Questions and Answers
Which of the following would be the earliest auscultatory finding in left ventricular failure (LVF)?
How should a patient with a pulled subclavian catheter be positioned?
Oxygen delivery (DO2) is the product of which of the following?
Which of the following is the most significant complication of status asthmaticus?
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A 22-year-old man is at significant risk for which condition after a motor vehicle collision?
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Which laboratory parameter is especially important to monitor for bleeding in a patient with blunt abdominal trauma?
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Which of the following is associated with chest pain, confusion, and petechiae?
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Which type of shock is most likely to be iatrogenic?
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What is the cause of hypernatremia in a patient with a recent increase in urine output and specific gravity below normal?
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What do the findings of split S2 on expiration and a single S2 on inspiration indicate?
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Which of the following is not an indication for mechanical ventilation in patients with asthma?
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A patient exhibiting nystagmus and ataxia likely has a lesion in which area?
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Which route is preferred for the rapid administration of fluids in hypovolemic shock?
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If a patient cannot tolerate PO due to nausea and vomiting, what is the treatment for hypoglycemia?
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Which drug would be contraindicated for a patient with hypertrophic cardiomyopathy?
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How would a pneumothorax appear on chest x-ray film?
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What are early indications of alcohol withdrawal syndrome?
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What potential complication arises from altering the pH of gastric secretions?
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What stage of infiltration is experienced if a patient on norepinephrine shows pain and discoloration?
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Which solution is most appropriate for initial fluid resuscitation after diarrhea and vomiting?
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Based on the assessment of a patient with bowel perforation, what would be the expected pulmonary artery occlusive pressure?
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What is the cause of metabolic acidosis in a patient with acute kidney injury?
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Which of the following are characteristics of myasthenia gravis?
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What is the purpose of PEEP in the treatment of ARDS?
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Which ventilator mode requires monitoring for auto-PEEP?
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Which of the following best differentiates hypovolemic from cardiogenic shock?
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What electrolyte imbalance should you suspect in a patient with carpopedal spasm?
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Which of these options would be expected laboratory values for a patient with acute kidney injury due to severe hemorrhaging?
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Which diagnostic test is most definitive in identifying aortic rupture?
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What should be done next for a patient with severe throbbing pain in the thigh after surgery for a femur fracture?
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What treatment for disseminated intravascular coagulation (DIC) in a case of rattlesnake bite would include?
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What is the most likely cause of an increase in intracranial pressure (ICP) in a patient on positive pressure ventilation?
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Which oxygen delivery system will provide the highest concentration of oxygen for a patient with acute respiratory distress syndrome?
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Which treatment would not be used for a patient with spontaneous pneumothorax?
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For a patient with a myocardial infarction, which treatment would not be indicated?
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Why is it important to wean a patient from a ventilator after thoracotomy as early as possible?
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What heart rate would be indicative of a ventricular escape rhythm in a patient with a third-degree atrioventricular block?
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Which treatment would not be included for flail chest?
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Which ventilatory parameters are most indicative of a patient's ability to cough and clear airways after lobectomy?
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What mechanism could explain a decrease in oxygen saturation to 90% after starting nitroprusside?
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Which are classic signs of systemic inflammatory response syndrome (SIRS)?
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In a patient presenting with substernal pain and a history of extensive smoking, what condition is he at particular risk for?
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What is the appropriate treatment for a ventricular tachycardia in an unstable elderly patient?
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What should be monitored closely for a patient started on norepinephrine?
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What would diminished breath sounds in a patient indicate, especially after a lobectomy?
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Which diagnostic panel is suggestive of disseminated intravascular coagulation (DIC) after a rattlesnake bite?
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What disease could an elderly patient with fever, redness, warmth, and exudate at the hip have?
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According to the volume-pressure curve, what is the effect of initial small increases in intracranial volume on ICP in a patient without brain pathology?
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Which symptoms would be most indicative of dehydration in an elderly patient presenting after nausea, vomiting, and diarrhea?
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Why is asking him to smile and checking for symmetry of facial movement important?
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A patient develops diabetes insipidus after a craniotomy. Which group of findings would be most characteristic of diabetes insipidus?
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A patient 5 days after an acute inferior myocardial infarction suddenly complains of severe dyspnea and palpitations. Which of the following is most likely to be descriptive of the pulmonary artery occlusive pressure (PAOP) in this patient?
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What is the priority of management in respiratory acidosis?
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A 77-year-old woman reports explosive diarrhea for 48 hours. Which of the following is of the most immediate concern?
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Which of the following describes the pulse pressure of a patient with aortic regurgitation?
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Which of the following is not a way that carbon dioxide is transported in the body?
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Which of the following may adversely affect the ability of pulmonary artery occlusive pressure (PAOP) to reflect preload?
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Which of the following would not be associated with a false-positive result for an acute myocardial infarction using the total creatine kinase (CK)?
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Which of the following is a manifestation of left atrial enlargement on the electrocardiogram?
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Nutrition is an important component of the therapeutic regimen for a patient with hepatic failure. Which of the following is characteristic of the therapeutic diet for the patient with hepatic failure?
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The blood pH is a measure of which of the following?
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A 45-year-old woman is admitted with deep venous thrombosis and pulmonary embolism. If she develops heparin-induced thrombocytopenia (HIT), what clinical sign would the nurse expect to see first?
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Which of the following assessment findings is specific to hemothorax rather than pneumothorax?
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A patient is admitted with subarachnoid hemorrhage. He develops a fever of 38.5° C. Which of the following is of greatest concern for this patient?
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A 27-year-old woman arrives in the emergency department 3 weeks after the vaginal delivery of her first child. What treatment is indicated at this time?
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A patient is admitted with subarachnoid hemorrhage. He develops a fever of 38.5° C. Which of the following is of greatest concern for this patient?
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The reciprocal changes of a posterior myocardial infarction (MI) are evident in which leads?
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A patient has gained 1 kg since yesterday. How much fluid does this weight gain represent?
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Which of the following drugs are used for first-line therapy for chronic management of hypertension?
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A 32-year-old woman has systemic lupus erythematosus and chronic kidney disease. Which of the following is indicated?
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Which mode of mechanical ventilation requires the nurse to monitor closely for auto-PEEP (positive end-expiratory pressure)?
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If a patient has a palpable radial pulse, the systolic blood pressure (BP) is at least:
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Your patient has an increase in venous oxygen saturation (SvO2) along with a decrease in oxygen consumption (VO2) and pH. What do you suspect?
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In multiple organ dysfunction syndrome (MODS), clinical indications of respiratory failure include:
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Which of the following would be an indication for the administration of blood in a patient with massive esophageal bleeding?
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Which of the following are the major sources of intracranial hypertension after craniocerebral trauma?
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A patient received one unit of packed cells. Which of the following would be the expected effects of the transfusion?
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A 20-mm S wave in lead V1 and a 25-mm R wave in lead V6 are noted on a patient's 12-lead electrocardiogram. This would indicate which of the following?
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Which of the following arterial blood gas findings supports the diagnosis of pulmonary embolism?
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Which of the following sets of hemodynamic data is associated with early septic shock?
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What would be the best laboratory test to evaluate this patient's glomerular filtration rate (GFR)?
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Which of the following is the oxygen concentration to be used in patients with cardiopulmonary arrest?
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Which of the following would be most indicative of improvement in a patient with septic shock after receiving treatment?
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The physician has prescribed mannitol for a patient with intracranial hypertension. Which of the following is an important consideration when administering mannitol?
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If a patient with a normal pH and temperature has a PaO2 of 60 mm Hg, his arterial oxygen saturation (SaO2) is closest to which of the following values?
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A patient had a craniotomy 2 days ago for removal of a tumor. He is awake and talking to the nurse and demonstrates no neurologic deficit. Which intravenous solution is most appropriate for fluid replacement?
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A 76-year-old man is admitted with complaints of sudden, sharp, 'tearing' chest pain radiating to the shoulders, neck, and back. Which of the following would not be an important aspect of care for this patient?
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Which of the following interventions would be helpful in prevention of aspiration in a patient receiving enteral feedings?
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Which of the following would not cause an elevated creatine kinase-muscle/brain (CK-MB)?
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The ability of the brain contents to be shifted to prevent intracranial hypertension when intracranial volume increases is referred to as:
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Which of the following is not a therapeutic effect of nifedipine when used for angina?
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Emergency decompression of a tension pneumothorax includes needle puncture at which of the following locations?
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Which dietary restrictions would be maintained for a patient with hepatic encephalopathy?
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A patient with myasthenia gravis develops hypoxemia with hypercapnia. What is the cause of hypoxemia in this patient?
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Which of the following drugs stabilizes epithelial mast cells, thereby reducing the release of histamine?
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Which of the following would not be used for hypertensive crisis in the presence of acute heart failure?
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Study Notes
Left Ventricular Failure
- Earliest auscultatory finding in left ventricular failure is S3.
- S3 sound indicates early heart failure, subtle changes in condition.
Patient with Catheter and Air Embolism
- Patient grasping and pulling out a triple-lumen subclavian catheter may lead to air embolism.
- Position the patient head down, left side to minimize air embolism movement.
Oxygen Delivery
- Oxygen delivery (DO2) is determined by SaO2, hemoglobin, and cardiac output.
- SaO2 reflects arterial oxygen saturation crucial for effective oxygen transport.
Complication of Status Asthmaticus
- Acute respiratory failure is the most significant complication associated with status asthmaticus.
Risk of Epidural Hematoma
- Linear fractures of the temporal bone pose a risk for epidural hematoma due to disruption of the middle meningeal artery.
Monitoring for Bleeding in Abdominal Trauma
- In patients with blunt abdominal trauma, hematocrit is crucial for monitoring potential bleeding.
Fat Embolism Syndrome
- Symptoms including chest pain, confusion, and petechiae are indicative of fat embolism occurring after long-bone fractures.
Iatrogenic Shock Type
- Septic shock is the type of shock most likely caused by medical treatment or procedures.
Hypernatremia Post-Craniotomy
- In cases of hypernatremia following craniotomy, water loss due to diabetes insipidus is the cause.
Cardiac Auscultation Findings
- A split S2 on expiration indicates left bundle branch block (LBBB) in the presence of a consistent PR interval and QRS duration.
Indications for Mechanical Ventilation in Asthma
- Respiratory alkalosis is not an indication for mechanical ventilation in asthmatic patients; severe fatigue and respiratory acidosis are.
Neurological Signs of Cerebellum Lesion
- Nystagmus, ataxia, and unsteady gait suggest a lesion in the cerebellum, responsible for balance and coordination.
Fluid Administration in Hypovolemic Shock
- A large-gauge, short peripheral catheter is preferred for rapid fluid administration in hypovolemic shock.
Treatment for Hypoglycemia
- Patients unable to tolerate PO due to vomiting should receive 25 ml of 50% dextrose in water (D50W) to treat hypoglycemia.
Contraindicated Drug in Hypertrophic Cardiomyopathy
- Digoxin is contraindicated in hypertrophic cardiomyopathy, as it increases contractility.
Chest X-ray Findings in Pneumothorax
- A pneumothorax appears more radiolucent than normal lung tissue on chest x-ray due to air in the pleural space.
Early Signs of Alcohol Withdrawal
- Early signs of alcohol withdrawal include diaphoresis and mild tachycardia, which are the least severe symptoms.
Gastric pH Alteration Complications
- Increasing gastric pH through medications like H2 blockers can lead to pneumonia due to gastric colonization.
Monitoring for Extravasation During Norepinephrine Infusion
- Signs of infiltration require administration of phentolamine for treatment, indicating Stage 4 infiltration.
Initial Fluid Resuscitation in Severe Hypovolemia
- Isotonic crystalloids are most appropriate for fluid resuscitation in cases of severe hypovolemia from diarrhea and vomiting.
PAOP in Dehydration
- In a dehydrated patient, the expected pulmonary artery occlusive pressure (PAOP) is around 4 mm Hg, indicating hypovolemic status.
Acid-Base Imbalance in Acute Kidney Injury
- Patient with metabolic acidosis shows inability of the kidneys to excrete acid by-products of metabolism.
Characteristics of Myasthenia Gravis
- Myasthenia gravis is characterized by muscle weakness and fatigability due to disrupted neuromuscular transmission.
Purpose of PEEP in ARDS
- PEEP is used to decrease intrapulmonary shunt by keeping collapsed alveoli open.
Monitoring for Auto-PEEP
- Pressure-controlled inverse ratio ventilation requires close monitoring for auto-PEEP due to prolonged inspiratory time.
Differentiating Shock Types
- Decreased pulmonary artery occlusive pressure distinguishes hypovolemic shock (decreased PAOP) from cardiogenic shock (increased PAOP).
Suspected Electrolyte Imbalance
- Carpopedal spasms and neuromuscular irritability suggest hyperphosphatemia, often paired with hypocalcemia.
Monitoring Mechanical Ventilation for Auto-PEEP
- Inverse ratio ventilation necessitates monitoring for auto-PEEP due to longer inspiratory times.
Palpable Radial Pulse and BP Relation
- A palpable radial pulse indicates a systolic blood pressure of at least 80 mm Hg.
Signs of Early Septic Shock
- Increased venous oxygen saturation (SvO2) with decreased oxygen consumption points towards early septic shock.
Respiratory Failure Indications in MODS
- In Multiple Organ Dysfunction Syndrome (MODS), clinical signs will include increased PaCO2 levels.### Respiratory and Blood Gas Findings
- A PaO2/FiO2 ratio greater than 300 mm Hg indicates a narrow A-a gradient, often seen in cases of mild respiratory distress.
- Increased PaCO2 due to hypoventilation leads to respiratory acidosis and could signal severe respiratory impairment.
Blood Transfusion Indications
- Administer blood for patients with symptoms of hypoperfusion, such as chest pain or dyspnea, rather than relying solely on hemoglobin or hematocrit levels.
- Massive bleeding management may require surgical intervention if endoscopic sclerosing therapy is ineffective.
Intracranial Hypertension
- Major contributors to increased intracranial pressure post-trauma include cerebral edema and expanding lesions, such as hematomas.
Blood Transfusion Effects
- One unit of packed red blood cells typically increases hemoglobin by 1 g/dL and hematocrit by 3% over the next few hours.
ECG Findings
- A 20-mm S wave in lead V1 and a 25-mm R wave in lead V6 suggests left ventricular hypertrophy, significant when the combined depth and height exceed 35 mm.
Diagnosis of Pulmonary Embolism
- Hypoxemia is a key indicator of pulmonary embolism due to impaired gas exchange and reduced PaO2 levels.
Hemodynamic Data in Septic Shock
- Early septic shock manifests with an increased cardiac index while systemic vascular resistance decreases, correlating with increased venous oxygen saturation.
Glomerular Filtration Rate Evaluation
- The urine creatinine clearance test is the most reliable method to assess GFR.
Oxygen in Cardiopulmonary Arrest
- 100% oxygen is essential and recommended during cardiopulmonary arrest without contraindications.
Indicators of Improvement in Septic Shock
- A decrease in arterial lactate levels denotes improved oxygen extraction and a return to aerobic metabolism, indicating a positive response to treatment.
Mannitol Administration
- Mannitol must be administered through an in-line filter to prevent particulate contamination.
Oxyhemoglobin Saturation Estimation
- A PaO2 of 60 mm Hg corresponds closely to an arterial oxygen saturation (SaO2) of about 90%, indicating significant desaturation.
Diabetes Insipidus and Fluid Replacement
- In patients with diabetes insipidus, 5% dextrose in water (D5W) is the appropriate fluid choice to replace lost free water and address hypernatremia.
Aortic Dissection Management
- Fibrinolytic therapy is contraindicated in suspected dissecting thoracic aortic aneurysms. Management should instead focus on blood pressure control and pain management.
Aspiration Prevention during Enteral Feedings
- Using a small-bore duodenal feeding tube reduces the risk of aspiration.
Creatine Kinase-MB Elevation
- Heart failure does not typically elevate CK-MB levels; myocardial injuries lead to increased CK-MB readings.
Intracranial Compensation
- The brain's ability to adapt to increased intracranial volume is termed compensation, distinct from autoregulation, which refers to blood flow normalization.
Nifedipine in Angina
- Nifedipine decreases preload and afterload without significantly affecting myocardial contractility, contrasting with other calcium channel blockers.
Emergency Procedures for Tension Pneumothorax
- Immediate needle decompression should be performed at the second intercostal space, midclavicular line on the affected side.
Dietary Management in Hepatic Failure
- In hepatic encephalopathy, patients should have restricted protein and sodium intake to manage ammonia levels and prevent edema.
Acute Respiratory Distress Syndrome (ARDS)
- Intrapulmonary shunting in ARDS is characterized by perfused alveoli with limited ventilation, often leading to hypoxemia.
Control of Phosphorus Levels
- In cases like Goodpasture syndrome with acute tubular necrosis, controlling phosphorus levels is crucial to prevent hypocalcemia.
Hemodynamic Changes in Septic Shock
- Increased venous oxygen saturation (SvO2) can occur in early septic shock, distinguishing it from other shock types where cardiac output decreases.
Carbon Monoxide Poisoning
- The primary effect of carbon monoxide poisoning is hypoxia due to impaired oxygen transport.
Myasthenia Gravis Complications
- Hypoxemia with hypercapnia in myasthenia gravis arises primarily from alveolar hypoventilation.
Cromolyn Sodium Action
- Cromolyn sodium stabilizes mast cells and reduces histamine release, but is ineffective in treating acute asthma attacks.
Hypertensive Crisis Management
- Esmolol, a β-blocker, is contraindicated in acute heart failure and hypertensive crises due to its negative inotropic effects.
Acute Kidney Injury Lab Findings
- Patients with acute kidney injury often present with high urinary osmolality and low urinary sodium concentration as the kidneys conserve sodium and water.
Definitive Test for Aortic Rupture
- The thoracic aortogram is the most definitive imaging modality for identifying aortic rupture.
Management of Snake Bite Complications
- Treatment for disseminated intravascular coagulation due to snake bites includes administering clotting factors alongside antivenom.
Intracranial Pressure Concerns
- Positive pressure ventilation can raise intracranial pressure by increasing intrathoracic pressure, making close monitoring essential.### Pulmonary and Respiratory Conditions
- A 24-year-old male with pulmonary contusion exhibits increasing dyspnea, respiratory alkalosis, hypoxemia, and fine crackles bilaterally, leading to the diagnosis of acute respiratory distress syndrome (ARDS).
- The nonrebreathing mask is the most effective oxygen delivery system for achieving close to 100% oxygen saturation.
- A 22-year-old male with spontaneous pneumothorax displays signs of respiratory alkalosis due to hyperventilation, requiring chest tube, analgesia, and calming patients, not calcium.
- In patients with flail chest, treatment includes mechanical ventilation and pain management, while chest tubes are not indicated solely for flail chest.
Cardiac Events
- A 72-year-old male presents with acute coronary syndrome signs and ST segment elevation, indicating a need for urgent treatment; lidocaine is not indicated.
- Treatment for unstable ventricular tachycardia includes synchronized cardioversion at 100 J; amiodarone would be appropriate for stable tachycardia.
- Elevated v waves and overestimation of LVEDP occur in patients with severe myocardial infarction when assessing pulmonary artery occlusive pressure.
Electrocardiogram and Arrhythmias
- A third-degree atrioventricular block manifests as a ventricular escape rhythm with a rate of 20 to 40 beats per minute.
- Pulmonary artery occlusive pressure can be affected by changes in ventricular compliance, leading to inaccurate preload reflection.
Metabolic and Endocrine Responses
- Classic signs of systemic inflammatory response syndrome (SIRS) include fever, tachycardia, and tachypnea.
- Diabetes insipidus post-craniotomy is characterized by polyuria, hypernatremia, and low urine specific gravity.
Fluid and Electrolyte Balance
- Patients with diarrhea and vomiting show signs of hypovolemia, which is critical to address urgently.
- In elderly patients, dehydration can be indicated through hypotension, tachycardia, and oliguria.
Nutrition and Metabolism in Illness
- Patients with hepatic failure require a therapeutic diet high in protein and calories to support recovery.
Other Clinical Considerations
- Factors contributing to false-positive results for myocardial infarction testing include hypothyroidism and hemorrhagic stroke, while ulcerative colitis is not associated.
- Osteomyelitis may present with fever, redness, and exudate in the hip, indicating a serious infection or inflammation.
Summary of Key Mechanisms
- Intrapulmonary shunts occur with ventilation-perfusion mismatch, commonly seen in ARDS.
- The body's response to changes in intracranial volume typically shows no effect on ICP until a critical threshold is reached; then even small increases in volume cause significant increases in pressure.
Diagnostic Implications
- Decreased platelets, decreased fibrinogen, prolonged PT, aPTT, and increased fibrin degradation products suggest disseminated intravascular coagulation (DIC), especially in trauma cases.
- EKG findings consistent with left atrial enlargement include wide, notched P waves in lead II.
General Clinical Principles
- Early weaning from positive pressure ventilation post-thoracotomy is essential to prevent maintaining air leaks.
- Continuous monitoring of patients on norepinephrine is crucial to assess for signs of excessive vasoconstriction and ischemia.
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