BKAT Study Set 2023 with verified questions and answers

Normal blood gases; pH 7.35-7.45 Normal blood gases: CO2 35-45 Normal blood gases: HcO3 22-26 Normal blood gases: PO2 80 or above Normal vacuum pressures for suction? 120-140 mmHg What may a high pressure vent alarm indicate? Pt is biting on the tubing, excessive secretions in the tubing, kinked tubing What may a low pressure vent alarm indicate? cuff leak or the tubing is disconnected somewhere How do you verify positioning of an endotracheal tube? -auscultate lung bases and apices for bilateral breath sounds -observe chest for symmetric chest wall movement -confirm with end tidal CO2 measure GOLD STANDARD: chest x-ray t/f: people with ET tubes should be suctioned routinely FALSE-- they should be suctioned on an as needed basis what should ET tube cuff pressure be kept at? 20-25 mmHg What measures should nurses take to avoid ET tube problems? -confirm that exit mark on ET tube remains constant when providing patient care, repositioning, and transporting patient -maintain proper cuff inflation (listen for an air leak-- if pt can talk, you must inflate more) -continually monitor SpO2, RR, HR and rhythm, mental status, and ABGs -pre-oxygenate before suctioning What should be done if a patient is not tolerating ET tube suctioning? STOP and manually hyperventilate with 100% oxygen Measures to prevent aspiration? -avoid bolus tube feedings -monitor tube feeding residuals -maintain HOB at LEAST 30 degrees or greater -maintain proper ET tube cuff inflation -perform frequent oral pharyngeal suctioning -maintain an NG tube connected to low, intermittent suction if feeding tube is placed below the pylorus what are recommendations for preventing ventilator associated pneumonia? -manage ventilated patients without sedatives whenever possible -interrupt sedation once a day (spontaneous breathing trials) -provide early exercise and mobility -provide regular oral care -minimize pooling of secretions above the ET tube cuff -use ET tubes with subglottic secretion drainage for patients likely to require greater than 72 hours of intubation -keep HOB elevated 30-45 degress -change ventilator circuit only if visibly soiled or malfunctioning What is the biggest complication associated with high cervical spinal cord injuries? BREATHING-- the diaphragm is innervated by C3-C5 levels C4-diaphragm will likely need mechanical ventilation mgmt signs and symptoms of increased intracranial pressure? -altered LOC -headache -bradycardia -decreased respirations -acute HTN with widening pulse pressure -N/V -worsening neuro deficits -pupils that are nonreactive What are the components of a neuro exam? (7) 1. LOC 2. mental status and cognitive function 3. cranial nerves 4. motor 5. sensory 6. coordination 7. reflexes What are the three components of the glasgow coma scale? 1. eye opening 2. motor 3. verbal What is a negative and positive babinski reflex? what do each indicate? negative (normal) response: toes curl downward positive (pathologic) response= toes curl upward a positive babinski in adults indicates dysfunction in the motor pathways of the brain or spinal cord what is the initial dosing of tpa? -0.9 mg/kg -10% as a bolus over 1 minute and 90% as continuous infusion over 60 minutes What are the requirements for receiving tpa? -onset of stroke was within 3-4.5 hours -CT negative for bleed or lesion -glucose 50 During the thrombolytic infusion of tpa, neuros need to be assessed every ___ minutes 15 What are the frequency of neuro checks after receiving thrombolytic tpa infusion? -VS and neuro checks every 15 min for 1 hour -every 30 min for 6 hours -then every hour for 16 hours what are possible complications of rTPA? -signs of ICH or ICP -systemic bleeding (wait 6 hours before inserting devices like foleys, etc) -angioedema of airway for patients receiving rTPA or IA therapy, treat prn for SBP ____ mmHg or DBP ____ mmHG treat for SBP 180 or DBP 105 mmHG we want to manage hypertension!!! Acute mgmt measures for ischemic stroke patients? 1. aspirin within 24 hours 2. NS (Avoid hypotonic IV solutions) 3. blood glucose maintain less than or equal to 150 mg/dL 4. surgical consult 5. no indication for steroids or anticonvulsants 6. rehab (PT/OT/SLP consults) in HEMORRHAGIC stroke patients, what do we want to keep their blood pressure at? SBP 150 mmHG and DBP 105 what do we want to keep ischemic stroke pt's BPs who have not received tpa? Treat PRN if SBP 220 mmHg, DBP 120 mmHG or MAP 130 what is the main complication with IV dilantin? must ONLY be combined with NS what occurs in SIADH? too much ADH!!! what are some neuro causes of SIADH? TBI SAH stroke CNS infection brain tumors Guillian-Barre (GBS) MS pituitary adenoma What is the recommended treatment for SIADH? (3) 1. fluid restriction 2. diuresis (Lasix) 3. administer sodium -- 3% saline (Frequent Na labs) Do not increase Na more than ___ mEq/L in 24 hours period d/t risk for central pontine myelinolysis 10 what is occurring in diabetes insipidus? not enough production of ADH!!! What are s/sx of DI? -increased urine output (250 cc/hr) -increased thirst -dehydration symptoms -dilute urine (low specific gravity 1.001-1.005) -decreased urine osmolality (400 mOsm/kg H20) -low urine Na -concentrated blood (serum osmolality 295 mOsm/L) -hypernatremia (145) Treatment for Diabetes Insipidus (DI)? 1. replace volume (oral fluids/IV fluids) 2. replace ADH by giving DDAVP or Vasopressin drugs given for increased ICP? 3% mannitol 23% what are s/sx of DKA? patient history -polyuria -polydipsia -weight loss -vomiting -blurry vision -weakness -abdominal pain Physical findings -poor skin turgor -kussmaul respirations -fruity breath -tachycardia -hypotension -mental status changes what are the three main components of treatment for DKA? 1. REHYDRATE 2. RESTORE GLUCOSE METABOLISM 3. CORRECT ELECTROLYTES AND ACIDOSIS what is the progression of IVF administration during DKA? -start with 1 L bolus NS over 1 hour -500 mL/hr for 2 hours -150 mL/hr for 1 hour -once glucose 250 mg/dL, change to D5 NS 0.45% 125 mL/hr why do we add D5 to solutions for DKA treatment later on? because hyperglycemia is corrected much faster than acidosis!! -the addition of dextrose to the fluids allows continued insulin administration until the ketonemia is cleared, while preventing hypoglycemia Do not start an insulin infusion for treatment of DKA until it is confirmed that the L level is greater than ____ 3.3 mEq/L what do we give to correct electrolytes and acidosis in DKA? potassium and bicarbonate! Why can hypokalemia occur in dka treatmnet/ because potassium shifts with insulin what are s/sx of hyperglycemia? polydipsia polyphagia polyuria fruity breath nausea/vomiting What are s/sx of hypoglycemia? increased HR, sweating, shaking, HA, vision changes (blurred) What is treatment for hypoglycemia? 1. if eating, give 15 g of fast acting carbohydrate like juice, oral gel, or glucose tablets -NOTE: repeat up to three times 2. if pt is NPO, administer 15-20 grams 50% dextrose 3. give glucaagon 1 mg IM if IV access not prompty available Treatment for hyperglycemia? usually insulin -follow endotool what is the impact of critical illness on blood sugars? critical illness causes hyperglycemia-- the patient will require increased dosages of insulin what meds should be tapered to prevent adrenal problems? corticosteroids Onset/Peak/Duration of Rapid-acting insulin? (Novolog) Onset: 15-30 minutes Peak: 0.5-3 hours Duration: 3-6 hours Onset/Peak/Duration of REGULAR insulin (humulin r)? Onset: 30-60 minutes Peak: 1-5 hours Duration: 6-10 hours Onset/Peak/Duration of intermediate acting insulin (NPH)? Onset: 1-2 hours Peak: 6-14 hours Duration: 16-24 hours Onset/Peak/Duration of Long-acting insulin (Lantus)? Onset: 1-2 hours Peak: relatively peakless Duration: 18-24 hours Lab indicators of renal failure INCREASED CREATININE (1.2) INCREASED BUN (20) INCREASED POTASSIUM FlUID OVERLOAD what adjustments are made with meds in renal failure? med dosages are decreased or the time between subsequent dosages is increased diet restrictions in acute renal failure (What would a tube feed consist of)? low potassium low sodium low phos low protein what are some complications of acute renal failure? -fluid overload -hyperkalemia (cardiac dysrhythmias) -HTN -metabolic acidosis What is normal urine output? 30 mL/hr CAUTI prevention measures -frequently assess need for catheter -prevent dependent loops -always assure that bag is less than half full -perform peri care every shift -maintain tubing free of kinks -if breaks in system are noted, replace catheter and collecting system NG tube placement verification Gold standard for confirmation is x-ray Assessing for GI bleed coffee ground drainage in suction container Aspiration precautions for gI patient -elevate hob 30-45 degrees -consider post-pyloric placement of feeding tube if residuals continue to be above 500 mL -Consider prokinetics to promote gastric emptying (such as erythromycin, metoclopramide, or naloxone) after three consecutive residuals 500 mL what are some indications for GI suction? to decompress the stomach (aspiration of gastric fluid content) if theres an obstruction what should be your first action when a transfusion reaction occurs? stop the infusion! what are some types of transfusion reactions? hemolytic febrile rxn allergic TRALI transfusion related immunmodulation (TRIM) treatment for hemolytic transfusion reaction Hemolytic transfusion reactions are treated as follows: Stop transfusion as soon as a reaction is suspected Replace the donor blood with normal saline Examine the blood to determine if the patient was the intended recipient and then send the unit back to the blood bank Furosemide may be administered to increase renal blood flow Low-dose dopamine may be considered to improve renal blood flow Make efforts to maintain urine output at 30-100 mL/h treatment for anaphylactic blood reaction Anaphylactic reactions are treated as follows: Stop the transfusion immediately Support the airway and circulation as necessary Administer epinephrine, diphenhydramine, and corticosteroids Maintain intravascular volume treatment for febrile infusion reaction Aggressive treatment of simple febrile reactions is not necessary; however, because the nonspecific symptoms are similar to those of a hemolytic transfusion reaction, differentiating this entity from a hemolytic reaction is necessary The transfusion should be terminated Evaluate the patient for evidence of hemolysis The patient's fever can be treated with acetaminophen what are the compensatory mechanisms for patients in shock? epi and norepi are released increase HR, SBP, RR, dilate coronaries ACTH, cortisol released and blood sugar increases RAAS system activated na+ and water retention occur with decrease in urine output Treatment for hypovolemic shock 1. fluids fluids fluids! (crystalloid/colloid replacement, RBC for hemorrhage) 2. support oxygenation 3. vasopressors started after fluid replacement WHAT ARE s/sx of cardiogenic shock? decreased BP, increased HR increased filling pressures (CVP, wedge) increased SVR decreased CO, CI what is the indicated treatment for cardiogenic shock? 1. support myocardial perfusion by decrease filing pressures and SVR (vasodilators like nitoglycerin) 2. use inotropes to support increase in CO (dobutamine, milrinone) 3. control rhythm disturbances 4. reduce myocardial workload and improve coronary flow (stent, bypass surgery) 5. remove obstruction (cardiac tamponade-- drain, aspirate or PE- give antithrombotic) what are the hemodynamic changes during anaphylactic shock? decreased BP increased HR CO/CI decreased CVP/PAWP decreased SVR decreased Treatment for anaphylactic shock? 1. REMOVE the causative factor 2. maintain patent airway 3. give epinephrine 4. meds! vasopressors, bronchodilators, benadryl, steroids, histamine blockers 5. educate to prevent in future Treatment for sepsis 1. draw lactate within 3 hours 2. blood cultures and abx within 1 hour 3. FLUIDS!!! 30 mL/kg of crystalloid fluids 4. start pressors to keep MAP 65 (LEvophed is first choice) 5. inotrope like dobutamine added if they have evidence of myocardial dysfunction what is blood glucose range goal for patient in sepsis? less than 180 what is the antidote to heparin? protamine sulfate What are s/sx of digoxin toxicity? Nausea/vomiting, diarrhea blurred vision (green/yellow halos) palpitations syncope dyspnea paroxysmal atrial tachycardia confusion/dizziness/delirium what is a medical power of attorney someone that you permit to speak on your behalf in regard to medical decisions, in the case that you cannot speak for yourself what is a living will A living will (sometimes called an advance directive, health care directive, or advanced medical directive expresses your wishes regarding medical treatment in very specific situations. what can be a respiratory complication from a long bone fracture? fat embolus-- dyspnea, SOB, what is the initial treatment for burn patients? FLUIDS, FLUIDS, FLUIDS What are some possible complications of chest trauma? PE, pneumothorax, pleural effusion, ARDS when treating a patient with hypothermia, what are the effects/concerns with rewarming them? -closely monitor for mass vasodilation and subsequent hypotension -gently handle -prevent afterdrop (continued cooling of temp even after rewarming) What is the initial treatment for chest pain? REST What is the most prominent EKG change that occurs in acute MI? ST segment elevation in two or more contiguous leads Cardiac enzymes are elevated in which conditions? in contrast, not elevated in what conditions? MI pericarditis myocarditis not so much elevated in congestive heart failure What is normal chest tube drainage PER HOUR? no more than 100 mL/hr what conditions commonly cause heart murmurs? oAortic dissection oAortic regurgitation (both acute and chronic) oMitral valve regurgitation (both acute and chronic) oMitral valve stenosis What are drugs that INCREASE preload? •Colloids •Crystalloids •Blood Hetastarch Drugs that DECREASE preload? •Dilators: • Nitroglycerin • Nitroprusside • Amrinone • Alpha and Calcium Channel blockers Drugs that increase contractility? INOTROPES -dobutamine -dopamine -milrinone -digoxin drugs that decrease contractility? beta-blockers calcium channel blockers drugs that increase afterload? vasopressors! -epinephrine -norepinephrine -dopamine -neosynephrine Drugs that DECREASE afterload? dilators -nitroprusside -nitroglycerin -amrinone -alpha and calcium channel blockers what are some complications when using thrombolytics? oBleeding/Hemorrhage oAllergic rxns oHypotension oHemorrhagic stroke oReperfusion arrhythmias what are some indications for external pacing? -symptomatic bradycardia -tachydysrhythmias -prophylaxis following a surgery, code, etc. S/sx of cardiac tamponade o Rise in filling pressure with decreased CO and hypotension o JVD o Elevated CVP, severe hypotension, and tachycardia o Pulses paradoxus o Narrowing pulse pressure o Tachycardia o Dysrhythmias o Decreased ECG voltage o Decreased UOP o Anxiety/restlessness o Chest pain radiating to neck, shoulders, back o Tachypnea o Muffled heart tones are a late sign o Chest x-ray may show enlarged cardiac silhouette o Discomfort that's relieved by sitting or leaning forward energy settings for biphasic defibrillator? 150 med for asystole epi (1mg) med for V tach with pulse? 150 mg Amiodarone MEd for atrial fib/atrial flutter? calcium channel blockers like cardizem Med for bradycardia atropine Drugs to decrease afterload/SVR/PVR Arterial Dilators) Nitroprusside, nitroglycerin, amrinone, alpha (Regitine) & Ca channel blockers Drugs to increased afterload/SVR/PVR PRessors -epinephrine -norepinephrine -neosynephrine/phenylephrine Drugs to decrease contractility/SVI Beta blockers (atenolol, metoprolol, propranolol, labetolol, esmolol) and Ca channel blockers Drugs to increase contractility/SVI Positive inotropes dobutamine, dopamine, milrinone, and digoxin Drugs to decrease preload/CVP/PAWP Venous Dilators - Nitroglycerin, nitroprusside, amrinone, alpha & Ca channel blockers Diuretics - Furosemide, bumex, mannitol Indication for dopamine/Intropes Acts on SNS to increased HR and BP. Indicated for hypotension, low CO, decreased renal blood flow. Use if patient is bradycardic. Doses of dopamine Low: 0.5-2 mcg/kg/min (dopaminergic) Intermediate: 2-10 mcg/kg/min (beta receptors, increases CO) High: over 10 mcg/kg/min (alpha receptors, vasoconstrict) SE of dopamine? -Watch volume and starting BP. -Use central line. -Inactivated by sodium bicarb. -Can cause acidosis. SE: ectopic beats, tachycardia, tissue necrosis d/t extravasation Indication for norepinepherine/Levophed Indicated for diastolic hypotension (specifically decreased SVR) and septic shock. Stimulates alpha & beta receptors. Increased contractility, HR, and vasoconstriction. SE of norepinepherine Replace volume first because it can cause GI and renal hypoperfusion. Have a central line. SE: dizziness, HA, hyperglycemia, myocardial/mesenteric/renal ischemia, tissue necrosis with extravasation. side effects of epinephrine? SE: myocardial/mesenteric/renal ischemia, tachycardia, hyperglycemia, HA, tissues necrosis with extravasation SE of neosynephrine Use central line. Wean this first! SE: Reflex bradycardia, myocardial/mesenteric/renal ischemia, tissue necrosis with extravasation Indications for vasopressin Antidiuretic hormone used to vasocontric. Endogenous hormone. Vasoconstricts peripheral arterioles & vasodilates coronary, pulmonary, and CNS circulation. Effective for hypotension, shock, decreases needs of other pressors, and Cardiac surgery. SE of vasopressin? SE: Skin/mesenteric ischemia, bradycardia, decrease UOP & result in hyponatremia, use with caution in neurosurgery patients SE of dobutamine? SE: ectopic beats, tachycardia, arrhythmias, tissue necrosis with extravasation. What is CVP measuring? pressure in the right atrium What is MAP measuring? basically a ratio of systolic/diastolic -the pressure in the arteries during one cardiac cycle what is PAP measuring? pressure in the pulmonary artery/lungs what is pulmonary artery wedge pressure? it's occluding off the artery to give us a measure of pressure in the LEFT ATRIUM what are causes of overdamped waveform? occlusions kinks compliant tubing excess tubing or stopcocks loose connections low fluid level in flush bag What are causes of underdamped waveform? air bubbles in transducer stopcocks defective transducer consider severe HTN what is normal MAP range? 70-105 what is normal CVP? 1-7 what is normal RV? 15-28/0-8 What is normal PAS/PAD/PAM? 15-25/6-12 MEAN PA 10-20 What is normal wedge pressure? 4-12 what is normal SVR? 800-1200 mmHG what are some complications of having an art line? arterial insufficiency peripheral neuropathy hemorrhage infection Describe procedure for removing an art line 1. MD order 2. standard precautions 3. remove dressing and suture 4. assess and palpate pulse 5. slowly pull line 6. allow 1-2 pusations 7. apply constant pressure for 5-10 min 8. pressure dressing 9. check site and pulses Normal CVP Waveform Normal arterial waveform normal wedge waveform