Partial preview of the text
Download CCRN Multiple Organ Exam with Questions and Answers and more Exams Medicine in PDF only on Docsity!
CCRN Multiple Organ Exam with Questions and Answers A patient arrives with multisystem trauma after falling out of a second-floor window. She has significant overt bleeding and is lethargic with peripheral cyanosis, Her vital signs are blood pressure 80/60 mm Hg, heart rate 145 beats/min, and respiratory rate 40 breaths/min. You would expect to give her what type of fluid immediately? A. Albumin B. O-negative blood c. Normal saline until typed and crossmatched blood is available D. Fresh frozen plasma until typed and crossmatched blood is available ANSWERV V B. This patient is exsanguinating. Only hemoglobin will carry oxygen, and it must be given immediately. If she had already been blood typed (but not crossmatched), you would give her type-specific blood, but she does not have time for a full crossmatch. O-negative blood is considered the universal donor and is indicated in an exsanguinating patient when you do not have a type-specific or fully typed and crossmatched blood available. The patient is losing blood, so consider that you need to replace what is lost. Best would be fully typed and crossmatched blood. Next best would be type-specific. Next best would be universal donor (O negative) blood. A 25-year-old man admitted with multiple trauma has had significant changes in the last 12 hours. His temperature is 39° C, his skin is warm and dry, and he is restless and agitated. The following are his hemodynamic parameters: Blood pressure 88/48 mm Hg Heart rate 124 beats/min Cardiac output 10.5 L/min Cardiac index 5.25 L/min/m2 Right atrial pressure 4 mm Hg Pulmonary artery occlusive pressure 3 mm Hg Systemic vascular resistance (SVR) 452 dynes/sec/em-5 Venous oxygen saturation 90% Vasopressors might be required in this patient to do which of the following? A. Maintain renal blood flow. B. Increase coronary blood flow. Cc Increase venous return and preload. If the radial artery can be palpated, the systolic BP is at least 80 mm Hg. If the brachial artery can be palpated, the systolic BP is at least 70 mm Hg. If only the carotid artery can be palpated, the systolic BP is approximately 60 mm Hg. To [cel a pulse as peripheral as the radial, you would expect that the BP would necd to be higher than 60 mm Hg. A 65-year-old man is admitted to the critical care unit with a diagnosis of septic shock. He has been receiving chemotherapy for lung cancer. His skin is warm and dry, and he is restless. His white blood cell count is elevated above normal. Hemoglobin, hematocrit, and red blood cell count are normal. Vital signs are blood pressure 80/50 mm Ig, heart rate 120 beats/min and regular, respiratory rate 32 breaths/min and regular, and temperature 39° C. Arterial blood gases reveal the following: pH 7.25 PaO2 60 mm Hg PaCO2 25 mm Hg HCO3 13 mEq/L Oxygen saturation 86% Dobutamine is started at 10 meg/kg/min. Normal saline is infusing at 150 ml/hr. Which of the following would be most indicative of improvement in this patient? A. Increase in venous oxygen saturation (SvO2) B. Decrease in arterial lactate fon Increase in cardiac output D. Increase in urine output ANSWERV V B. Oxygen delivery is being increased by dobutamine and normal saline infusions, but the real issue is whether the tissues have been able to extract the oxygen being delivered. An increase in SvO2 would indicate that even less oxygen is being extracted from the arterial blood. An increase in cardiac output and urine output indicate that oxygen delivery is increased but do not indicate whether the tissues have been able to extract the oxygen. Lacti ‘id is produced by anaerobic metabolism, and arterial lactate will be decreased if the tissues convert back to aerobic metabolism. Associate lactate with lactic acid. You know that a decrease in lactic acid would indicate less anaerobic metabolism. Adequate oxygen extraction and aerobic metabolism would decrease the lactic acid level. Choose option "Decrease in arterial lactate.” The initial management of any drug intoxication is to do which of the following? AY Prevent further absorption of the drug. Vasopressors and inotropes Cc. Antihistamines and antibiotics Dd. Corticosteroids and vasopressors ANS WERVV A. Antihistamines block the effects of the histamine. Corticosteroids stabilize the mast cells, which normally release histamine. Therefore, histamine release is decreased. Consider that anaphylaxis is about histamine, and only option "Antihistamines and corticosteroids" include two drug choices that affect histamine release or effect. A 25-year-old man admitted with multiple trauma has had significant changes in the last 12 hours. His temperature is 39° C, his skin is warm and dry. and he is restless and agitated. The following are his hemodynamic parameters: Blood pressure 88/48 mm Hg Heart rate 124 beats/min Cardiae output 10.5 L/min Cardiac index 5.25 L/min/m2 Right atrial pressure 4 mm Hg Pulmonary artery occlusive pressure 3 mm Hg Systemic vascular resistance (SVR) 452 dynes/sec/em-5 Venous oxygen saturation 90% Appropriate therapies at this time probably would include which of the following? A. Crystalloids and vasopressors B. Crystalloids and vasodilators Cc. Colloids and vasopressors D. Colloids and vasodilators ANSWERV V A. Fluids to fill the enlarged vascular space should be in the form of crystalloids because the mediators released in response to infection and resultant SIRS not only cause vasodilation but also increase capillary permeability. This contraindicates colloids because they would Icak through the capillary wall and take more fluid with them. Vasopressors may be used to restore vascular tone if fluids are inadequate to restore perfusion. In a series answer like this one. go with what you know. You know the SVR is less than 500 dynes/sec/em-5, so you need to fill the space and restore normal vascular tone. In multiple organ dysfunction syndrome, which of the following is the earliest indication of hepatic failure? Cc. They increase perfusion to vital organs. D. They increase interstitial and intracellular volume. ANSWERV ¥ D. Hypotonic solutions are hypotonic to blood, so they move from the intravascular space to the interstitial space and intracellular space. Remember that the comparison is to the tonicity of blood. So IV fluid that is lower tonicity than blood is going to leave the vascular space and enter interstitium and intracellular spaces. Which of the following is associated with thiamine deficiency? A. Wernicke syndrome B. Goodpasture syndrome [on Nephrotic syndrome Wellen syndrome ANSWERVV A. Thiamine is necessary for use of glucose. Administration of glucose in patients with thiamine deficiency may cause Wernicke syndrome (also called Wernicke encephalopathy). The syndrome is characterized by diplopia, nystagmus, lack of coordination, and decreased metal function. This is why thiamine is included in the classic "banana bag" given to patients with alcoholism. The "banana bag" (also in some areas called a rally pack) usually includes glucose, multivitamins, thiamine, and magnesium. Goodpasture syndrome is an autoimmune process that affects the basement membranes of the kidney and the lung, causing renal failure with hemoptysis. Nephrotic syndrome is a renal condition characterized by marked proteinuria, hypoalbuminemia, and edema. Wellen syndrome is myocardial ischemia caused by proximal left anterior descending artery stenosis. Your patient has an increase in venous oxygen saturation (SvO2) along with a decrease in oxygen consumption (VO2) and pH. What do you suspect? A. Larly septic shock B. Cardiogenic shock &. Hemorrhagic shock Decrease preload and afterload. D. Decrease afterload and increase cardiac contractility. ANSWERV V A. The primary effects of IABP are decreased afterload and improved coronary artery perfusion pressure. IABP does not directly affect preload, and it does not directly increase cardiac contractility. Because ischemia and infarction are the problems with this patient, look for an option that indicates improvement of these problems. The patient's hemodynamic parameters indicate that preload (PAOP) and afterload (SVR) are increased. Option "Decrease afterload and improve coronary artery perfusion” includes improvement of coronary artery perfusion and afterload The asphyxiation that can occur with anaphylaxis is caused by: A. pulmonary edema. B. unconsciousness causing relaxation of the tongue against the hypopharynx. c change in intrathoracic pressure. D. laryngeal edema. ANSWERV ¥ D Angioedema causes laryngeal edema, which can cause asphyxiation if severe enough and if anaphylaxis is not treated promptly. Consider the stridor that is characteristic of anaphylaxis. This is an indication of upper airway obstruction caused by laryngeal edema. A 65-year-old patient has been in the ICU for 10 days with a diagnosis of acute respiratory failure that required mechanical intubation. During this time, he had a urinary catheter inserted to insure adequate output calculations. He also has a central line that was used to infuse vasopressors and crystalloids on hospital 1 to 4 days. He is at risk for a number of hospital-acquired infections. Which of the following actions will not reduce his risk of CLABSI? AL Perform hand hygiene immediately before and after each episode of patient contact. B. Use sterile end-caps or needleless connectors on all unused lumens. Cc. Sanitize access ports before and after each use, a method known as "Serub the Hub." Note that option "Recognition of high-risk patients and early manifestations of organ dysfunction" is a more general statement than the other three statements. Which route would be preferred for the rapid administration of fluids in hypovolemic shock? A. Central venous catheter B. Large-gauge, short peripheral catheter Cc. Needle inserted into saline lock Dz. Large-gauge, long peripheral catheter ANSWERVV B. The most rapid administration of fluids is achieved through a large-gauge, short catheter. Central venous catheters are long and, if multiple-lumen, each lumen may be smaller gauge than large-gauge peripheral catheters. Large-gauge, long peripheral catheters, including peripherally inserted central catheters, would be slower than a short peripheral catheter. The slowest of all would be to piggyback an infusion through a needle inserted into a saline lock. A patient is admitted with the family reporting that the patient had consumed many pills of various types. Regardless of the drugs that were actually consumed, the initial management of any overdosage is: A. securing the airway. B. administering the antidote. c. preventing further gastrointestinal absorption. D. inercasing the excretion of toxins. ANSWERV V A. Airway is always the first priority. Many patients with an overdosage of prescription or illegal drugs are admitted with an altered level of consciousness. ‘The tongue is often a source of airway obstruction in these patients. They also are at increased risk of aspiration because of loss of gag reflex. Go with what you know: basic life support measures. If the patient does not have a patent airway, nothing else matters. Choose option "securing the airway." A 48-year-old male patient with a history of inferior myocardial infarction (MI) is admitted with an acute anterolateral MI. He is tachyeardic and hypotensive. Cardiac index is 1.9 L/min/m2. Pulmonary artery occlusive pressure (PAOP) is 20 mm Hg, and systemic vascular resistance (SVR) is 2000 dynes/sec/em-5. Which of the following is the priority in this patient? Heart rate 124 beats/min Cardiac output 10.5 L/min Cardiac index 5.25 L/min/m2 Right atrial pressure 4 mm Hg Pulmonary artery occlusive pressure 3 mm Hg Systemic vascular resistance (SVR) 452 dynes/sec/em-5 Venous oxygen saturation (SvO2) 90% Which of the following does the SvO2 of 90% demonstrate? A. A hypoxemice state B. An increase in oxygen delivery Cc. A decrease in oxygen extraction D. Intracardiac shunt ANSWERV V C. The decrease in vascular tone and SVR decrease the perfusion gradient, so less oxygen is delivered to the tissues for use. Sepsis results in the inability of the tissues to extract and use oxygen. This results in blood returning to the right side of the heart with more of the oxygen still attached to the hemoglobin. Typoxemia would decrease the SyO2, but all of the other options would increase SyO2. From the clinical picture and knowledge of the pathophysiology of septic shock, choose option "A decrease in oxygen extraction." Which of the following solutions would be most appropriate for initial uid resuscitation of a patient with severe hypovolemia caused by several days of diarrhea and vomiting? A. An isotonic crystalloid B. A hypotonic crystalloid Cc. A hypertonic crystalloid D. A colloid ANSWERVYV A. In this situation, the intravascular and the interstitial spaces would be depleted. The priority is the intravascular space, which would be replaced best with isotonic solution. Because isotonic fluids equilibrate across all spaces, the interstitial space also would be replaced. Consider: What did the patient lose? Crystalloid and electrolyte. Then ask: Which crystalloid would replace the intravascular and interstitial spaces’? An isotonic crystalloid. Electrolytes would be added 
