BOARDS STISSUES/TRENDS/POLICY You want to get more funding for your hospital’s Rapid Response Team. How should you present this issue to the committee? What is the best way for the AGACNP to get involved in policy making? What is the best way for the AGACNP to demonstrate and advocate for full scope of practice? Which of the following is considered a high acuity role for the AGACNP? What is the best way to advocate for gay and lesbian population in your area? Which of the following is most important to evaluate statistical significance when reviewing the literature? When closing a practice, the NP is required to do all of the following except Which of the following components of an evidenced based research process is the most important for NP to participate in? 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? Can you tell the pt’s wife, for her protection, that her husband has HIV? How can the ANCP prepare to get involved in future mass casualty event? 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? Your pt is worried about insurance coverage and asks you for advice on Medicaid. You instruct the patient that Medicaid: 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? Health Literacy: Average American-8th grade education level Know your QA/QI/CPI basic definitions and goals: 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? 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: Which clinical scenario does the NP evaluate for a quality improvement process change? Goals set forth in “Healthy People 2020” by the United States Department of Health and Human Services include: Based on the individual’s culture, ethnicity, and personal choices, the NP can optimize the therapeutic partnership w/the patient by: 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: 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? What legislation allowed nurse practitioners to be recognized Medicare providers in all geographical areas with their own provider number? True/False: restraining an unwilling patient is grounds for malpractice? 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? The NP program initiated, primarily, because of what issue in healthcare at the time? 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? Pt calls to complain about bills and states he has Medicare, which should cover all costs. You explain: 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: NP working on ESRD research project . A colleague renal specialist asks for pt info on your patients: Who enforces HIPPA- Who ISN’T covered by HIPPA? Law enforcement/Municipal Offices, CPS/Schools, Employers/Workman’s Comp, Life insurance Definitions Root Cause Analysis Benchmarking Managed Care: Peer review Sensitivity vs specificity Reliability: Validity of results in an article: Statistical significance: Medical futility Privileging Institutional bylaws Informed Consent: Case management Nondisclosure: Negligence: 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? Quantitative and Qualitative Know difference between advanced directive and living will: Living will provides “POA/healthcare proxy” Billing: NP sees a pt for HF and performs an H & P. What % is expected to be paid? General Tips LOTS of therapeutic communication Scope of practice: integration of care across the acute illness continuum with: Collaboration*: 4 Roles of a Nurse Practitioner: Pt is getting dc and needs wound care, pulmonary, and follow up: NP’s role is: Government is moving towards being cost effective. What is the best way? Protected health information: How should the ACNP stay up to date with current information? “Incident to” billing rules Medicare levels and what they cover. 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? Healthcare exchange: DECISION MAKING You notice there have been less favorable outcomes and satisfaction surveys in patients treated for sickle cell anemia. How do you approach this problem? 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? Your patient has refused human blood products based on religious beliefs. He is now rapidly destabilizing. What do you do? What is the best way to make sure a patient will follow up as instructed? 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 patient visits your clinic for sinusitis. She requests a PAP smear since she has not had one in “years.” You: A patient visits your cardiology She requests a PAP smear since she has not had one in “years.” You: 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? 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? Now the husband presents to ED with drug overdose. What is your action? The medical resident obtained consent for an operative procedure. On your visit, the pt is confused/refusing the procedure. 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? Your clinical student breaks the sterile field. How do you handle this situation? 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 code you are in does not go well, and staff members afterwards are criticizing each other. How do you deal with the situation? 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? 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 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? 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? 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? 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? 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? You notice that another NP in your group is frequently contacted by pharmacy for prescription errors. How do you handle the situation? 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? 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: 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: What procedure does the AGACNP perform to evaluate cytology, only, in the tumor? 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: 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? ASSESS the pt before you order tests What is most important when assessing status? A woman of child-bearing age c/o abdominal pain. What level of exam do you document? A diabetic pt complains of abd pain. Which type of exam do you conduct? What qualifies pt for HHC: is home bound, has a prescription, requires care services, wound care, select care Pt is refusing care: Guy in ER needs refill on Ritalin: Knowledge deficit in ICU, what would you for nurses: A patient has advanced dementia, ESRD, and HF, what do you do for him? COMMON PROBS/CULTURE/RISK 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? Your patient is a Chinese female immigrant living in the US. You notice she is avoiding eye contact. What is this due to? Your patient speaks only Spanish and you need to evaluate his pain. What do you do? 58yo Japanese M with CP 4/10 for 3 hours, reluctant to answer questions. Which of the following in the ED warrant admission? A 77M patient’s wife cares for him at home. Which statement by the wife indicates a need for a SNF? Which psychiatric disorder is most commonly diagnosed, yet least commonly treated? Your pt w/PNA is noted to have a heavy drinking habit. 2 days p admit he becomes combative/agitated. What is Tx? Your patient has developed a fever of unknown origin. What is the next step? How long will it take to begin to see healing in a pressure ulcer that has a clean, well-vascularized bed? The patient has been in a bar fight and has a human bite on his hand. What should you do next? Your patient has a chronic, nonhealing decubitus ulcer. He c/o pain when he moves his leg. What is a potential complication? What is the strongest predictor of functional impairment prior to discharge of the elderly pt? Your pt has been taking Thorazine and now has fever, sweating, lethargy, and a temp of 39.4 (102.92): You suspect your patient on TPN with a PICC has a CLABSI. What is the first intervention? Your patient has a fever 3 days post op, WBC are 15,000, Blood Cx (-), and Eos 9%. What is the dx? What are protein supplements best used for? Which macronutrient of TPN significantly increases the osmolality of the solution? Which electrolyte are you most concerned about monitoring in a cachexic patient? Which lab do you monitor daily in a patient on nutritional supplements? What alternative therapy can you order to relax the pt prior to a procedure? Which helps a Parkinson’s pt. with coordination Which 2 headaches can be treated with triptans? What kind of dressing do you use on a decubitus ulcer with necrotic tissue? 45 yo s/p double mastectomy 2 months ago. Now is c/o pain at the incision site. What does the leg /foot look like in a hip fracture? Internally rotated or externally rotated? Pt has a post-op fever: WHO pain ladder: Best pain indicator: Best alternative therapy to decrease pain in clavicle fracture: Picture of Gunshot wound to the R lung area: you purpose of dressing. Cocaine induced psychosis: Pt comes in tachycardic, hallucinating, all kinds of other crazy symptoms w/ … pupils: Antidepressant OD: ASA overdose: s/s: n/v, tinnitus, dehydration, hyperthermia, apnea, cyanosis, metabolic acidosis. How do you treat group A strep on skin: Pt has cellulitis of lower extremity with a wound, what do you treat with? Mallampati grades for visualization of oral cavity: Osteomalacia Hospice vs palliative care: Venous stasis ulcer: 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: Tdap vaccine is an example of what type of immunity? How often should a woman between the ages of 20-39 have a PAP with HPV? If born on or after what year is it indicated to receive 2 doses of mumps vaccine? What age does an individual receive Zostavax? At what age do males start colonoscopy every 10 years? When should PSA levels be initiated and how often? Annual PSA and DRE are indicated in what group? 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? 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? What is the leading cause of death in African Americans M ages 40-59? What is the leading cause of deaths in Hispanics in the US? FLUID VOLUME AND ELECTROLYTES The most common cause of hyponatremic hyperosmolality? What method should you use to treat hyponatremia related to SIADH? What is a potential cause of hyperkalemia? Your patient has a Na of 128 and was treated with colloids 3 days ago. What is the treatment? 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? 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 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? Your patient has complications from parenteral nutritional support. All of the following are plausible explanations except: 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? 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? ABG reads high HC03 and pCO2 55mmhg. What electrolyte abnormality is most likely associated with these values? 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: Low serum Na and high serum osmolality: A patient with hypovolemic, hypotonic, hyponatremia and what fluids to give: Low protein =low BUN=hypoosmolar hyponatremia 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: Which electrolyte imbalance leads to confusion and lethargy in the ETOH abuse pt? What electrolyte should be monitored prior to administering succinylcholine? Hypercalcemia: ASA overdose- which electrolyte to monitor: What sx is associated with hepatotoxicity s/p acetaminophen toxicity? Pt at highest risk for hyperkalemia: TF S/E: Diarrhea: What pt requires labs to be monitored closely after initiating TF? ENDOCRINE What disorder can be ruled out using the Cosyntropin stimulation test? What side effect of levothyroxine is most likely to lead to non-compliance when first initiated? You are treating a patient for hypothyroidism. Which lab value is monitored for treatment/synthroid effectiveness? What method should you use to treat hyponatremia related to SIADH? 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? Which of the following is not a criteria of Metabolic Syndrome? Cushing labs, symptoms: Addison’s disease labs & Tx: Pt is hypotensive Addison’s. Tx?: SIADH Urine Na 28, serum osmo 250, urine osmo 115. What is the suspected cause? 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? 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 HHNK: fluids to use: Understand hypothyroidism, hyperthyroidism signs and symptoms and treatment. Thyroid labs: S/S of thyroid storm/crisis: Myxedema coma treatment: Pt w/BP 210/110 HA, then BP ↓ 160’s, what is 1st Tx: What is the first test you run when you see s/s of pheochromocytoma? Diagnostic test confirmative for pheochromocytoma: DKA pt: Somogyi Effect: 15-year-old pt with DM1 reports ↑BG in am. The ACNP determines hyperglycemia is d/t dawn phenomenon: CARDIOVASCULAR Your patient has a history of coagulopathy and is about to go to surgery. Which order is appropriate for DVT/Bleeding prophylaxis? Which of the following is least likely to experience a DVT? 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. 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? Which of the following is contraindicated for a patient receiving a renal angiogram? Your 45M patient has new onset Atrial Fibrillation, but no other past medical history. What should you prescribe? Which is best used to diagnose pulmonary HTN? Your patient has overdosed on Lopressor. It has been 5-6 hours. What do you order? Your pt is pre-operative for an elective surgery. You notice a pulsating mass in the mid abdomen (AAA). What is next action? Your patient is post-op after an aneurysm clipping. Which intervention is used? 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? Which of the following lipid panels shows 3 out of 4 abnormal values? Your patient is an obese 38 F with the following fasting lipid panel: TC 270, LDL 168, HDL 28. What is your action? Which med must be on the d/c list of a patient admitted for CHF? 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? When d/c an 85F pt w/stasis dermatitis, the NP includes instructions to: 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? A patient with HF has DOE and sleeps all night while using 3 pillows. What is her NYHA HF stage? Identify: 2nd type 2 or Complete/3rd degree block: 2nd type 1 Pt had an EF of 20 and bronchospasm-what med caused it? Afib: What grade murmur do /you first hear a thrill: On physical exam, you note a mod. Loud MM with no thrill. What grade? Pt has low diastolic rumble murmur in the left lateral position with no radiation: Pt presents with suspected mitral regurg. What physical findings would confirm? Blood flow thru heart: Stages of heart failure Pt w/Hx of HF or PRBCs, wet LS, LE edema, dyspnea- cause of edema: What is the purpose of cardiac stress testing? STEMI guidelines Pt is post-MI, on a beta blocker and statin. What do they need? HTN DM: Which drug prevents cardiac remodeling: Pt w/ 14 hrs of CP presents to the ED. next step of action? Pericarditis- pt with normal CXR, low grade temp, elevation in all leads– best diagnostic test- A pt post CABG with abd distention, labs provided, Dx = Gerontology and cardiac PAD/PVD: CVI: How pt w/ DM and dz decrease LDL non-pharm? Temporal arteritis requires immediate Tx in order to prevent: 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? 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? GI What among the following is a common cause of pancreatitis? Your pat is s/p liver transplant. He develops fever and his bile production decreases to 20 from 300. What should you do next? Which of the following displays a current or recent Hepatitis A infection? Your patient is post-op cardiothoracic surgery. She develops nausea, periumbilical abdominal pain, moderate Lipase, LDH, ALT, ↓ What is the diagnosis? Your patient complains of tarry stools, change in stool caliper, and constipation. What intervention is appropriate? Your pt has been on peritoneal dialysis long term, and develops a fever and cloudy peritoneal fluid. What do you order first? Most critical symptom for diagnosing peritonitis/bowel perforation? What is GI angioplasty used to diagnose? Your pt with Sickle Cell Anemia is complaining of nausea and lack of sleep. What med is best? Pt presents with RLQ pain, 1-2 episodes of vomiting, and Psoas sign. What dx are confirmatory of appendicitis? 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 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? 42 y M with epigastric pain that is better after he eats: 65 yr ETOH use 25 yr smoking. S/s: dysphagia and epigastric pain. What is Dx: XR identification: Avoid Diverticulitis flare ups: Tx for diverticulitis:. True/False: Barium enema is indicated in the conservative management of diverticulitis? Lab values and acute pancreatitis: Which disorder worsens epistaxis? Bowel obstruction 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? Profuse vomiting and variable epigastric pain are 2 symptoms of what diagnosis? Lots of UC and crohns. Know the tx and presentation for Crohns. (diarrhea, abd p, abscess/fistulas, abx: Who is at risk for Toxic megacolon: 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? 17 year old with UC, what is the worst complication? Question on a young male with UC, what would be a probable finding? Ulcerative colitis meds… What abx do you use for UC? When would you find “thumb printing sign” on abd XRAY? Woman ETOH has liver dz but husband does not: What causes GI bleed in elderly? Do not use protonix (PPI) LT: Why would you pick a PPI over phenergan for treatment: Patient on PD Dialysis has an infected dialysis 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? NEURO What is the most important assessment finding in determining patient’s mental status? Your patient has a severe closed head injury. VS are listed. Which value is it crucial in evaluating him for brain death? 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? Your patient has suffered a spinal cord injury. What sign indicates recovery has begun? 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? 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? Patient has a hip fracture, carotid bruit, weakness, and confusion. What do you order? A patient was diagnosed with cauda equina syndrome and neurosurgery has been consulted. What is the NP responsibility in anticipation of surgery? Your patient has had a CVA and is now having trouble feeding himself. Who do you consult? A patient has hyperactive reflexes of the lower extremities. The adult-gerontology acute care nurse practitioner assesses for ankle clonus by: Which muscle moves the eye from center, to side, and back? There is a patient with a TBI and increasing hypercapnia/lethargy. The NP is worried about ICP, what should she consider? Change in LOC: MS: Tx for a flare-up: Myasthenia gravis patho, s/s, Tx, – Patho: MMSE: MSE on older pt: test is Dementia vs delirium: What is the number one cause of death in dementia patients? Pt with a 50% R-sided carotid artery occlusion r-sided weakness that went away (TIA) CVA tPA contraindication: Chronic subdural hematoma: Latest sign that you missed a herniation? Homonymous hemaniopia: Left middle cerebral artery infarct CN sensory only: CN both motor and sensory? CN nerve: hands on the side of pt face and ask them to chew: Status epilepticus-meds not working, low SaO2/desating, family can’t decide: Cauda Equina Syndrome: What is the pathology of Parkinson’s disease? You are examining a pt with PMH of seizures. Pt sustains a seizure lasting around 1 minutes. What is the most appropriate intervention? Initial action in a patient with new onset seizures? 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? What CSF values are characteristic of bacterial meningitis? PULMONARY 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? Your patient has a Gunshot chest wound. What kind of dressing does he need? Your pt is 3d post appendectomy and develops dysphagia, drooling, and expiratory stridor. What is going on (there will be lots of distracting information): Your patient is ventilated and becomes confused with arm edema. What low cost test do you order? (Pt could also have HIV) Your patient with VAP is on broad spectrum coverage including Levaquin, Cefipime, & Vancomycin. Your culture comes pack growing Pseudomonas. What do you do now? Which of the following does not cause hypoxemia? What is the initial finding in a pulmonary embolism? Your 32M patient has a history of MVR (distractor) and c/o wheezing with exercise. What is your order? 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 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? 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 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 What is the earliest sign of PNA in the elderly patient? Your patient is a 79 M Japanese immigrant. What TB induration measurement is diagnostic? 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? What is paradoxical abdominal and diaphragmatic movement? Which of the following is reason to intubate in an asthmatic patient? What history do you ask about before you prescribe a sleep aid to your 69 yr old patient? Your patient is an RN with a positive PPD. Her CXR comes back negative/WDL. What do you do now? Which national measure is more important to prevent VAP, ↑HOB or frequent oral care? XR identification: numerous poorly defined small airspace dz: a pattern of fine reticulation may also occur XRay: Blunting of costophrenic angle: Exudative effusion: higher ratio of pleural protein and LDH to serum levels When is the greatest risk for a mechanically ventilated pt to contract VAP? VAP: 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? PE: Spontaneous pneumothorax common in what disorder: Most important HPI questions in pt w/hemoptysis: Patho of PE: What is the best non-pharmacologic tx in a pt with end stage COPD: Which med decreases mortality in COPD: Example of a patient most likely to have emphysema? Mainstay COPD Tx: What PFTs show asthma: Most important in a status asthmatic patient who was extubated: A patient has TB and lives with 6 other people. Do you treat the 6 other people, or test them? A patient who has HIV or some comorbidity tests positive for TB. It wants you to select Tx: Pt presents with night sweats and dry cough with wt loss. You suspect TB. Which of the following is diagnostic? 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? What confirms the dx of PNA? Which of the following is recommend for asthmatics or smokers ages 19-64? 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? IMMUNOLOGIC/MISC Your patient needs to start treatment with a DMARD for RA. Which is the least expensive? Where are Bouchards Nodes located? Which of the following is NOT an early sign of HIV/AIDS? Which of the following patients is most likely to get HIV? Which of the following demonstrates the appearance of normal veins on a funduscopic examination? Your HIV patient has CMV. What is the appropriate treatment? Your patient has RA and her corticosteroids are not working. What is your next step? Your patient stepped on a nail and does not know his tetanus status. Do you give Td or Tdap? In which pt would sarcopenia be the most expected finding? Why are so many HIV pts noncompliant? Know HIV testing: HIV pt with petechiae on legs (bone marrow suppression) and leg weakness (malaise) What should you test for?: HIV Meds S/E: ESR (sed rate) elevated: In addition to a positive serum ANA, what dx is supportive of dx. A patient with SLE ? 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? Which of the following drugs can cause lupus-like symptoms? RA: methotrexate, DMARDS, corticosteroids, hydrochloroquine, gold salts. most cost effective: methotrexate (monitor LFTs) Felty’s syndrome: Pt c/o wrist /hand, swollen redness & pain worse in m and resolves as the day goes on. What dx would support RA? 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? What is associated with HA, fever, and elevated ESR? EYES: Best way to verify your treatment is working for open angle glaucoma? Which of the following meds is not indicated in the management of closed angle glaucoma? 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? Picture of an elderly persons arm with a skin tear… Older lady with iron deficiency anemia is opening a jar and sustains a spiral fx of her arm. Why? CRITICAL CARE/TRAUMA Your patient ABGs come back as follows: pH 7.37, HCO3 19, pCO2 24. What is the diagnosis? Your anaphylactic patient is wheezing and states she feels like her throat is closing. What is the priority action? Your patient has tachycardia, anxiety, urticaria in recovery from a cardiac catheterization. What is the treatment? What kind of shock is exhibited by the following values? PCWP 18, CI 2.0, SVR 1800 Your patient has had treatment for a hematoma. He is … and combative. It is necessary that he lie still for several hours. What do you do? Your ventilated pt has these settings: SIMV, FiO2 60%, PEEP 5. You notice pulmonary shunting. What is your action? Your intubated pt has sounds coming out from around the tube. What is the cause? The NP correctly … hemodynamic profile of a pt in hypovolemic shock as being most closely represented by which of the following? 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 … initiated for this pt? 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 … 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? Early septic shock First priority in a septic shock hypotensive patient? Hemodynamic parameters all types of shock How would you know cardiogenic shock: only shock with initially high wedge Pt was stung by a bee and is in respiratory distress what do you do first? 54 yo M s/p acute MI on levophed, epi, vasopression and nitro. BP 160/75, now 81/50. Which med would you decrease? What pathological finding can cause both cardiogenic and obstructive shock? Hypovolemic Shock: Cardiogenic Shock: Obstructive shock: Anaphylactic Shock (distributive): Neurogenic Shock (distributive)– Spinal cord injury, regional anesthesia Septic shock (distributive) Basic vent settings: Lung protective vent settings:for ARDS. Pain scale to use in ventilated or unconscious patient: Pt is 2 days post extubation, is now stable but failed a swallow eval in ICU: Pt decompensating and family not sure if they want to intubate right now what do you do? Sepsis Quality measure: What acid-base imbalance indication for CRRT? Resp acidosis: Know anion gap: (Na K) – (HCO3 Cl–) normal is 7-17 Central line is placed, pain develops, in respiratory distress absent breath sounds.: Which valve condition is a contraindication for intra-arterial balloon pump? Lab for Rhabdo When to transfer burns: Pt was … in explosion. Burns feature moisture on the skin w/ blisters and redness (2nd degree burns). He was … on each arm, his face, and his neck. The pt wants to know how much of his body was … The NP states? A bedside parasternal ultrasound reveals fluid in the pericardial sac. What is the initial action in managing this patient? Cervical spine xray of guy who hung himself: Testicular torsion: A pt dx with compartment syndrome should immediately receive what? To check for other sources of bleeding in a pelvic fracture: There is a trauma hypotensive pt. distractor is blood transfusion: LeForte Criteria: Malocclusion and x-ray: Leforte: Your patient has Mx Facial fractures, malocclusion, broken palate & teeth. What do you do? DRUGS Which antiemetic blocks the 5-HTS serotonin receptor and can cause extrapyramidal symptoms? What can contribute to Dilantin toxicity in a patient with diabetes mellitus? Which of the following anti-epileptic drugs is the LT drug of choice for treating pts dx with convulsive status epilepticus? There is a question asking ‘which of the following factors puts the patient at risk for drug toxicity’? 52 yo F is concerned with hormonal replacement therapy. What are the … SE? Hormonal replacement therapy … to improve what dx? 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 … ? Dantroline sodium/Dantrium. Tx: Detrol LA Ginseng Hypoalbuminemia: Metformin: Methotrexate: Metoclopramide (Reglan) S/E: NSAIDS: Opiate naïve, how long do you monitor? PPI: r/o Coumadin, how do you know pts understands instructions: Getting Renal angiogram: Tamoxifen S/E: (estrogen modulator) St John’s wort: Succinylcholine: Synthroid: Transplant questions: TCA overdose expected finding? What would you monitor post-op with serotonin HT3? What 2 herbs are … with relieving premenstrual symptoms? Elderly pt takes an herbal root to help fight colds, however has a history of renal insufficiency. Which medication could exacerbate his diagnosis? RENAL/URO/STI Which of the following is not an indicator of prerenal failure? 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? Your 33F patient tells you she does not use protection during sexual intercourse. Cervical motion tenderness in addition to what other finding indicates PID? 53 yo M c/o dribbling and nocturia. You suspect BPH. PSA is 3.2. What confirms the dx? A male patient you have placed on an alpha blocker for BPH comes in complaining of increased urinary frequency. What do you do? 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: Pt w/hx AFib has maintained NSR w/ sotalol (Betapace), is hospitalized for acute pyelonephritis. The appropriate antibiotic regimen for this patient is: A young female pt in ED w/ a vaginal d/c. After a pelvic exam, the NP documents which finding? Your female pt presents with mucopurulent cervical drainage, fever >102 F, adnexal tenderness, & distended, rigid abdomen. What is the appropriate measure? Lower UTI Tx: Male pt w/UTI on 3 day regimen of abx, comes in requesting stronger abx: UTI pt allergic to PCN: UTI during pregnancy: Most common UTI etiology in women? Difference between upper UTI and lower UTI: First test to order with a male presenting with BPH? BPH to shrink: 5 alpha-reductase inhibitors: At what age is the PSA screening indicated in a non-African American male with no family hx? ATN causes: What is the leading cause of intrinsic acute renal failures? Renal disease gives what metabolic abnormality? What is the cause of anemia in renal failure? What is azotemia? What should the dietary protein requirement be with chronic renal insufficiency? Chronic renal insuff results in what calcium imbalance? Gold standard for dx nephrolithiasis? Most common types of stones: 45 yo M s/p ABD Sx has now developed ARF: BUN 100/Cr 4.5, indications for dialysis:. Treatment for chlamydia? 25 yo F presents w/ green vaginal discharge, what is dx: Pt sexually active with gonorrhea who is not practicing safe sex: Minor with STI: What is the confirmatory test for diagnosing syphilis? When treating a pt … with syphilis, what drug allergy is most important to consider before initiating Tx? HEME/ONC Which lab value is … in iron deficiency anemia? Which vitamin is appropriate for a post-operative patient with alcoholism? Your patient is a 30 Greek F with microcytic anemia who has just returned from the middle east. What lab is not … in her anemia? What does allopurinol prevent in Non-Hodgkin Lymphoma? Your patient is on 5FU for chemotherapy. What symptoms are most likely to cause discontinuation of treatment? Which of the following is not … with anemia of chronic disease? 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? 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? Your pt had an appendectomy chemo for symptomatic relief of cancer. Is this curative or adjuvant treatment? Several anemias: Another name for macrocytic anemia is Megaloblastic! Iron Deficiency Anemia: What race is at highest risk for cancer: Pernicious anemia: know this Know coagulation labs re: Hodgkins: Non-hogkins lymphoma Lymphoma present in R axilla and R neck. What stage? AML Leukemia w/low WBC-what to avoid infection: Leukemia COPD: low WBC, CXR and ABG pretty normal, lungs diminished and you give steroid: What is the DIC confirmatory test? Passive immunity: ITP Tx: Sickle cell anemia crisis Tx: Jehovah’s Witness needs sx but is refusing blood products. Give Von Willenbrand disease