Keiser University
Course Code: NUR2230C
Course Title: Advanced Adult Healthcare
Credit Hours:8.0
Exam: Final Exam
Date:2026
A 58-year-old man with a 30-year history of alcohol use disorder is admitted with
hematemesis. Upper endoscopy confirms bleeding esophageal varices. His blood pressure is
78/48 mmHg, HR 124 bpm, and hemoglobin is 6.2 g/dL. After initial resuscitation, the
intensivist orders octreotide infusion, ceftriaxone, and urgent endoscopic band ligation. The
nurse correctly understands that ceftriaxone is administered prophylactically in this patient
primarily because:
A. Esophageal varices are caused by bacterial overgrowth and require antibiotics as first-line
treatment B. Cirrhotic patients with upper GI bleeding have a 20-50% risk of bacterial infection
and spontaneous bacterial peritonitis, and antibiotic prophylaxis reduces mortality and rebleeding
risk C. Ceftriaxone prevents aspiration pneumonia from the blood pooled in the stomach D.
Antibiotics are required before endoscopy to prevent endocarditis in all cirrhotic patients
Correct Answer: B
Rationale: In cirrhotic patients, upper gastrointestinal bleeding triggers a cascade of
pathophysiological events that dramatically increase infection risk. Bacterial translocation from
the gut (where cirrhosis disrupts mucosal integrity and immune surveillance), combined with
impaired hepatic reticuloendothelial function and altered gut motility from blood in the lumen,
creates conditions highly favorable for spontaneous bacterial peritonitis (SBP), bacteremia, and
urinary tract infections. Evidence from multiple randomized controlled trials and meta-analyses
demonstrates that short-term antibiotic prophylaxis (ceftriaxone 1 g IV daily for 7 days is now
preferred in advanced cirrhosis) significantly reduces bacterial infection rates, early rebleeding,
and 30-day mortality. This is a Class I recommendation in all major hepatology guidelines. The
nurse must also understand that octreotide reduces splanchnic blood flow by inhibiting
vasodilatory hormones, lowering portal pressure and variceal bleeding.
A 44-year-old woman with systemic sclerosis (scleroderma) presents to the rheumatology
clinic reporting increasing dyspnea on exertion over the past three months, with a recent six-
minute walk distance of only 280 meters. Her echocardiogram shows an estimated right
ventricular systolic pressure (RVSP) of 58 mmHg and tricuspid regurgitation. Right heart
catheterization confirms mean pulmonary arterial pressure of 38 mmHg and pulmonary
vascular resistance of 6 Wood units. The nurse understands this patient has developed:
A. Left heart failure with pulmonary venous hypertension requiring diuresis B. Pulmonary arterial
1
,hypertension (PAH) classified as Group 1 WHO, requiring targeted vasodilator therapy C.
Pulmonary hypertension from interstitial lung disease classified as Group 3 WHO D. Chronic
thromboembolic pulmonary hypertension (CTEPH) requiring anticoagulation alone
Correct Answer: B
Rationale: Pulmonary arterial hypertension is defined by right heart catheterization as mean
pulmonary arterial pressure (mPAP) greater than 20 mmHg, pulmonary arterial wedge pressure
(PAWP) less than or equal to 15 mmHg, and pulmonary vascular resistance (PVR) greater than 3
Wood units. Scleroderma (systemic sclerosis) is one of the most common connective tissue diseases
causing PAH, affecting up to 15% of patients. PAH from connective tissue disease is classified as
WHO Group 1, sharing the same pathobiological mechanisms (endothelial dysfunction, smooth
muscle proliferation, vasoconstriction) as idiopathic PAH. Treatment targets three pathways: the
endothelin pathway (bosentan, ambrisentan), the nitric oxide/cGMP pathway (sildenafil,
riociguat), and the prostacyclin pathway (epoprostenol, treprostinil). The nurse must educate this
patient that scleroderma-PAH carries worse prognosis than idiopathic PAH and requires annual
screening echocardiography.
A 67-year-old man with a 15-year history of type 2 diabetes is admitted with acute-onset
flank pain, rigors, and a temperature of 39.8°C. Urinalysis shows 3+ nitrites, 4+ leukocyte
esterase, and WBC casts on microscopy. His blood cultures are pending. CT abdomen shows
perinephric stranding and a 2 cm gas collection within the left renal parenchyma. The nurse
recognizes this CT finding as diagnostic of:
A. Renal cell carcinoma with central necrosis B. Emphysematous pyelonephritis, a life-threatening
necrotizing infection requiring emergency surgical consultation C. Uncomplicated acute
pyelonephritis manageable with oral antibiotics D. Renal abscess requiring CT-guided
percutaneous drainage alone
Correct Answer: B
Rationale: Emphysematous pyelonephritis (EPN) is a rare, life-threatening necrotizing infection of
the renal parenchyma characterized by gas formation within the kidney, collecting system, or
perinephric space, caused by gas-forming organisms (predominantly E. coli, Klebsiella
pneumoniae) fermenting glucose in the diabetic microenvironment. It occurs almost exclusively in
patients with poorly controlled diabetes mellitus (90% of cases) or urinary tract obstruction. CT
imaging is diagnostic and essential for classification. Class 1-2 EPN (gas in collecting system or
parenchyma without extension) may be managed with aggressive IV antibiotics and percutaneous
drainage; Class 3-4 EPN (bilateral, perinephric extension, or bilateral involvement) carries
mortality rates of 50-80% and typically requires emergency nephrectomy. This patient requires
immediate broad-spectrum IV antibiotics, urgent urological surgical consultation, and ICU-level
monitoring.
A 71-year-old woman with a mechanical mitral valve replacement on warfarin (target INR
2.5-3.5) is scheduled for elective colectomy in 5 days. The surgical team plans to bridge her
anticoagulation. The nurse correctly understands the bridging anticoagulation protocol as:
A. Stopping warfarin 5 days before surgery and starting unfractionated heparin infusion
immediately, continuing until 1 hour before the procedure B. Stopping warfarin 5 days
preoperatively, initiating therapeutic LMWH when INR falls below 2.0, holding the last LMWH
dose 24 hours before surgery, and resuming anticoagulation postoperatively when hemostasis is
assured C. Continuing warfarin at half the dose throughout the perioperative period without any
bridging requirement D. Stopping warfarin only 24 hours before surgery because mechanical
valves require continuous anticoagulation at all times
Correct Answer: B
Rationale: Mechanical heart valves, particularly mitral position valves, carry the highest
2
,thromboembolic risk of any indication for anticoagulation (annual stroke risk up to 22% without
anticoagulation). Warfarin is stopped approximately 5 days preoperatively to allow INR to fall
below 1.5, the threshold considered safe for most surgical procedures. As the INR drops below 2.0
(typically 2-3 days before surgery), therapeutic-dose LMWH (e.g., enoxaparin 1 mg/kg twice daily)
is initiated as bridging anticoagulation to minimize the period of subtherapeutic anticoagulation.
The last dose of LMWH is held 24 hours before surgery (24 hours for BID dosing to allow
approximately 4 half-lives of clearance, reducing anti-Xa activity to safe levels). Warfarin is
typically resumed 12-24 hours postoperatively when surgical hemostasis is confirmed, and LMWH
continues until INR re-enters therapeutic range. The nurse plays a critical role in patient
education, adherence monitoring, and coordinating care between surgical and anticoagulation
teams.
A 52-year-old woman with metastatic breast cancer receiving her third cycle of doxorubicin-
cyclophosphamide chemotherapy presents to the oncology clinic on day 12 post-cycle with
temperature of 38.6°C, HR of 108 bpm, and absolute neutrophil count (ANC) of 320
cells/mcL. She has a right-sided subclavian port-a-cath in place. After blood cultures are
drawn peripherally and from the port, the nurse prepares to administer which intervention
as the highest priority?
A. Granulocyte colony-stimulating factor (G-CSF) subcutaneously to raise the neutrophil count
before starting antibiotics B. Broad-spectrum empirical IV antibiotics (piperacillin-tazobactam or
cefepime) within 60 minutes of presentation, consistent with febrile neutropenia protocols C. Oral
ciprofloxacin and discharge home with instructions to return if fever persists beyond 72 hours D.
Acetaminophen for fever reduction and reassessment after 4 hours before making antibiotic
decisions
Correct Answer: B
Rationale: Febrile neutropenia (ANC less than 500 cells/mcL or less than 1,000 cells/mcL with
predicted decline, plus fever greater than 38.3°C or two readings greater than 38.0°C) is an
oncological emergency with mortality rates that increase dramatically with each hour of antibiotic
delay. IDSA, NCCN, and ASCO guidelines mandate broad-spectrum empirical IV antibiotics
within 60 minutes of triage, targeting gram-negative organisms including Pseudomonas
aeruginosa. Anti-pseudomonal agents (piperacillin-tazobactam, cefepime, meropenem) are the
backbone of therapy. Vancomycin is added if there is hemodynamic instability, suspected central
line infection (which this patient with a port-a-cath is at risk for), or if gram-positive coverage is
otherwise clinically indicated. Delayed antibiotic administration, use of oral agents alone, or fever
reduction strategies before initiating antibiotics are associated with significantly increased
mortality in this population. Blood cultures from both peripheral sites and the central line are
critical for source identification.
A 63-year-old man with nonischemic dilated cardiomyopathy (ejection fraction 22%)
undergoes placement of a left ventricular assist device (LVAD) as destination therapy. Three
weeks post-implant, his family reports he has become acutely confused, has right-sided arm
weakness, and cannot speak clearly. His LVAD flow alarms show no abnormalities. The
nurse's immediate priority assessment and intervention is:
A. Check LVAD controller and battery connections as device malfunction is the most likely cause
of neurological symptoms B. Perform rapid neurological assessment using NIH Stroke Scale,
obtain emergency non-contrast CT head, check INR immediately, and activate stroke protocol C.
Reassure the family that confusion is expected in the early post-LVAD period due to hemodynamic
adjustment D. Administer IV lorazepam in case the patient is having a seizure from electrolyte
imbalances
Correct Answer: B
3
, Rationale: LVAD patients are at significantly elevated risk for both ischemic stroke (from thrombus
formation in the device or pump, inadequate anticoagulation) and hemorrhagic stroke (from
supratherapeutic anticoagulation or LVAD-associated acquired von Willebrand syndrome).
Neurological complications are the second most common cause of morbidity and mortality in
LVAD patients. Any acute neurological change must be treated as a stroke emergency. Immediate
non-contrast CT head differentiates ischemic from hemorrhagic stroke, which is critical because
management is diametrically opposed: ischemic stroke may require thrombolytics or
thrombectomy (with careful risk-benefit analysis given anticoagulation status), while hemorrhagic
stroke requires anticoagulation reversal (life-threatening in an LVAD patient who may thrombose
the device). The INR must be checked immediately. The stroke team, cardiac surgery, and
neurology must be simultaneously activated. This patient's INR may be supratherapeutic or
subtherapeutic, either causing hemorrhage or thromboembolism.
A 49-year-old woman with known Crohn's disease for 22 years is admitted with a high-
output enterocutaneous fistula draining 1,200 mL/day from a wound in her right lower
quadrant. She has lost 9 kg over the past 6 weeks. Her albumin is 2.1 g/dL, prealbumin is 8
mg/dL (normal 15-36 mg/dL), and C-reactive protein is markedly elevated. The nutrition
team recommends initiating parenteral nutrition (PN). The nurse monitoring this patient
after PN initiation must be most vigilant for:
A. Hyperglycemia from the glucose load in PN and hypophosphatemia from refeeding syndrome in
a severely malnourished patient B. Weight gain from excess fluid and protein in the PN
formulation as the primary concern C. Catheter occlusion as the only significant complication
unique to parenteral nutrition D. Hypoglycemia from excess insulin secreted in response to the
glucose infusion
Correct Answer: A
Rationale: Two critical metabolic complications dominate PN monitoring in severely malnourished
patients. First, PN formulations contain high concentrations of dextrose (150-350 g/day), requiring
the pancreas to rapidly increase insulin secretion; hyperglycemia (target blood glucose 140-180
mg/dL in critically ill patients) causes increased infection risk, poor wound healing, and osmotic
complications. Second, and more acutely dangerous, is refeeding syndrome. After prolonged
starvation, intracellular electrolytes (phosphate, potassium, magnesium) are depleted while serum
levels remain falsely normal. When carbohydrate reintroduction triggers insulin release, glucose-
driven cellular uptake of these electrolytes causes precipitous drops in serum levels within 24-72
hours. Severe hypophosphatemia (less than 1.0 mg/dL) is the hallmark of refeeding syndrome,
causing respiratory failure (impaired diaphragmatic function), cardiac arrhythmias, hemolytic
anemia, and rhabdomyolysis. Electrolytes must be checked daily, PN initiated at 25-50% of goal
rate and advanced cautiously, with aggressive electrolyte replacement.
A 77-year-old man with advanced chronic kidney disease (eGFR 11 mL/min/1.73m²) who has
declined dialysis is admitted with hyperkalemia of 7.1 mEq/L. His ECG shows absent P
waves, wide QRS complexes, and tall peaked T waves. The nurse prepares multiple
interventions. Which intervention acts most rapidly to protect the myocardium and should be
administered first?
A. Sodium polystyrene sulfonate (Kayexalate) orally or rectally B. Sodium bicarbonate 8.4% IV
infusion C. Calcium gluconate 10% solution 10-20 mL IV over 2-5 minutes D. Regular insulin 10
units IV with 50 mL of 50% dextrose
Correct Answer: C
Rationale: Managing life-threatening hyperkalemia requires understanding the distinct temporal
profiles of available interventions. Calcium gluconate (or calcium chloride) does not lower serum
potassium but acts within 1-3 minutes to stabilize the cardiac membrane by raising the threshold
4
Course Code: NUR2230C
Course Title: Advanced Adult Healthcare
Credit Hours:8.0
Exam: Final Exam
Date:2026
A 58-year-old man with a 30-year history of alcohol use disorder is admitted with
hematemesis. Upper endoscopy confirms bleeding esophageal varices. His blood pressure is
78/48 mmHg, HR 124 bpm, and hemoglobin is 6.2 g/dL. After initial resuscitation, the
intensivist orders octreotide infusion, ceftriaxone, and urgent endoscopic band ligation. The
nurse correctly understands that ceftriaxone is administered prophylactically in this patient
primarily because:
A. Esophageal varices are caused by bacterial overgrowth and require antibiotics as first-line
treatment B. Cirrhotic patients with upper GI bleeding have a 20-50% risk of bacterial infection
and spontaneous bacterial peritonitis, and antibiotic prophylaxis reduces mortality and rebleeding
risk C. Ceftriaxone prevents aspiration pneumonia from the blood pooled in the stomach D.
Antibiotics are required before endoscopy to prevent endocarditis in all cirrhotic patients
Correct Answer: B
Rationale: In cirrhotic patients, upper gastrointestinal bleeding triggers a cascade of
pathophysiological events that dramatically increase infection risk. Bacterial translocation from
the gut (where cirrhosis disrupts mucosal integrity and immune surveillance), combined with
impaired hepatic reticuloendothelial function and altered gut motility from blood in the lumen,
creates conditions highly favorable for spontaneous bacterial peritonitis (SBP), bacteremia, and
urinary tract infections. Evidence from multiple randomized controlled trials and meta-analyses
demonstrates that short-term antibiotic prophylaxis (ceftriaxone 1 g IV daily for 7 days is now
preferred in advanced cirrhosis) significantly reduces bacterial infection rates, early rebleeding,
and 30-day mortality. This is a Class I recommendation in all major hepatology guidelines. The
nurse must also understand that octreotide reduces splanchnic blood flow by inhibiting
vasodilatory hormones, lowering portal pressure and variceal bleeding.
A 44-year-old woman with systemic sclerosis (scleroderma) presents to the rheumatology
clinic reporting increasing dyspnea on exertion over the past three months, with a recent six-
minute walk distance of only 280 meters. Her echocardiogram shows an estimated right
ventricular systolic pressure (RVSP) of 58 mmHg and tricuspid regurgitation. Right heart
catheterization confirms mean pulmonary arterial pressure of 38 mmHg and pulmonary
vascular resistance of 6 Wood units. The nurse understands this patient has developed:
A. Left heart failure with pulmonary venous hypertension requiring diuresis B. Pulmonary arterial
1
,hypertension (PAH) classified as Group 1 WHO, requiring targeted vasodilator therapy C.
Pulmonary hypertension from interstitial lung disease classified as Group 3 WHO D. Chronic
thromboembolic pulmonary hypertension (CTEPH) requiring anticoagulation alone
Correct Answer: B
Rationale: Pulmonary arterial hypertension is defined by right heart catheterization as mean
pulmonary arterial pressure (mPAP) greater than 20 mmHg, pulmonary arterial wedge pressure
(PAWP) less than or equal to 15 mmHg, and pulmonary vascular resistance (PVR) greater than 3
Wood units. Scleroderma (systemic sclerosis) is one of the most common connective tissue diseases
causing PAH, affecting up to 15% of patients. PAH from connective tissue disease is classified as
WHO Group 1, sharing the same pathobiological mechanisms (endothelial dysfunction, smooth
muscle proliferation, vasoconstriction) as idiopathic PAH. Treatment targets three pathways: the
endothelin pathway (bosentan, ambrisentan), the nitric oxide/cGMP pathway (sildenafil,
riociguat), and the prostacyclin pathway (epoprostenol, treprostinil). The nurse must educate this
patient that scleroderma-PAH carries worse prognosis than idiopathic PAH and requires annual
screening echocardiography.
A 67-year-old man with a 15-year history of type 2 diabetes is admitted with acute-onset
flank pain, rigors, and a temperature of 39.8°C. Urinalysis shows 3+ nitrites, 4+ leukocyte
esterase, and WBC casts on microscopy. His blood cultures are pending. CT abdomen shows
perinephric stranding and a 2 cm gas collection within the left renal parenchyma. The nurse
recognizes this CT finding as diagnostic of:
A. Renal cell carcinoma with central necrosis B. Emphysematous pyelonephritis, a life-threatening
necrotizing infection requiring emergency surgical consultation C. Uncomplicated acute
pyelonephritis manageable with oral antibiotics D. Renal abscess requiring CT-guided
percutaneous drainage alone
Correct Answer: B
Rationale: Emphysematous pyelonephritis (EPN) is a rare, life-threatening necrotizing infection of
the renal parenchyma characterized by gas formation within the kidney, collecting system, or
perinephric space, caused by gas-forming organisms (predominantly E. coli, Klebsiella
pneumoniae) fermenting glucose in the diabetic microenvironment. It occurs almost exclusively in
patients with poorly controlled diabetes mellitus (90% of cases) or urinary tract obstruction. CT
imaging is diagnostic and essential for classification. Class 1-2 EPN (gas in collecting system or
parenchyma without extension) may be managed with aggressive IV antibiotics and percutaneous
drainage; Class 3-4 EPN (bilateral, perinephric extension, or bilateral involvement) carries
mortality rates of 50-80% and typically requires emergency nephrectomy. This patient requires
immediate broad-spectrum IV antibiotics, urgent urological surgical consultation, and ICU-level
monitoring.
A 71-year-old woman with a mechanical mitral valve replacement on warfarin (target INR
2.5-3.5) is scheduled for elective colectomy in 5 days. The surgical team plans to bridge her
anticoagulation. The nurse correctly understands the bridging anticoagulation protocol as:
A. Stopping warfarin 5 days before surgery and starting unfractionated heparin infusion
immediately, continuing until 1 hour before the procedure B. Stopping warfarin 5 days
preoperatively, initiating therapeutic LMWH when INR falls below 2.0, holding the last LMWH
dose 24 hours before surgery, and resuming anticoagulation postoperatively when hemostasis is
assured C. Continuing warfarin at half the dose throughout the perioperative period without any
bridging requirement D. Stopping warfarin only 24 hours before surgery because mechanical
valves require continuous anticoagulation at all times
Correct Answer: B
Rationale: Mechanical heart valves, particularly mitral position valves, carry the highest
2
,thromboembolic risk of any indication for anticoagulation (annual stroke risk up to 22% without
anticoagulation). Warfarin is stopped approximately 5 days preoperatively to allow INR to fall
below 1.5, the threshold considered safe for most surgical procedures. As the INR drops below 2.0
(typically 2-3 days before surgery), therapeutic-dose LMWH (e.g., enoxaparin 1 mg/kg twice daily)
is initiated as bridging anticoagulation to minimize the period of subtherapeutic anticoagulation.
The last dose of LMWH is held 24 hours before surgery (24 hours for BID dosing to allow
approximately 4 half-lives of clearance, reducing anti-Xa activity to safe levels). Warfarin is
typically resumed 12-24 hours postoperatively when surgical hemostasis is confirmed, and LMWH
continues until INR re-enters therapeutic range. The nurse plays a critical role in patient
education, adherence monitoring, and coordinating care between surgical and anticoagulation
teams.
A 52-year-old woman with metastatic breast cancer receiving her third cycle of doxorubicin-
cyclophosphamide chemotherapy presents to the oncology clinic on day 12 post-cycle with
temperature of 38.6°C, HR of 108 bpm, and absolute neutrophil count (ANC) of 320
cells/mcL. She has a right-sided subclavian port-a-cath in place. After blood cultures are
drawn peripherally and from the port, the nurse prepares to administer which intervention
as the highest priority?
A. Granulocyte colony-stimulating factor (G-CSF) subcutaneously to raise the neutrophil count
before starting antibiotics B. Broad-spectrum empirical IV antibiotics (piperacillin-tazobactam or
cefepime) within 60 minutes of presentation, consistent with febrile neutropenia protocols C. Oral
ciprofloxacin and discharge home with instructions to return if fever persists beyond 72 hours D.
Acetaminophen for fever reduction and reassessment after 4 hours before making antibiotic
decisions
Correct Answer: B
Rationale: Febrile neutropenia (ANC less than 500 cells/mcL or less than 1,000 cells/mcL with
predicted decline, plus fever greater than 38.3°C or two readings greater than 38.0°C) is an
oncological emergency with mortality rates that increase dramatically with each hour of antibiotic
delay. IDSA, NCCN, and ASCO guidelines mandate broad-spectrum empirical IV antibiotics
within 60 minutes of triage, targeting gram-negative organisms including Pseudomonas
aeruginosa. Anti-pseudomonal agents (piperacillin-tazobactam, cefepime, meropenem) are the
backbone of therapy. Vancomycin is added if there is hemodynamic instability, suspected central
line infection (which this patient with a port-a-cath is at risk for), or if gram-positive coverage is
otherwise clinically indicated. Delayed antibiotic administration, use of oral agents alone, or fever
reduction strategies before initiating antibiotics are associated with significantly increased
mortality in this population. Blood cultures from both peripheral sites and the central line are
critical for source identification.
A 63-year-old man with nonischemic dilated cardiomyopathy (ejection fraction 22%)
undergoes placement of a left ventricular assist device (LVAD) as destination therapy. Three
weeks post-implant, his family reports he has become acutely confused, has right-sided arm
weakness, and cannot speak clearly. His LVAD flow alarms show no abnormalities. The
nurse's immediate priority assessment and intervention is:
A. Check LVAD controller and battery connections as device malfunction is the most likely cause
of neurological symptoms B. Perform rapid neurological assessment using NIH Stroke Scale,
obtain emergency non-contrast CT head, check INR immediately, and activate stroke protocol C.
Reassure the family that confusion is expected in the early post-LVAD period due to hemodynamic
adjustment D. Administer IV lorazepam in case the patient is having a seizure from electrolyte
imbalances
Correct Answer: B
3
, Rationale: LVAD patients are at significantly elevated risk for both ischemic stroke (from thrombus
formation in the device or pump, inadequate anticoagulation) and hemorrhagic stroke (from
supratherapeutic anticoagulation or LVAD-associated acquired von Willebrand syndrome).
Neurological complications are the second most common cause of morbidity and mortality in
LVAD patients. Any acute neurological change must be treated as a stroke emergency. Immediate
non-contrast CT head differentiates ischemic from hemorrhagic stroke, which is critical because
management is diametrically opposed: ischemic stroke may require thrombolytics or
thrombectomy (with careful risk-benefit analysis given anticoagulation status), while hemorrhagic
stroke requires anticoagulation reversal (life-threatening in an LVAD patient who may thrombose
the device). The INR must be checked immediately. The stroke team, cardiac surgery, and
neurology must be simultaneously activated. This patient's INR may be supratherapeutic or
subtherapeutic, either causing hemorrhage or thromboembolism.
A 49-year-old woman with known Crohn's disease for 22 years is admitted with a high-
output enterocutaneous fistula draining 1,200 mL/day from a wound in her right lower
quadrant. She has lost 9 kg over the past 6 weeks. Her albumin is 2.1 g/dL, prealbumin is 8
mg/dL (normal 15-36 mg/dL), and C-reactive protein is markedly elevated. The nutrition
team recommends initiating parenteral nutrition (PN). The nurse monitoring this patient
after PN initiation must be most vigilant for:
A. Hyperglycemia from the glucose load in PN and hypophosphatemia from refeeding syndrome in
a severely malnourished patient B. Weight gain from excess fluid and protein in the PN
formulation as the primary concern C. Catheter occlusion as the only significant complication
unique to parenteral nutrition D. Hypoglycemia from excess insulin secreted in response to the
glucose infusion
Correct Answer: A
Rationale: Two critical metabolic complications dominate PN monitoring in severely malnourished
patients. First, PN formulations contain high concentrations of dextrose (150-350 g/day), requiring
the pancreas to rapidly increase insulin secretion; hyperglycemia (target blood glucose 140-180
mg/dL in critically ill patients) causes increased infection risk, poor wound healing, and osmotic
complications. Second, and more acutely dangerous, is refeeding syndrome. After prolonged
starvation, intracellular electrolytes (phosphate, potassium, magnesium) are depleted while serum
levels remain falsely normal. When carbohydrate reintroduction triggers insulin release, glucose-
driven cellular uptake of these electrolytes causes precipitous drops in serum levels within 24-72
hours. Severe hypophosphatemia (less than 1.0 mg/dL) is the hallmark of refeeding syndrome,
causing respiratory failure (impaired diaphragmatic function), cardiac arrhythmias, hemolytic
anemia, and rhabdomyolysis. Electrolytes must be checked daily, PN initiated at 25-50% of goal
rate and advanced cautiously, with aggressive electrolyte replacement.
A 77-year-old man with advanced chronic kidney disease (eGFR 11 mL/min/1.73m²) who has
declined dialysis is admitted with hyperkalemia of 7.1 mEq/L. His ECG shows absent P
waves, wide QRS complexes, and tall peaked T waves. The nurse prepares multiple
interventions. Which intervention acts most rapidly to protect the myocardium and should be
administered first?
A. Sodium polystyrene sulfonate (Kayexalate) orally or rectally B. Sodium bicarbonate 8.4% IV
infusion C. Calcium gluconate 10% solution 10-20 mL IV over 2-5 minutes D. Regular insulin 10
units IV with 50 mL of 50% dextrose
Correct Answer: C
Rationale: Managing life-threatening hyperkalemia requires understanding the distinct temporal
profiles of available interventions. Calcium gluconate (or calcium chloride) does not lower serum
potassium but acts within 1-3 minutes to stabilize the cardiac membrane by raising the threshold
4
