1. QA- A process for evaluating the care of patients using established standards of care to ensure quality
2. CQI- quality can be improved by Continually monitoring structure, process, and outcome
Continuous Process Improvement measures what three measures to improve nursing
• Structure: inputs into care such as resources, equipment, or numbers and qualifications of staff
• Processes of care: Include assessments, planning, performing treatments and managing complications
• Outcomes: include complications, adverse events, short term results of treatment and long term results of patient health and functioning
Goals set forth in Healthy people 2020 by the US department of health and human services include?
• Increase the quality and years of healthy life
• Eliminate health disparities among Americans
Who is not required to follow HIPPA?
• Law enforcement
• Municipal offices
• Employers/Workman’s comp
• Life insurance
An insurance company is calling to verify some patient appointments. What is the first thing to look for or ask before disclosing information?
• Is there a medical release form signed by the patient?
o If so, then give the requested information to them
Define root cause analysis
• A tool for identifying prevention strategies to ensure safety… Why why why
There is a 60-year-old patient with a new diagnosis of cancer. To appropriately plan for discharge, what should the NP do?
a. Consult CM
b. Consult SW
c. Refer to oncology
d. Refer to hospice
e. Consult case management
• Case management- mobilize, monitor, and control resources that a patient uses during course of an illness while balancing quality and cost
• (moves patient through the system appropriately)
What does Medicare A cover?
• covers inpatient/hospitalization
• skilled nursing facility services
• home health services associated with inpatient event
• hospice associated with inpatient event
• Most individuals qualify to receive benefits at 65 years of age
What does Medicare B cover?
• Covers physician services
• Outpatient hospital services
• Laboratory and diagnostic procedures
• Medical equipment
• Some home health services
Medicare pays 80% of the patient’s bill for physician services and the patient pays 20%
NPs and CNS receive 85% of physician reimbursement for services provided in collaboration with a physician
What does Medicare C cover?
• Medicare Advantage
• Patients entitled to Part A and enrolled in Part B, are eligible to receive all of their health care services through one of the provider organizations under part C (HMOs, PPOs, etc)
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 staff
d. Form individualized Tx plans that can be used by all healthcare staff
C- Form a standardized Tx plans for all pts that can be used by all healthcare staff
• Think quality assurance – standards of care
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
C-Share the information he requests
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
C- Continue to research alternative treatments
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?
b. Home Health care
d. Private Duty RN
C- SNF- Subacute nursing facility
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
C- Call the resident to clarify the patient was not confused when he signed the first consent
• Was the patient able to:
o Communicate, understand, reason, differentiate
o Remember CURD
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
C- Meet with all who participated in the code and have a one-time briefing
• Risk management
o Action taking initiatives
Correction and education
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
C- Ask if the patient has an advanced directive
Appropriate level of physical exam documentation
1. Problem focused
2. Expanded problem focused
1. A limited examination of the affected body area or organ system
2. A limited examination of the affected body area or organ system and any other symptomatic or related body areas or organ systems
Appropriate level of physical exam documentation
1.An extended examination of the affected body areas or organ system and any other symptomatic or related body area or organ system
2. A general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area or organ system
3. 3rd degree (full thickness) = dry, leathery, black, pearly, waxy; extends from epidermis to dermis to underlining tissues, fat, muscle and/or bone
What is the management of burns?
• prophylactic intubation if there are:
o burns to face,
o singed nares or eyebrows
o dark soot/mucous from nares and/or mouth
• Fluid resuscitation 4ml/kg X TBSA (total body surface area) during first 24hrs
o General rule ½ of all the fluid requirement needed during the first 24 hrs are administered with the first 8hrs of injury
• Maintain normal temp (37-37.5C)
• Caused by a bite of a tick
• Usually identified by Erythema Margins and Bullseye rash
o Doxycycline or Oral amoxicillin
o Typically resolves in about 1-2weeks with tx
1. 58yo Japanese M with CP 4/10 for 3 hours, reluctant to answer questions. Which of the following in the ED warrant admission?
c. Pain level
Ethnicity (underestimates pain, taught to be stoic. Pain is probably much more severe)
1. The patient has been in a bar fight and has a human bite on his hand. What should you do next?
B. Order PO abx
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)
1. 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
E. Drug fever (eos – allergic rxn. Normal is 1-4%)
Dietary protein intake recommended for critically ill patients receiving TF/TPN is based on nitrogen balance. What does this mean?
The concept of nitrogen balance is the difference btw nitrogen intake and loss reflects gain or loss of total body protein.
• If more nitrogen (protein) is given to the patient than lost, the patient is considered to be anabolic or “in positive nitrogen balance”. If more nitrogen is lost than given, the patient is considered to be catabolic or “in negative nitrogen balance”.
o A nitrogen balance within −4 or −5 g/day to +4 or +5 g/day is usually considered “nitrogen equilibrium”.
• Maintain nitrogen balance along with metabolic needs
1. Which electrolyte are you most concerned about monitoring in a cachexic patient?
E. K+ (refeeding syndrome. hypokalemia. also hypophosphatemia)
Which electrolyte do you monitor in Refeeding Syndrome?
A. Phos (refeeding syndrome. hypokalemia. also hypophosphatemia)
1. Which lab do you monitor daily in a patient on nutritional supplements?
D. BMP (And monitor LFTs weekly)
What two types of headaches can be treated with triptans
Migraines and cluster headaches
Best alternative therapy to decrease pain in clavicle fracture
● 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.
1. The most common cause of hyponatremic hyperosmolality?
D. Hyperglycemia (usually from HHNK
Serum osmolality >290
1. 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:
(Na<10 is nonrenal cause. Diuretics are associated with renal cause, Urine Na >20)
1. 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?
• Decreased amplitude on ECG
• Broad T waves
• Prominent U waves
• PVCa, V-tach, or V-fib
1. Type 1 DM patho
2. Signs and symptoms
1. Insulin dependent/juvenile diabetes.
• Ketone development usually occurs
2. Polyuria, polydipsia, polyphagia
3. FBG >126 on 2 separate occasions, Hgb A1c >7, elevated BUN/Creatinine, Ketonemia, Ketonuria
4. Ketones = insulin therapy 0.5 u/kg/day
1. Type 2 DM patho
2. Signs and symptoms
1. Adult onset, circulating insulin exists enough to prevent ketoacidosis, but is inadequate to meet pt insulin needs
• Associated with metabolic syndrome
2. Polyuria, polydipsia, recurrent vaginitis in women
3. No ketones in blood/urine
4. Oral antidiabetic medication- glipizide
What is the somogyi effect
How do you treat it?
Happens when the patient is hypoglycemic at 0300 but rebounds with an elevated blood glucose at 0700
Tx: reduce or omit the at bedtime dose of insulin
What is the Dawn Phenomenon?
How do you treat it?
Results when tissue becomes desensitized to insulin nocturnally. The blood glucose becomes progressively elevated throughout the night, resulting in elevated glucose levels at 0700
1. Plasma free metanephrienes –used to help detect or rule out tumor – (fastest test)
• TSH is normal, CT of adrenals used to confirm and localize tumor
2. Assay of urine 24hr collection-
3. Surgical removal of tumor is treatment of choice
• Treat symptoms
What is the management of Hyponatremia?
1. Treat based on cause
2. Treat underlying condition
3. If hypovolemic, give NS IV
4. If urine sodium>20, treat cause
5. If hypervolemic, implement water restriction
6. If the patient is symptomatic, give NS IV with a loop diuretic
7. If CNS symptoms are present, consider 3% NS IV with loop diuretics
Heart Sounds and Anatomical Location
1. S1-closure of Mitral/tricuspid (AV)valves, opening of aortic/pulmonic (similumar) valves
2. S2-closure of aortic/pulmonic valves, opening of mitral/tricuspid valves
3. Systole-is period between S1 and S2
4. Diastole- is period between S2 and S1
1. When do you hear S3?
2. When do you hear S4?
1. “Ken-Tuck-y” this happen with increased fluid status
a. i.e CHF or pregnancy
2. “Ten-ne-ssee” this happens with there are stiff ventricular walls
• i.e MI, left ventricular hypertrophy, chronic hypertension
What are the stages of Murmurs?
2/6=Audible but faint
3/6=Moderately loud; easily heard
4/6=Loud; associated with a thrill
5/6=Very loud; heard with one corner of stethoscope off the chest wall
list location and sound of Mitral stenosis and mitral regurgitation
1. Mitral stenosis:
• Mid-diastolic; apical “crescendo” rumble
• Loud S1 murmur
• Low pitched
2. Mitral regurgitation:
• S3 with systolic murmur at 5th ICS MCL(apex)
• May radiate to the base or left axilla
• Musical, blowing, or high pitched
list location and sound of Aortic stenosis and Aortic regurgitation
1. Aortic Stenosis
• Systolic, blowing harsh murmur at 2nd right ICS
• Usually radiating to the neck
2. Aortic regurgitation
• Diastolic, blowing murmur at 2nd left ICS
What are the different types of heart failure
1. Systolic HF: inability to contract results in decreased CO
2. Diastolic HF: inability to relax and fill results in decreased CO
3. Acute HF: abrupt onset usually follows acute MI or valve rupture
4. Chronic HF: develops as a result of inadequate compensatory mechanisms that have been employed over time to improve CO
What are the signs and symptoms of Acute HF
Acute HF is Left sided HF
• Dyspnea at rest
• Coarse rales over all lung fields
• Wheezing frothy cough
• Appears generally healthy except for the acute event
• S3 gallop
• Murmur of mitral regurgitation (systolic murmur loudest at the apex)
What are the signs and symptoms of Chronic HF?
Chronic HF is right sided HF
• Hepatomegaly, splenomegaly
• Dependent edema: as a result of increased capillary hydrostatic pressure
• Paroxysmal nocturnal dyspnea
• Appears chronically ill
• Abd fullness
• Displaced PMI
• Fatigue on exertion
• S3 and/or S4
List HF classification and Manifestations per New York Heart Association (NYHA)
Class 1: No limitation of physical activity
Class 2: slight limits of physical activity but comfortable at rest (fatigue, palpitations, dyspnea, or angina)
Class 3: Marked limits of physical activity but comfortable at rest – 3 pillows
Class 4: Severe; inability to carry out any physical activity without discomfort (signs and symptoms while at rest)
Lab/diagnostics for Heart Failure
• Hypoxemia and hypocapnia on ABG
• BMP usually normal unless chronic failure is present
• CXR=pulmonary edema, kerley B lines, effusion
• ECHO=will show contractile/relaxation, valve fx, EF
• ECG=my show underlying Problem-Acute MI, dysrhythmia
• PFT for wheezing during exercise
Management of Heart Failure
• Na restriction
• Rest/activity balance
• Weight reduction
• ACE inhibitors
• Diuretics: Thiazide, loop
• Anticoagulation therapy for A-fib
In-patient management of Acute Pulmonary Edema
1. 02 at 1-2L while awaiting ABG
2. place in sitting position
3. Morphine 2-4mg IVP PRN
4. Lasix 40mg IVP repeat 10 mins if no response
5. If severe bronchospasm present give inhaled bronchodilator
6. If severe, afterload and preload reduction with nipride and hydralazine
7. If CI remains low, dobutamine 2.5-20ug/kg/min;
• if SBP<100 dopamine 5-20ug/kg/min is preferred
What are the JNC7 classification Guidelines for HTN
1. HTN treatment recommendation for non-African-American
2. HTN tx rec for African American
3. HTN tx rec for Adults>18 with CKD with or without diabetes
• Thiazide Diuretics (screen for sulfa allergy, monitor lytes)
• Calcium channel blockers (monitor HR, may cause HA, flushing, or bradycardia)
• ACE1 (avoid ARB, avoid with K+>5.5)
• ARB (avoid ACE, contraindicated in pregnancy, avoid K+>5.5)
2. African American
• Thiazide diuretics (increases excretion of Na & H2O)
3. Adult>18 with CKD with or without diabetes
• ACE (causes vasodilation, blocks Na and water retention)
• Regardless of race or other medical condition
What is the recommended treatment Goals for HTN?
1. Treatment goal for initial treatment is 1 month
• Increase dose or add second drug
• Continue to assess monthly until goal is reached
• Do not use an ACE1 and ARB together
• Refer to hypertensive specialist if 3 or more drugs are needed
What is Hypertensive Urgency?
What is the management?
BP > 180/110 without progressive target organ dysfunction
• May or may not be associated with severe HA, SOB, nose bleed, or severe anxiety
Management –oral therapies
• Clonidine (catapress)- preprevents vasoconstriction, causes vasodilation, and slow HR. Do not D/C abruptly=rebound HTN
• Captopril (Capoten)-
• Nifedipine (Procardia)
• Loop diuretics
What is Hypertensive Emergency?
What is the management?
BP >180/120 with target organ dysfunction
• May occur at a lower BP if complicated by evidence of impending or progressive target organ dysfunction
Management- IV agents, critical care, art line needed
• BP should be lowered to 160-180 systolic or to less than 105 diastolic (no more than 25% within minutes to 1-2hrs) and then gradually lowered over several days with oral therapy
• Common agents- Nicardipine, Nipride
List examples that could cause Hypertensive Emergency
• Malignant Hypertension
• Hypertensive encephalopathy
• Intracranial hemorrhage
• Unstable angina
• Acute MI
• Acute LV failure with pulmonary edema
• Dissecting aortic aneurysm
What is Angina?
What are the different types?
Angina- decreased blood flow through the vessel that leads to tissue ischemia
• Stable (classic or chronic) occurs with physical activity
• Prinzmetal’s (variant) occurs at various times, even rest
• Unstable (pre-infarction, rest or crescendo, coronary syndrome)
• Microvascular (metabolic syndrome)
What is metabolic syndrome
• is a cluster of conditions — increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels — that occur together, increasing your risk of heart disease, stroke and diabetes.
What are the physical exam findings of Angina?
Signs and symptoms of Angina
Physical Exam Findings
• May see signs of peripheral arterial disease
• Levine’s sign= Clenched fist sign
• Transient S4 not uncommon during angina
Signs and symptoms
• Characteristic chest discomfort lasting several min
• Exertional is usually precipitated by physical activity; subsides with rest
• Nitroglycerin shortens or prevents attacks
Lab and diagnostic findings for Angina
• ECG may be normal- with down sloping or ST segment, or T-wave peak or inversion
• Exercise ECG
• Serum lipid levels should be elevated
• Coronary angiography is the definitive diagnostic procedure but not indicated solely for diagnosis
• Janeway lesions: small macules on the palms and soles
• Roth spots: small retinal infarcts
4. Lab, diagnostics
• WBC may be normal or elevated but there is always a shift with bands
• ECHO for valvular damage
• Blood cultures for causative organism
o 3 separate cultures at 3 separate sites in 1 hr
• ESR always elevated
• Hold abx until cultures are confirmed in stable and not acutely ill or cardiac failure
• In unstable patients empiric abx should be initiated
o PCN G 2million units IV q4
o Nafcillin (Unipen) 2 g IV q4
o Vanco- used for PCN-resistant strep and MRSA
What are some Gerontology considerations for cardiovascular physiologic changes?
• Arterial walls thicken and stiffen-resulting in decreased compliance
• The heart becomes stiffer and increase in size related to LV and arterial hypertrophy
• Sclerosis of valves
• Maximum HR decrease, resting HR and CO are unaffected
• Baroreceptors that monitor BP become less sensitive
• Circulatory changes with diminished blood flow
• Loss of pacemaker cells with increased AV conduction time
• Arteriosclerosis and atherosclerosis
What are some Cardiovascular physical findings and/or results?
• Hypertension: increased risk for CVA, MI, and renal failure
• Heart murmurs are common
• Decrease cardiac reserve (may lead to orthostatic hypotension or syncope
• Overall diminished peripheral pulses and cool extremities
1. What disorder can be ruled out using the Cosyntropin stimulation test?
B. Adrenal insufficiency
Cosyntropin is a lab/diagnostic for Addison’s disease
• In healthy individuals, the cortisol level should increase above 18-20 µg/dl within 60 minutes on a 250 mg cosyntropin stimulation test.
• In Addison's disease, both the cortisol and aldosterone levels are low, and the cortisol will not rise during the cosyntropin stimulation test
1. You are treating a patient for hypothyroidism. Which lab value is monitored for treatment/synthroid effectiveness?
Lab/diagnostics for Hypothyroidism
• TSH usually elevated
• T3 and T4 decreased
• T3 not reliable test and T4 can also be normal in Hypothyroidism
1. 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?
B. After a high dose of dexamethasone, there is a 90% reduction in urinary free cortisol (In Cushings, pituitary does not respond to dexamethasone)
1. Which of the following is not a criteria of Metabolic Syndrome?
D. BP > 140/90 (it’s ≥130/85)
• Waist > 40men >35women
• BP > 130/85
• TG > 150
• FBG> 100
• HDL< 40men <50women
What is the treatment if a patient is hypotensive with Addison’s?
IVF (D5NS) should be treatment of choice. Vasopressors are usually ineffective
Inpatient management of Addison
• Hydrocortisone 100-300mg IV initially with NS;
• Replace volume with D5NS at 500cc/hr X4hrs and then taper per condition
• Treat underlying causes
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?
C. Sodium bicarb is only indicated for DKA if pH <7.1
• Isotonic fluids (NS) at least 1L in first hr then 500cc/hr
• If glucose > 500 use ½ NS after first hr (as water deficits exceeds sodium loss)
• Glucose < 250 change to D5 ½ NS to prevent hypoglycemia
• Regular insulin
• Correct sever acidosis (pH<7.1) with bicarb gtt (44-48 mEq in 900ml ½ NS until pH>7.1
• Do not treat hyperkalemia
Which of the following is contraindicated for a patient receiving a renal angiogram?
D. Ace Inhibitor
Ace inhibitors may cause cough, rash, taste disturbances, hyperkalemia, renal impairment etc
1.Your 45M patient has new onset Atrial Fibrillation, but no other past medical history. What should you prescribe?
A- ASA (young with no risk factors/history)
• Coumadin (would be used in old-65 with + RF/Hx)
1. 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
D-TC 180, LDL 136, HDL 25, TG 160
• LDL<130 <100 <70
A patient with HF has DOE and sleeps all night while using 3 pillows. What is her NYHA HF stage?
Class 3 indicates marked limitations of physical activity but comfortable at rest.
1. Your female pt presents with mucopurulent cervical drainage, fever >102 F, adnexal tenderness, & distended, rigid abdomen. What is the appropriate measure?
1. Call surgery and arrange for an exploratory laparotomy & pelvic abscess drainage (key is rigid abdomen)
What is azotemia?
Azotemia – an excess of nitrogenous waste products in the blood- high levels of uria
BUN>100= tx dialysis
● What should the dietary protein requirement be with chronic renal insufficiency?
1. Which lab value is expected in iron deficiency anemia?
B. Elevated TIBC (>450)
1. 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%
E. Low serum ferritin (<15)
1. 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?
• Cause is unknown
• More common in males; avg age is 32 yrs
• Usually presents with cervical adenopathy and spreads in a predicatable fashion along lymph node groups
• Characteristic Reed-Sternberg cells differentiate form non-hodgkin’s disease
● 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
Lymphoma present in R axilla and R neck. What stage?
Stage II – same side of diaphragm.
What is Von Willenbrand disease and tx for sugery
Lack of factor VIII
Give DDAVP preoperatively
What are the 12 Cranial nerves and their fx
1. Olfactory= smell
2. Optic= vision
3. Oculomotor= most EOMs opening eyelids, pupillary constriction
4. Trochlear= down and inward eye movement
5. Trigeminal= Muscles of mastication, sensation of face, scalp, cornea, mucus, membranes and nose
6. Abducens= lateral eye movement
7. Facial= move face, close mouth and eyes, taste, saliva and tear secretion
1. Your ventilated pt has these settings: SIMV, FiO2 60%, PEEP 5. You notice pulmonary shunting. What is your action?
a. Increase PEEP to 10
b. Order a Beta agonist nebulizer
c. Increase FIO2 to 70%
d. Add +5 Pressure Support
Increase PEEP to 10 (shunting d/t atelectasis)
1. 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
CO 3.0 L/min, CVP 1 mmHg, PCWP 3 mmHg, SVR 1400 (everything is low except SVR)
1. 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?
b. Hydrocortisone suppositories
d. PRBC transfusion
• Maintain BP while initiating tx of underlying cause
• Fluid admin with use of vasopressors (levo, dopamine
1. 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
Partial thickness burn
● How would you know cardiogenic shock:
● only shock with initially high wedge PCWP
1. What is CAM-ICU
is an adaptation of the Confusion Assessment Method (CAM) score for use in ICU patients
1. Acute onset of mental status changes or a fluctuating course and
2. Inattention and
3. Altered level of consciousness or
4. Disorganized thinking =
Know anion gap
Anion gap = (Na +K)-(HCO3 + CI)
Which of the following lab values would indicate a pre-renal ARF?
D. FENa <1%
PFT DLCO decreased in:
D. Prolonged QT
ACE slow progression of renal insufficiency in:
D. Chronic glomerrulonephritis with >1g/dL proteinuria
D. confusion, hyperthermia, dilated pupils, HTN, and tachycardia
Acetaminophen overdose- elevated LFTs
B. within 24-48h
SIADH lab values:
D. Na <130, SOsmo <280
Intermittent segments of erosion in the small bowel and colon:
A. Crohn's disease
Replacement therapy for primary adrenal insufficiency:
A. Combination of glucocorticoids and mineralocorticoids
D. hyperpigmentation, tachycardia
Obstructive lung disease
C. Decreased FEV1/FVC
Hallmark labs with TLS:
B. Aching, throbbing, and localized
Pre-renal failure caused by:
D. hypochromic, microcytic
When treating a patient with dementia, which of the following medications has shown positive results?
Endocarditis + holosystolic murmur in the area of the apex of the heart:
D. Mitral regurgitation
Triple H therapy: hypervolemia, HTN, and hemodilution recommended in:
B. Aneurysmal SAH
B. High TSH, decreased T3/T4
42F mensural irregularities and believes she is experiencing early menopause. Fatigue and restless. Thin woman with fine hair, moist, warm skin, goiter with bruit. HR 110, 140/80
A. Graves' disease
For MCV the addition of CPAP:
A. Increased FRC
Life-threatening cause of delirium:
Posterior wall MI:
C. Tall and wide R waves and ST depression in V1 and V2 leads
Typical complication of mitral stenosis:
D. Right-sided HF
A. Elevated BUN, low Na, high K
Aortic stenosis: in addition to chest pain, which would indicate urgent need for aortic valve replacement?
Colonoscopy: continuous areas of inflammation and ulceration extending from he rectum to the sigmoid colon. Colonic biopsies reveal crypt abscesses. Which of the following is he patient most likely to have?
B. Ulcerative Colitis
Adults 40-70 years old USPSTF recommends DMII screening:
q3 years if overweight or obese
50 years or older annual:
FOBT to screen for colon cancer
Tonometry annually for those at increased risk for glaucoma