AGACNP II - Test -2 Questions and Answers

AGACNP II - Test -2 Questions and Answers What is oxygenation determined by? (1) Partial pressure of oxygen in the alveoli (2) Condition of the alveolar capillary membrane (3) Hemoglobin (4) Cardiac output of the patient Oxygen consumption is the rate at which oxygen is _________ from the blood. removed Refers to the exchange of extra pulmonary and intra alveolar gas mixtures ventilation Insufficient oxygenation is called hypoxemia When using a nasal canula, each additional liter of flow increases the FiO2 by ____%. 4 When using a nasal canal, flow rates should be limited to ___L/min or less. 5 Works by preventing alveolar collapse during expiration CPAP Non-rebreathing masks can achieve oxygen concentrations of... 80-90% Works by supporting both inspiration and expiration; decreases the work of breathing BiPAP CPAP and BIPAP should be limited to patients who are... conscious, can cooperate and protect their airway How much pressure should initially be applied to CPAP? What increments can you increase it by? What should the max me? Initially 5 cm H2O increase by 3-5 cm H2O Max of 10-15 cm H2O Normal PaO2 in ABG 80-100 As a general rule, PaO2 should be ___-___x the percentage of O2. 4-5 PaO2/FiO2 ratio describes the degree of impairment in... pulmonary gas exchange Ventilation is reciprocally reflected by ... PaCO2 What are some absolute contraindications to an arterial line? Abnormal modified Allen's test Severe PVD Active Raynaud's What is a normal PaO2/FiO2 ratio? 300-500 SpO2 of 90% = PaO2 of 60 SPO2 of 75% = PaO2 of 40 SpO2 of 50% = PaO2 of 27 With alkalosis or hypothermia, the PaO2 may be _______ than predicted by the SpO2. lower With acidosis or hyperthermia, the PaO2 may be ______ than predicted by the SpO2 higher Idiopathic pulmonary fibrosis is strongly linked to... cigarette smoking If the amount of blood that collects is more than _______ cc, it is considered a massive hemothorax. 1500 What are some causes of hemothorax? (1) Trauma (2) Lung cancer (3) Complication of anticoagulation Factors that predispose patients to primary spontaneous pneumothorax? (1) Smoking (2) Family history (3) Marfan (4) Homocystinuria (5) Thoracic endometriosis The type of pneumothorax caused by ruptured air blisters is most likely to occur in people between what ages? 20-40 What kind of ABG will you see in a pneumothorax? Respiratory acidosis What kind of CXR view is best to visualize a pneumothorax? AP view taken on expiration What kind of test can you run on a suspected pneumothorax on a patient who needs to remain supine? US What are the "normal signs" during an ultrasound that would suggest a pneumothorax does not exist? (1) Sliding sign (2) Comet tails What is the gold standard for the diagnosis of a pneumothorax? Chest CT How do you manage a small primary spontaneous pneumothorax? Observation Serial CXRs Likely to reabsorb the air in 10-14 days How do you manage a tension pneumothorax? Rapid insertion of large bored needle into the second intercostal space, midclavicular line of the affected side How do you manage an open pneumothorax? Application of a three sided dressing leaving one side unsecured How do you manage a massive hemothorax? (1) Fluid resuscitation with LR (2) Chest tube What is thought to play a central role in idiopathic pulmonary fibrosis pathophysiology? (1) Pulmonary epithelial cell injury (2) Aberrant wound healing What is the most common cause of interstitial lung disease among elderly? IPF What lab value is beneficial in diagnosing IPF? antinuclear antibodies Exposure to what 4 things has also been shown to be a risk factor for IPF? stone metal wood organic dusts IPF has a sudden or gradual onset? Gradual Where would you find people who have been exposed to deep fungi such as Histoplasma capsulatum? Chicken coops in the midwest Where would you find people who have been exposed to Coccidioides immitis? Dust in the SW desert and Central Valley of California Which vaccinations should a person with IPF absolutely get? (1) Influenza (2) Pneumococcal What is the treatment for IPF? (1) Corticosteroids for 12 weeks (2) Immunosuppressive therapy with Cytoxan or imuran (3) Noninvasive use of positive airway pressure (4) Lung transplant ... ultimate therapy To test for IPF, what is safe and should be done first? Obtaining lung tissue via BAL (if clinically stable...get a open lung biopsy) Pulmonary hypertension is defined as an elevated mean pulmonary arterial pressure greater than _____ mm Hg at rest 25 Mortality rates for pulmonary hypertension are greatest in which types of people? African American women Pulmonary hypertension is most often due to... left heart disease or parenchymal lung disease What group Pulmonary Hypertension? -Pulmonary arterial hypertension -Idiopathic -Drugs , toxins -Familial -Schistosomiasis Group 1 What group Pulmonary Hypertension? -Left heart disease -Elevated pulmonary pressures due to a high left atrial pressure Group II What group Pulmonary Hypertension? -Associated with lung diseases or hypoxemia Group III What group Pulmonary Hypertension? -Due to chronic thrombotic and/or embolic disease? Group IV What group Pulmonary Hypertension? -Miscellaneous, hematologic and systemic disorders Group V What is the most common symptom you will see in patients with pulmonary hypertension? Dyspnea with exertion What cardiac sound might you hear in pulmonary hypertension? Split S2 Right sided failure is called... cor pulmonale What is your FIRST test when diagnosing pulmonary hypertension? Echo If a shunt is suspected, what test do you follow up with? TEE What will CONFIRM your diagnosis of pulmonary hypertension? Cardiac cath --Elevated mean pulmonary artery pressure Which WHO classification is characterized by... -No symptoms with exercise or rest -Usually patients that are being screened -Usually patients that have showed a response to therapy Class I Which WHO classification is characterized by... -No symptoms at rest -Uncomfortable and SOB with normal activity Class II Which WHO classification is characterized by... -May not have symptoms at rest, but activities GREATLY limited by SOB, fatigue, near fainting -Have to take breaks while doing ADLs Class III Which WHO classification is characterized by... -Symptoms at rest and severe symptoms with any activity Class IV Chronic __________________ improves survival, primary in idiopathic pulmonary hypertension anti-coagulation Warfarin is dosed to achieve an INR of what? 1.5-2.5 If polycythemia is severe, therapeutic phlebotomy should be considered to yield a goal hematocrit of what? 55% Pharmacological therapy is usually started for what WHO functional class? II, III, IV What class of medications are used in pulmonary hypertension? Prostanoids Prostacyclins Endothelin receptor antagonists What is a commonly under recognized cause of PH in the elderly? Heart failure with preserved EF If you decide to intubate your patient with a pneumothorax, what would you have for settings: PEEP: Pressure support: Tidal volume: PEEP: 5 Pressure support: 10 Tidal volume: 6 ml/kg An embolus is considered massive if... more than 50% of the blood flow is obstructed What is hemodynamically unstable PE? Hypotension 90 mmHg or Drop in SBP 40 mmHg for more than 15 minutes or Hypotension that requires pressers What are the WELLS criteria? Clinical signs Alternative diagnosis less likely Previous PE/DVT Surgery/immobilizzation Heart rate above 100 active cancer hemopytsis There is a higher case of PE in what population of patients Men African Americans What is Virchow's Triad? Venous stasis Endothelial injury Hypercoagulability DVT in the _____ and ______ leads to 70% of pulmonary embolisms lower extremity pelvis Acute PE occurs... immediately after obstruction of the pulmonary vessels Sub acute PE occurs... days/weeks after the initial event What is the most common symptom in PE? Dyspnea What kind of ABG will you see on someone with a PE? Respiratory alkalosis What lab value is usually obtained if DVT and PE are suspected? D dimer Which test has good accuracy for the detection of larger PEs but it has a lower sensitivity for detecting small emboli Chest CT What is the gold standard for diagnosis of PE? Pulmonary angiography PE that lodges at the bifurcation of the main pulmonary artery saddle When a patient presents with suspected acute pulmonary embolism, initial therapy should focus on what? -oxygenating -stabilizing How is Heparin administered for VTE? Initial bolus of 80 units/kg followed by a continuous infusion of 18 units/kg What do you want your PTT to be? 2-2.5 times the control What is the dosage for Enoxaparin/Lovenox 1 mg/kg subQ every 12 hours What is the first dose of Warfarin? 5-10 mg Adequate oral anticoagulation with coumadin is... 2-2.5 for at least 2-3 days What is the length of treatment for Warfarin? 3-6 months for the initial PE