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A patient has had a large anterior myocardial infarction last month and developed a ventricular aneurysm. He now has episodes of ventricular tachycardia that are not prevented or converted with antidy... srhythmic agents. An implantable cardioverter-defibrillator (ICD) is implanted. Four days after surgery he develops ventricular tachycardia. The ICD has delivered three shocks but has not converted the rhythm. He is pulseless and apneic. Cardiopulmonary resuscitation is in progress. What is the priority action now? A. Administer epinephrine IV. B. Administer amiodarone. C. Defibrillate. D. Reset the ICD. - ✔✔Defibrillate A 28-year-old woman is admitted to the critical care unit from the emergency department with a diagnosis of asthma. Her initial arterial blood gases on a 28% Venturi mask are as follows: pH 7.48 PaCO2 30 mm Hg HCO3 24 mEq/L PaO2 64 mm Hg Which of the following repeat arterial blood gases on 40% oxygen indicate that the patient's condition is worsening? A. pH 7.48, PaCO2 30 mm Hg, PaO2 68 mm Hg B. pH 7.46, PaCO2 32 mm Hg, PaO2 61 mm Hg C. pH 7.40, PaCO2 40 mm Hg, PaO2 62 mm Hg D. pH 7.39, PaCO2 30 mm Hg, PaO2 60 mm Hg - ✔✔C. pH 7.40, PaCO2 40 mm Hg, PaO2 62 mm Hg The case study shows stage II asthma. Option c shows stage III asthma. The patient is still breathing at a fast rate, but carbon dioxide is starting to be retained as evidenced by the increase of the PaCO2 into normal range. Options a and b are still stage II. Option d shows a respiratory alkalosis with a metabolic acidosis because you would have expected the pH to be in an alkalotic range with the PaCO2 of 30. A patient experiencing alcohol withdrawal syndrome describes the swirls in the wallpaper as being worms. This is an example of which of the following? A. Delusion B. Hallucination C. Illusion D. Visual impairment - ✔✔C. Illusion An illusion is a misperception or misinterpretation of an actual external stimulus. Illusions and hallucinations (a perception that has no actual external stimulus) are common during alcohol withdrawal syndrome. A patient arrives in the emergency department with multiple gunshot wounds. He requires massive transfusion for blood loss from chest and abdominal wounds. The electrocardiogram should be observed closely for changes indicative of which of the following? A. Atrioventricular block B. Hyperkalemia C. Hypercalcemia D. Hypomagnesemia - ✔✔Hyperkalemia Banked blood is high in potassium because of hemolysis. Look for tall, peaked T waves and widening of the QRS complex. Other considerations with massive transfusion of banked blood are hypocalcemia, hypothermia, and decreased tissue oxygen delivery caused by decreased levels of 2,3-diphosphoglycerate. A 65-year-old woman reports severe dyspnea 2 days after abdominal surgery. She is transferred to the critical care unit. On 5 L of oxygen by nasal cannula, her arterial blood gases are as follows: pH 7.39 PaCO2 35 mm Hg HCO3 19 mEq/L PaO2 40 mm Hg Arterial oxygen saturation 75% Why does this patient have hypoxemia without hypercapnia? A. Because carbon dioxide is more diffusible than oxygen B. Because carbon dioxide has more driving pressure C. Because carbon dioxide is less diffusible than oxygen D. Because carbon dioxide excretion by the kidney is increased - ✔✔Because carbon dioxide is more diffusible than oxygen Carbon dioxide is 20 times more diffusible than oxygen. In conditions that affect diffusion but do not affect ventilation, expect the PaO2 to be decreased and the PaCO2 to be normal (or decreased in hyperventilation, as in this patient). If ventilation were affected, such as if this patient were fatiguing, the PaCO2 then would increase. Driving pressure is the fraction of the gas in inspired air multiplied by the barometric pressure. Because carbon dioxide is ~0.5% of inspired air, the driving pressure would be very low. The kidney eliminates bicarbonate and hydrogen ions, but the lungs eliminate carbon dioxide. A 55-year-old patient has headache, nuchal rigidity, photophobia, and positive Kernig's and Brudzinski's signs. These are consistent with which of the following? A. Intracranial hemorrhage B. Subarachnoid hemorrhage C. Epidural hemorrhage D. Subdural hemorrhage - ✔✔Subarachnoid hemorrhage When there is bleeding from an aneurysm, that blood irritates the meninges. The clinical presentation is very similar to meningitis. This clinical presentation is not consistent with intracranial, epidural, or subdural bleeding because the blood is not in contact with the meninges in those situations. An extra heart sound preceding S1 is most likely an S4 if the stethoscope's: A. diaphragm is over the apex. B. bell is over the aortic area. C. diaphragm is over the aortic area. D. bell is over the apex. - ✔✔bell is over the apex. S3 and S4 are low pitched, so choose options with the bell being used. S3 and S4 are heard at the mitral area (i.e., apex) unless the right ventricular is affected, and then they are heard in the tricuspid area. Low-Pitched is best heard with Bell The charge nurse on the 7 pm to 7 am shift was asked to assist a group of nurses to resolve their conflict so that their two opposing goals are discarded and new goals are adopted. This is an example of which of the following? A. Smoothing of conflict B. Facilitating collaboration C. Encouraging compromise D. Democratic approach - ✔✔Facilitating collaboration This is an example of facilitating collaboration. The nurse is, in essence, acting as mediator to assist these two groups in developing common goals. In smoothing, you would try to reduce the emotional stress of the conflict, but the conflict really would not get resolved. In compromising, each group would give up something that it wants. In a democratic approach, majority rules. Which of the following are the most clinically significant intracranial pressure (ICP) waveforms that require immediate intervention? A. A waves B. B waves C. C waves D. D waves - ✔✔A waves, or plateau waves, are spontaneous, rapid increases in pressure between 50 and 200 mm Hg that last 5 minutes or more. A waves cause cerebral ischemia and are the most clinically significant ICP waveforms. Immediate intervention is necessary to prevent further brain injury and herniation. A waves are Awful Which of the following diagnostic tests would provide definitive evidence of a pneumothorax? A. Arterial blood gases B. Chest x-ray film C. Pulmonary function studies D. Spiral computed tomography - ✔✔Chest x-ray film (Which is not really true.. but the test says so.. Which of the following does not shift the oxyhemoglobin dissociation curve to the left or the right? A. Blood pH B. 2,3-diphosphoglycerate (2,3-DPG) levels C. Body temperature D. Cardiac output - ✔✔Cardiac output Body temperature, body pH, PaCO2 levels, and 2,3-DPG levels affect the oxyhemoglobin dissociation curve. Cardiac output does not directly affect the curve. Which of the following is the primary difference between a tracheostomy tube and a laryngectomy tube? A. The laryngectomy tube is longer. B. The laryngectomy tube does not have a cuff. C. Only the tracheostomy tube has an inner cannula. D. The tracheostomy tube has a larger lumen. - ✔✔The laryngectomy tube does not have a cuff. A cuff is not necessary because food and fluid from the mouth can go only to the esophagus and the stomach, and air going into the laryngectomy tube can go only into the lungs. The only way this patient can aspirate is if a fistula develops because the anatomy has been surgically altered by removal of the larynx. The mean QRS axis of ventricular tachycardia is most likely to be: A. normal or left axis deviation. B. right axis deviation or indeterminate axis. C. right axis deviation or left axis deviation. D. left axis deviation or indeterminate axis. - ✔✔left axis deviation or indeterminate axis. Ventricular tachycardia is most likely to be left axis deviation of −30 or greater or indeterminate axis, whereas aberrancy is more likely to be normal axis or right axis deviation. A 58-year-old man is admitted to the critical care unit with upper gastrointestinal bleeding. He has a history of chronic renal failure. When one is administering antacids, it is important to remember to avoid: A. magnesium-containing antacids. B. phosphate-binding antacids. C. calcium-containing antacids. D. histamine2 receptor antagonists. - ✔✔magnesium-containing antacids. Magnesium-containing antacids can lead to magnesium intoxication in the patient with renal failure. A patient is complaining of dull, diffuse abdominal pain. Of the following possible causes, which is most likely to be the cause? A. Appendicitis B. Cholecystitis C. Ulcerative colitis D. Large intestinal obstruction - ✔✔Large intestinal obstruction The rest are sharp pain Vt for extubation - ✔✔5ml/kg A 30-year-old man is in the surgical intensive care unit after exploratory laparotomy performed after he sustained a gunshot wound to the abdomen. He now has developed a pancreatic fistula. Which acid-base imbalance is this patient at risk for developing? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis - ✔✔Metabolic acidosis The stomach is acidic, but the gastrointestinal tract below the stomach is alkaline. Pancreatic secretions are rich in bicarbonate, and these losses would cause metabolic acidosis. A 65-year-old man was admitted 2 hours ago after coronary artery bypass grafting. He has had the following vital sign changes: Admission 2 Hours Later Blood pressure (mm Hg) 110/80 96/76 Heart rate (per minute) 85 100 Right atrial pressure (RAP; mm Hg) 6 2 Pulmonary artery pressure (PAP; mm Hg) 24/12 18/6 Pulmonary artery occlusive pressure (PAOP; mm Hg) 10 5 Cardiac output (L/min) 6 4 Cardiac index (L/min/m2) 3.5 2.5 Systemic vascular resistance index (SVRI; dynes/sec/cm−5) 1920 2590 What is the most likely cause of these changes? A. Stunned myocardium B. Blood loss C. Cardiac tamponade D. Intraoperative myocardial infarction - ✔✔Blood loss Note that all of the volume indicators (RAP, PAP, PAOP) have decreased. The increase in SVRI is compensatory and is caused by sympathetic nervous system stimulation. Stunned myocardium and intraoperative myocardial infarction more likely would cause an increase in PAOP because of heart failure. Cardiac tamponade would cause an increase in RAP, PAP, and PAOP. Provision of adequate nutrition in a malnourished patient may cause severe deficiency of which of the following electrolytes? A. Potassium B. Magnesium C. Calcium D. Phosphate - ✔✔Phosphate This often is called refeeding syndrome. Nutritional support allows the cells to begin making more adenosine triphosphate (ATP), and phosphate supplies are depleted. The same thing happens in diabetic ketoacidosis with treatment when insulin allows glucose to move into the cell increasing production of ATP and depletion of phosphate. Which of the following would be a contraindication to the use of fibrinolytic drugs, such as recombinant tissue plasminogen activator? A. [Show More]

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