medication could exacerbate his diagnosis? Echinacea causing nephrotoxicity RENAL/URO/STI 1. Which of the following is not an indicator of prerenal failure? a. BUN/Cr ratio > 10:1 b. FeNa < 1 c. Specific Gravity > 1.015 d. Urine Na > 40 (this is postrenal) Know all your values from this chart in Barkley pg128 2. A 34 year old female presents to the ED w/severe flank pain, nausea, and vomiting. The pt states she had trouble urinating before the onset of her other s/s. A CT scan reveals a 2.5 mm stone in the L kidney just above the upper ureter. Which course of action is most appropriate? a. Give IVF and discharge home b. Strain the urine immediately (she may pass it on her own) c. Schedule laser lithotripsy 3. Your 33F patient tells you she does not use protection during sexual intercourse. Cervical motion tenderness in addition to what other finding indicates PID? a. adnexal tenderness b. vaginal itching c. UTI d. No other symptoms 4. 53 yo M c/o dribbling and nocturia. You suspect BPH. PSA is 3.2. What confirms the dx? Transrectal ultrasound 5. A male patient you have placed on an alpha blocker for BPH comes in complaining of increased urinary frequency. What do you do? Leave it alone, the med is working 6. A 78-year-old male pt w/CHF develops a bacterial UTI 2° to an indwelling f/c. Pt has a known allergy to PCN and sulfonamides. The appropriate choice for antimicrobial therapy is: ciprofloxacin 7. Pt w/hx AFib has maintained NSR w/ sotalol (Betapace), is hospitalized for acute pyelonephritis. The appropriate antibiotic regimen for this patient is: IV ceftriaxone (Rocephin). 8. A young female pt in ED w/ a vaginal d/c. After a pelvic exam, the NP documents which finding? Cervical motion tenderness. 9. Your female pt presents with mucopurulent cervical drainage, fever >102 F, adnexal tenderness, & distended, rigid abdomen. What is the appropriate measure? Call surgery and arrange for an exploratory laparotomy & pelvic abscess drainage (key is rigid abdomen) • Lower UTI Tx: Bactrim, Cipro, Augmentin, for 3 days course • Male pt w/UTI on 3 day regimen of abx, comes in requesting stronger abx: Levaquin (another version is narrow the spectrum) • UTI pt allergic to PCN: TMP/SMX (Bactrim) • UTI during pregnancy: Amoxicillin, Macrobid, Keflex, for 7 days • Most common UTI etiology in women? E.Coli (Men = Proteus) • Difference between upper UTI and lower UTI: Flank pain • First test to order with a male presenting with BPH? U/A • BPH to shrink: 5 alpha-reductase inhibitors: finasteride (Proscar) and dutasteride (Avodart) • At what age is the PSA screening indicated in a non-African American male with no family hx? 50 • ATN causes: ischemia (prerenal/perfusion related), sepsis, and nephrotoxins (IV contrast) • What is the leading cause of intrinsic acute renal failures? Nephrotoxic drugs • Renal disease gives what metabolic abnormality? Metabolic acidosis, IVF with NS and possible sodium bicarb needed • What is the cause of anemia in renal failure? Decrease in erythropoietin • What is azotemia? BUN >100, tx is dialysis • What should the dietary protein requirement be with chronic renal insufficiency?<40g/day • Chronic renal insuff results in what calcium imbalance? Hypercalcemia (d/t 2nd hyperparathyroidism, renal osteodystrophy) • Gold standard for dx nephrolithiasis? CT scan • Most common types of stones: Calcium 80%, Gout = uric acid, women = struvite • 45 yo M s/p ABD Sx has now developed ARF: BUN 100/Cr 4.5, indications for dialysis: ↑K, metabolic acidosis, & encephalopathy My question simply asked me to pick which disturbance was an indication for diaylsys and the answer was metabolic acidosis. • Treatment for chlamydia? Azithromycin • 25 yo F presents w/ green vaginal discharge, what is dx: Gonorrhea (Females s/s dysuria, urinary frequency, abd pain, fever, n/v Males: asymptomatic white/yellow-green discharge. Tx: Ceftriaxone 125mg IM X1, cervical culture with Thayer Martin media, gram – diplococci, Tx Cephtriaxone IM x 1, Zithromax 1 gm PO x 1, report to health department) • Pt sexually active with gonorrhea who is not practicing safe sex: Educate • Minor with STI: have parent step out of room • What is the confirmatory test for diagnosing syphilis? Fluorescent treponemal antibody absorption (FTA-ABS) • When treating a pt diagnosed with syphilis, what drug allergy is most important to consider before initiating Tx?PCN allergy, syphilis is treated with PCN G HEME/ONC 1. Which lab value is expected in iron deficiency anemia? a. Elevated MCHC b. Elevated TIBC (>450) c. Elevated MCV d. None of the above 2. Which vitamin is appropriate for a post-operative patient with alcoholism? a. D b. K c. B1 (thiamine) d. A 3. Your patient is a 30 Greek F with microcytic anemia who has just returned from the middle east. What lab is not expected in her anemia? a. Low serum ferritin (<15) b. Low Hgb c. TIBC 300 d. MCHC < 32% 4. What does allopurinol prevent in Non-Hodgkin Lymphoma? a. Gout b. hypokalemia c. nausea and vomiting d. tumor lysis syndrome 5. Your patient is on 5FU for chemotherapy. What symptoms are most likely to cause discontinuation of treatment? a. alopecia b. mouth sores c. nausea/vomiting and mucosal irritation 6. Which of the following is not associated with anemia of chronic disease? a. HIV b. COPD c. SLE d. ulcerative colitis? 7. A 32-year-old patient who underwent an open splenectomy for a ruptured spleen is preparing for discharge. An adult- gerontology acute care nurse practitioner reviews the potential complications with the patient. The nurse practitioner emphasizes which instruction to the patient? Follow up with primary care provider for vaccinations. 8. 32 yo presents with c/o fever, night sweats and unexplained wt loss. Upon exam you note a swollen cervical lymph node. A subsequent CXR reveals mediastinal adenopathy. Which of the following is the dx? Hodgkin’s lymphoma 9. Your pt had an appendectomy+ chemo for symptomatic relief of cancer. Is this curative or adjuvant treatment? Adjuvant • Several anemias: Know them all! • Another name for macrocytic anemia is Megaloblastic! There was a question with lots of details in the stem, the patient has some macrocytic anemia (lists MCV) and a fever, PLT 30K, and some other random labs. One option in the answers is megaloblastic anemia, another is ITP. • Iron Deficiency Anemia: Ferritin < 15, TIBC >450 • What race is at highest risk for cancer: Black men (per CDC website) • Pernicious anemia: know this. + Babinski sign (toes fan up/out) • Know coagulation labs re: what blood products to give: o PLT (150-400K) give PLT o Clotting factors give FFP,(Factors V, VIII, PT: INR) o Fibrinogen (if <170 mg/dL) give Cryoprecipitate • Hodgkins: Lymphedema in cervical chain • Non-hogkins lymphoma • Lymphoma present in R axilla and R neck. What stage? Stage II – same side of diaphragm. Know staging • AML • Leukemia w/low WBC-what to avoid infection: hand washing • Leukemia + COPD: low WBC, CXR and ABG pretty normal, lungs diminished and you give steroid: ventilate • What is the DIC confirmatory test? ↑FDPs • Passive immunity: immunoglobulin injections • ITP Tx: steroids • Sickle cell anemia crisis Tx: IVF for hydration (most important), analgesics for pain, oxygen for hypoxemia. My question listed all of these treatments and wanted to know which was most important • Jehovah’s Witness needs sx but is refusing blood products. Give Epogen or colony stimulating factor. When do you give alternative: before sx • Von Willenbrand disease– lack of factor VIII. give DDAVP preoperatively (can consider VWF)