IRAT Exam #1

Which of the following is most indicative of decreased left ventricular preload? Select all that apply. A. Increased central venous pressure (CVP) B. Increased cardiac output/index C. Decreased central venous pressure (CVP) D. Dampened waveform on the monitor E. Decreased pulmonary artery wedge pressure (PAWP) F. Increased pulmonary artery wedge pressure (PAWP)

E. Decreased pulmonary artery wedge pressure (PAWP)

You are providing care to a patient who is intubated and sedated. Their ventilator settings are as follows: Mode: Assist/Control FiO2: 75% Rate: 22 Peep: 8 Tidal Volume: 450 What strategies listed below will are the best to reduce the risk of your patient getting ventilator associated pneumonia? Select all that apply. A. Administration of medication to decrease gastric juices B. Extubate the patient and utilize non-invasive measures when safely able to do so C. Daily sedation vacations (breaks from sedation) as tolerated D. Suction secretions from the oral cavity and airways when needed E. Disconnect the ventilator often to remove moisture from the tubing F. Place the patient in a high Trendelenburg position G. Decrease the PEEP from 8 to 5

A, B, C, D

Your patient is returning from a carotid endarterectomy procedure in which the MD decided to leave the arterial line in due to the patient's fluctuating blood pressures. You situate the patient and level and rezero the patient's arterial line. Your patient asks you, "Why are you doing that?" What is an appropriate response? (Select all that apply.) A. "It is important to line up the reference point to the left side of the top of your heart." B. "Leveling the transducer above or below the reference point on your body can result in erroneous readings." C. "If we use the same reference point, we will obtain consistent measurements." D. "This is just something we do periodically cause they told us we had to." E. "Zeroing removes the effects of atmospheric pressure on the readings."

A, B, C, E

You are receiving report from the ED RN about your patient. The RN reports that your patient presented with dyspnea, fatigue, and a productive cough. The physician admitted the patient to the ICU for an acute heart failure exacerbation. Which interventions would you anticipate the physician to order? (Select all that apply.) A. Morphine for peripheral dilation and to decrease anxiety B. Dopamine to decrease contractility of the heart C. Sodium Nitroprusside to decrease pulmonary artery wedge pressure D. Albumin to decrease preload. E. Nitroglycerin to decrease afterload and subsequently preload

A, C, E

Your patient is scheduled for a computed tomography angiography to rule out a pulmonary embolism as the cause of the patient's respiratory distress. To reduce the risk of acute kidney injury, what strategies should be implemented? A. Administer smallest dose of low contrast media possible, fluid volume expansion before and after the procedure, and avoidance of repeat contrast media injections within 48 hours B. Aggressive hydration with normal saline during the procedure and initiation of a sodium bicarbonate drip to correct the acidosis from the pulmonary embolism C. Discontinuing all nephrotoxic drugs 8 hours prior to procedure, hydration with an intravenous infusion of fenoldopam, and oral administration of oral N-acetylcysteine D. Administration of oral N-acetylcysteine, intravenous sodium bicarbonate, and initiation of a low dose nitroglycerin drip

A. Administer smallest dose of low contrast media possible, fluid volume expansion before and after the procedure, and avoidance of repeat contrast media injections within 48 hours

You are monitoring a patient's central venous pressure (CVP) when suddenly it increased from 10 to 48 mm Hg. You assess lung sounds which are clear except for fine rales at the bases. Your patient is not exhibiting any signs of respiratory distress. What would be your priority action? A. Check the level of the transducer. B. Place a STAT call into the physician. C. Nothing as this reading is still within normal limits. D. Administer ordered prn Lasix.

A. Check the level of the transducer.

A patient is brought into the ER. You observe cracked lips, poor skin turgor, and dry mucous membranes. There is a strong smell of urine and his pants appear to be wet. The wife explains her husband has a history of mental illness and lately has been refusing to take his meds. She also tells you that for the past 2 days he has been drinking 5 gallons of water a day and not eating. You understand that this patient is experiencing what form of Diabetes Insipidus? A. Dipsogenic DI B. Nephrogenic DI C. Latrogenic DI D. Central diabetes insipidus (DI)

A. Dipsogenic DI

You are working in the Emergency Department when your patient presents with chest pain, diaphoresis, and shortness of breath. You suspect the patient is having a myocardial infarction. An EKG reveals an anterior wall myocardial infarction (MI) and the physician orders oxygen and nitroglycerin. You as the nurse understand that this therapy should reduce or relieve chest pain by which mechanism? A. Increasing oxygen delivery and decreasing oxygen demand B. Increasing preload and decreasing afterload C. Preventing dysrhythmias and decreasing cardiac contractility D. Minimizing plaque formation and preventing vasospasm

A. Increasing oxygen delivery and decreasing oxygen demand

You are caring for a patient that was admitted to your floor with sepsis related to a urinary tract infection. A pulmonary artery catheter was placed for continuous hemodynamic monitoring. During a routine assessment, you observe that the patient's SvO2 has dropped from 68% to 56%. What does this finding indicate? A. Oxygen supply is not equal to demand. B. Oxygen supply is equal to demand. C. Oxygen is not being extracted by the tissues. D. Oxygen saturation is not accurate

A. Oxygen supply is not equal to demand.

The point directly after the QRS complex that starts the ST-segment is called what? A. The "J" point B. The breaking point C. The point of returned isoelectricity D. The "S" point

A. The "J" point

In a single rhythm strip, a junctional rhythm may have an absent or inverted "P" wave because? A. The impulse originates from the AV node and travels away from the lead, causing a negative deflection. B. The impulse traveling from the SA node to the AV node is not as strong and therefore recorded as a negative number. C. The computer is interpreting the impulse incorrectly and should be taken out of the room to be fixed. D. The patient was coughing before each of the heartbeats.

A. The impulse originates from the AV node and travels away from the lead, causing a negative deflection.

You observe the following hemodynamic profile for your patient: B/P: 112/60 PAP: 44/24 CVP: 3 PAOP: 22 CI: 1.9 l/min/m2 SVR: 1600 dynes/s/cm-5 SVI: 23 mL/m2 SVO2: 58% Based on this profile, which of the following conclusions is correct? A. The patient has evidence of left ventricular failure. B. The patient is hypovolemic. C. The patient has developed ARDS. D. The patient seems to have sepsis.

A. The patient has evidence of left ventricular failure.

You hear a patient call out while on night shift. You enter the room to find them restless and agitated. The monitor shows the patient's rhythm has changed to atrial fibrillation and they are experiencing nausea and vomiting. You take a set of vitals and find the patient has a fever of 38.9 degrees Celsius. Labs reveal a potassium of 5.4, Mg of 2.1, blood glucose of 236, TSH 0.1, T3 325, and T4 15. You understand that these lab values indicate the patient is experiencing what? A. Thyroid Storm, give tapazole and continue to monitor the patient. B. Hyperkalemia, give the patient IV insulin, dextrose, lokelma, and albuterol. C. Hypoglycemia, give the patient dextrose and apple juice, followed up with a protein source. D. A negative reaction to the lasix pill. Give benadryl, epinephrine, and provide sedation until the reaction is over.

A. Thyroid Storm, give tapazole and continue to monitor the patient.

Your patient is admitted with the following clinical findings: Chief complaint of shortness of breath and fatigue, bibasilar crackles noted with and S3 gallop, chest radiography shows venous congestion and cardiomegaly, weight increase of 20 pounds in the last two weeks. Which of the following hemodynamic alterations is found with her presenting problems AND what treatment and rationale for that treatment are indicated? A. increased afterload, decreased contractility, and increased preload; dobutamine to increase contractility. B. decreased afterload, increased contractility, and increased preload; amiodarone to decrease preload. C. decreased afterload, decreased contractility, and increased preload; Lasix (furosemide) to increase afterload. D. increased afterload, decreased contractility, and decreased preload; nesiritide to increase contractility.

A. increased afterload, decreased contractility, and increased preload; dobutamine to increase contractility.

You have a new admission to your floor for a patient with HHS. The admitting blood sugar was 735 mg/dl. The physician orders the adult hyperglycemic protocol. When the patient arrives to the floor a recheck of the blood glucose is now 762 mg/dl. The patient weighs 68 kg and has a serum Na of 130. According to the protocol you will (Select All That Apply). A. Calculate the initial infusion rate by multiplying the patients weight by 0.05 units/kg/hr. B. Run 0.9% NS at 250 mL/hr. C. Initiate insulin gtt at 8 units/hr. D. Hold the infusion if the patients BG drops to 71-100 mg/dl. E. Check a BMP every 4 hours and replace electrolytes as needed.

B, D, E

While conducting your admission assessment you ask your patient what brought them into the hospital. Which of the following statements made by the patient would lead to you believe they are experiencing early signs on peripheral artery disease? A. "At night I have to sleep with several pillows underneath my head. Otherwise I feel like I can't breathe." B. "Every time I take my dog snuffles for our walk I get the nagging cramp in my leg." C. "I have been getting these headaches lately that really knock me down. I get really sensitive to bright lights and my vision gets so blurry." D. "After working on my feet for my full shift at the plant, my feet are so swollen I feel like I am going to bust out of my shoes."

B. "Every time I take my dog snuffles for our walk I get the nagging cramp in my leg."

You are providing diabetic education to your patient prior to discharge. Your patient provides teach back on the education and makes the following statements. Which statement made by the patient indicates the teaching was effective? A. I will take my long-acting insulin before a meal." B. "I need to rotate the site I use to administer my insulin." C. "I will monitor my blood sugar weekly." D. "If I am not going to eat right away, it is okay to take my short-acting insulin anyway."

B. "I need to rotate the site I use to administer my insulin."

For a cardiac rhythm to be considered a normal sinus rhythm (NSR) it must meet all of the following criteria EXCEPT? A. A "QRS" complex that is no more than 0.10 seconds in length. B. A PR-interval that is greater than 0.2 seconds in duration. C. A positively deflected "P" wave that is associated with a QRS. D. A rate of 60-100 beats per minute.

B. A PR-interval that is greater than 0.2 seconds in duration.

All of the following are clinical features of acute respiratory distress syndrome, except: A. Bilateral chest infiltrates on a chest x-ray B. A wedge pressure greater than 18 mmHg C. Refractory hypoxemia D. Tachypnea

B. A wedge pressure greater than 18 mmHg

This scenario will apply to questions 6 and 7. Ensure you are taking adequate notes to answer the next question. YOU WILL NOT BE GIVEN THE SCENARIO AGAIN. You are working day shift in the PCU when a patient is admitted to your floor for acute respiratory distress. Objective assessment reveals circumoral cyanosis and increased work of breathing. The patient is alert and and awake and states that he, "feels like I can't catch my breath." Pertinent history includes recurrent UTIs, HTN, COPD, DM2, and BKA of the right extremity. You notify the physician who orders a STAT ABG with the following results: pH - 7.22, PaCO2 - 62, PaO2 - 71, SaO2 - 81 %, HCO3 - 25, FiO2 21% Based on this information, you understand the patient is experiencing what condition? A. ARDS B. Acute respiratory failure C. Acute on chronic heart failure exacerbation D. A pulmonary embolism

B. Acute respiratory failure

From the previous question, what would the priority treatment be at this time? A. Intubate and initiate mechanical ventilation to remove excess CO2 B. Increase FiO2 C. Use positioning to drain fluid from lungs D. Administer a bronchodilator

B. Increase FiO2

You are the Nurse of a transplant patient who is on long-term steroid therapy to ensure the success of the transplant. You understand that the prolonged use of steroids have serious consequences and would want to monitor your patient for signs and symptoms of what? A. Hyper Aldosteronism B. Secondary Cushing's syndrome C. Acute Addison's disease D. Myxedema of the orbital sockets

B. Secondary Cushing's syndrome

You are filing your hourly vital signs when you notice you patient's blood pressure recorded at 240/119. You go in to check on your patient and she explains that she has the worst headache she has ever had. You check a manual blood pressure and confirm the reading to be accurate. You anticipate the physician will order what medication? A. Furosemide B. Sodium Nitroprusside C. Digitalis D. Vasopressin

B. Sodium Nitroprusside

Your patient was admitted to your floor with a diagnosis of acute renal failure related to the use of an antibiotic prescribed for a bacterial infection. The patient has been NPO for several days. The patient has now been cleared to safely eat and the physician orders a diet. What meal would be most appropriate to order your patient? A. Tomato soup, grilled low-fat cheese sandwich, and diet soda B. Tuna salad on lettuce with low-salt crackers and iced tea C. Cheeseburger with french-fries, a side salad, and a milkshake D. Ham and cheese sandwich on whole-grain bread with pickle, potato chips, and milk

B. Tuna salad on lettuce with low-salt crackers and iced tea

As a part of your residency, you are attending a case study review style lecture on Pulmonary Embolisms. Which statement if made by your classmate would indicate that the education was effective? A. "High doses of heparin is a good choice for this patient to dissolve the clot and improve V/Q mismatch." B. "Mobilization of these patients is key to improvement. We should start walking them as soon as they are admitted to the floor." C. "TPA/TNK can be used in patients with severe pulmonary embolism and hemodynamic instability." D. "I was surprised to hear that continuous nebulizer treatments were necessary for this patient population."

C. "TPA/TNK can be used in patients with severe pulmonary embolism and hemodynamic instability."

Your patient was brough in by ambulance from a local nursing home for general feeling of unwellness. They are alert and oriented. A pulmonary artery catheter is placed for concerns of hemodynamic compromise. The PAC provides the following information: pulmonary artery wedge pressure (PAWP) of 3 mm Hg, blood pressure of 82/49 mm Hg, and a cardiac index of 1.7. You note that their urine output is 13 mL/h since admit. The patient's blood urea nitrogen (BUN) is 44 mg/dL and creatinine is 1.5 mg/dL. Lungs are clear to auscultation with no peripheral edema noted. Which plan of care would be best to stabalize your patient? A. Transfuse 1 U of packed red blood cells B. Lasix 40 mg intravenous push C. 500mL bolus and initiation of normal saline at 125 mL/h D. Dopamine 15 mcg/kg/min

C. 500mL bolus and initiation of normal saline at 125 mL/h

Your patient was found to be in a complete heart block requiring the implantation of a permanent pacemaker (PPM). For placement purposes there is an arterial and venous sheath inserted into their right femoral vein and artery. The PPM was successfully implanted and the patient returned to you with the sheaths already removed. Which complication of sheath insertion will you assign the highest priority? A. Infection B. Weak pedal pulses C. Bleeding D. Nephropathy

C. Bleeding

You are caring for a patient who has been in the hospital for 7 days. The patient is receiving continuous non-invasive mechanical ventilation VIA a BiPAP for worsening respiratory failure. Which of the following developments would indicate that it might be time to intubate your patient? A. Frequent non-productive cough with a fever B. An increase in the FiO2 from 40% to 50% C. Difficult to arouse and a change in mental status D. Two positive blood cultures with signs on early sepsis

C. Difficult to arouse and a change in mental status

You are finishing up your morning tasks with your patient. You brush their teeth, weigh them, and get them up to the chair for breakfast. You record the patients weight as 93 kg in EPIC. You also check your patient's morning labs and see that they have a serum creatinine of 0.9 mg/dL. You return that night and review your patient's chart in preparation for you shift and note that the serum creatinine is now 1.9 mg/dL and that the has voided only 35 mL/h while you were gone. Acute kidney injury (AKI) is suspected. Using the RIFLE acronym, this patient's data represents what stage of acute kidney dysfunction? A. Risk B. Failure C. Injury D. Loss

C. Injury

A patient is admitted for an acute on chronic exacerbation of heart failure (HF). While in your care, you administer medications per the physicians order and assesses the patient's response. What is/are the goal(s) of therapy for this patient population? A. Increasing preload while decreasing afterload B. Enhancing the renin-angiotensin-aldosterone system (RAAS) C. Managing fluid overload and improving cardiac output D. Maximizing systemic vascular resistance

C. Managing fluid overload and improving cardiac output

Your 87-year-old patient was brought into the ED after a motor vehicle collision. A full trauma code is called and imaging shows significant internal hemorrhaging. The patient is now stable and admitted to your floor. You know that this patient is at risk for developing what kind of acute renal failure? A. Pre-operative B. Intrarenal C. Prerenal D. Postrenal

C. Prerenal

Your patient is a Type II diabetic on a sliding scale. You check the morning sugar and provide insulin according to the sliding scale prior to their breakfast tray being delivered. After you complete your next med pass, you return to your patients room to find them lethargic, confused, sweating, and shaky. You recheck their sugar and find that they are low. In an attempt to correct this, what early action does your body take in an attempt to return the glucose level to normal? A. Your body will not make any attempts to correct the sugar. B. Massive metabolism of fat deposits and protein C. Release of glucagon D. Decreased urine output to retain glucose in the system.

C. Release of glucagon

Supraventricular tachycardia is a blanket term for dysrhythmias that originate above the AV node. This includes all of the following EXCEPT. A. Sinus tachycardia B. Atrial Fibrillation C. Ventricular tachycardia D. Atrial tachycardia E. Junctional tachycardia

C. Ventricular tachycardia

A patient with continuous SVO2 monitoring has a sustained decreased in SVO2 to 53%. Priority interventions would include all of the following EXCEPT: A. checking the patient's temperature. B. checking O2 sat with a pulse oximeter. C. checking the urine output. D. checking the B/P and the CO/CI.

C. checking the urine output.

The nurse is choosing the appropriate lead to monitor the patient's electrocardiogram rhythm. For which patient would lead II be the most appropriate lead? A. A postintervention recovery patient after a stent placement for a lateral infarct B. A patient with a right bundle branch block C. A patient who is having supraventricular versus ventricular tachycardia D. A patient in atrial fibrillation

D. A patient in atrial fibrillation

Your patient develops mild tachypnea, a productive cough, and bronchial breath sounds in the right middle and lower lobes with auscultation. Percussion of the right lower chest reveals dullness. Their SPO2 is 92% on 7 L oxymask. Which of the following interventions would be appropriate/indicated for this patient? A. Use of non-invasive mechanical ventilation B. Contact the provider for a bronchodilator C. Maintain the patient in the supine position D. Avoid turning the patient on their right side

D. Avoid turning the patient on their right side

Patients with acute renal failure also experience life-threatening electrolyte imbalances. One of those imbalances is retention of potassium related to decreased urine output. Which of the following describes an appropriate intervention and clinical reasoning for hyperkalemia? A. Glucose and insulin to promote higher excretion of potassium in the urine and Lokelma to drive potassium into the cells. B. Glucose and insulin bind with potassium, lowering available amounts and calcium gluconate for the protection of cardiac myocytes. C. Glucose and insulin force potassium out of the cells, lowering it on a cellular level. Albuterol for improvement of oxygenation. D. Glucose and insulin force potassium into the cells, lowering it on a serum level. Lokelma to bind potassium and aid in its excretion.

D. Glucose and insulin force potassium into the cells, lowering it on a serum level. Lokelma to bind potassium and aid in its excretion.

You are providing your night time care to your patient admitted with multiple fractures and back pain related to a collapsed vertebra. While providing care your patient becomes highly irritable with you and throws the emesis basin on the floor. While wiping their face, there appears to be hemifacial spasming unrelated to pain. You draw your nighttime labs, turn the bed alarm on, and lower the bed to its lowest position. You suspect the patient's labs might show what abnormality? A. Hypomagnesemia B. Hyponatremia C. Hyperkalemia D. Hypocalcemia

D. Hypocalcemia

Your are caring for a patient on a post surgical critical care floor. The patient is post-op 4 hours from a lung resection due to a small cell carcinoma of the lung. Your patients urine has decreased to 5mL per hour x 2 hours. You troubleshoot and draw labs. Which results from the labs would lead you to believe the patient is experiencing SIADH? A. Increased serum ADH, increased serum osmolality, decreased urine osmolality B. Increased serum ADH, decreased serum osmolality, decreased urine osmolality C. Decreased serum ADH, increased serum osmolality, decreased urine osmolality D. Increased serum ADH, decreased serum osmolality, increased urine osmolality

D. Increased serum ADH, decreased serum osmolality, increased urine osmolality

You were floated from your home unit (CCU) to the renal floor and given an admission slip from the charge nurse for a patient in the ED being assigned to your room. You review their chart and find laboratory results related to the patient's kidney function: Serum blood urea nitrogen, 64 mg/dL; serum creatinine, 2.4 mg/dL; urine osmolality, 210 mOsm/kg; specific gravity, 1.002; and urine sodium, 96 mEq/L. The patient's urine output has been 120 mL since admission 2 hours ago. You suspect that this patient is being admitted for a disease that is causing what kind of acute renal failure? A. Prerenal B. Postrenal C. Advanced D. Intrarenal

D. Intrarenal

What occurs when the delivery of oxygen to the tissues is insufficient enough to meet metabolic demand. A. Hypoxia B. Heart failure C. Shortness of breath D. Ischemia

D. Ischemia

Which laboratory value indicates a heightened risk for the development of coronary artery disease (CAD)? A. Total cholesterol level of 170 mg/dL B. Triglyceride level of 120 mg/dL C. HDL cholesterol level of 30 mg/dL D. LDL cholesterol level >190 mg/dL

D. LDL cholesterol level >190 mg/dL

Your are caring for a patient experiencing an acute on chronic COPD exacerbation. Your assessment of the lungs reveals crackles and wheezes can be heard in the lower lobes; he is tachycardic with and a bounding pulse. You assess oxygenation and ventilation with an ABG with the following results: pH 7.30, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60 mm Hg. What is your interpretation of this result? A. Partially compensated respiratory acidosis without hypoxemia B. Fully compensated respiratory acidosis C. Mixed acid-base disorder D. Partially compensated respiratory acidosis with hypoxemia E. Uncompensated metabolic alkalosis with hypoxemia F. Partially compensated metabolic acidosis without hypoxemia

D. Partially compensated respiratory acidosis with hypoxemia

You are walking past a room on your unit when you observe a patient that suddenly awakens from their sleep complaining of nausea and feeling light-headed. You notice that they are sweating and grabbing their chest. You assess for chest pain and they report it to be an 7/10. You administer sub-lingual nitroglycerin and assess the response. After 5 minutes the pain is not relieved. You suspect that this patient is experiencing what problem associated with acute coronary syndrome? A. Silent ischemia B. Stable angina C. Variant angina D. Unstable angina

D. Unstable angina

You are checking in on your patient that is being monitored with an arterial blood pressure line. You look up at the Phillips monitor and it appears that the arterial waveform has changed. The recommended method for assessing the adequacy of the catheter / tubing system is to: A. calibrate the Phillips monitor. B. check a cuff pressure. C. level and zero the transducer. D. perform a square wave test.

D. perform a square wave test.

Creation of an AV shunt in patients with severe pulmonary hypertension is a surgical intervention whose goal is aimed at: A. increasing volume to the left side of the heart to improve cardiac output / cardiac index. B. preventing clotting in the right ventricle by decreasing blood stasis. C. decreasing oxygen stores to the body by introducing de-oxygenated blood into the systemic circuit. D. relieving pressure in the right atrium as a result of increased volume backing up from the right ventricle.

D. relieving pressure in the right atrium as a result of increased volume backing up from the right ventricle.

A myocardial infarction of the inferior wall poses the greatest risk of heart failure and cardiogenic shock. True or False?

False

You just got done with an in-service about the treatment of asthma with epinephrine from your local pharmaceutical representative. You return to the ED when a 37 year-old female enters the ED complaining of shortness of breath and tells you that she was walking in the park when she suddenly felt she couldn't breath. Patient has a history of CAD, HLD, HTN, Asthma, and reports having seasonal allergies. Standard practice of care for the patient would be administration of oxygen, breathing treatments, and IM epinephrine. True or False?

False

Your patient asks you for a cup of water because they "need to take their medicine." You ask them what medicine they have that they wish to take. They explain that they need to take their metformin to control their blood glucose levels. Since they are alert and oriented, is ok for the patient to take their medication they brought from home. True or False?

False

For the purposes of this class and the NCLEX examination, pain is to be treated as a psychosocial event. True or False?

True

The difference between a second degree type I and a second degree type II AV block is the consistency of the PR-intervals. True or Flase?

True

Your patient is suffering from acute on chronic renal failure related to sepsis. Urine output has markedly dropped and your concerned about the kidney function. You understand that a creatinine clearance test is the most reliable and accurate estimate of glomerular filtration and kidney function? True or False?

True