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4EH PCCN Flashcards

1
Q

What does the renal system conserve on injury?

A

Water and sodium

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2
Q

What is the lag time on creatinine?

A

12 hours

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3
Q

What is fluid balance regulated by?

A

Aldosterone, thirst, ADH, ANP, RAAS

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4
Q

Aldosterone release is triggered by what?

A

Elevated K+ (to get rid of it)

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5
Q

AKI causes what

A 
Retention of metabolic waste (acidosis)
Fluid overload
Electrolyte imbalance (K, mag, and phos all increase)
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6
Q

Which medications can cause AKI

A

Vanco, gent, and antivirals

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7
Q

What is the normal BUN/Creatinine ratio?

A

10:1

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8
Q

GFR estimates what?

A

Creatinine clearance

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9
Q

What would you see in the urine with tubular distress?

A

Proteinuria

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10
Q

Normal creatinine clearance is what?

A

80-120 mL/min

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11
Q

Post-renal AKI may be caused by what

A

Urethral obstruction

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12
Q

Pre-renal AKi labs would look like

A

Conserve Na+ and H20, decreased UOP. Urine Na+ would be low 2/2 conservation of sodium in body

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13
Q

Pre-renal AKI results from

A

Hypoperfusion (Sepsis, HF, trauma, hypovolemia)

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14
Q

What would the BUN:Creatinine look like in pre-renal AKI

A

25:1 because BUN readily elevates, creatinine takes time

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15
Q

Renal protection bundle consists of what

A

Adequate HYDRATION
Adequate PERFUSION
Stop NEPHROTOXIC meds (i.e. vanc)

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16
Q

BUN:Creatinine in ATN

A

10:1 but BOTH ELEVATED

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17
Q

Management of ATN

A

Supportive tx
Permanent damage to tubules means pt will likely need HD
Prevent acidosis, electrolyte imbalance, and uremia

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18
Q

You would expect to see ___ in the urine of someone with ATN

A

Casts

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19
Q

Toxic ATN

A

**REVERSIBLE with early intervention
Caused by meds (vanco gent, antivirals)
Uniform, wide-spread damage
Can recover in 8 days

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20
Q

Ischemic ATN

A

Irregular damage along tubular membranes
Tubular cell damage and cast formation
Poor to no perfusion to kidneys
Long recovery with 50% mortality rate

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21
Q

Your patient is in the polyuria (diuretic) stage of ATN. Because of this you know you must monitor which lab?

A

Serum Potassium

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22
Q

3 phases of ATN

A

Oliguric phase, diuretic phase, recovery phase

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23
Q

Oliguric phase of ATN

A

Insult to injury within 48 hours
Decreased UOP
Increased metabolic waste
Electrolyte imbalance (K+, mag, phos)
High urine specific gravity 2/2 Na+ conservation
Decreased bicarb because pt becoming acidotic
Needs HD

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24
Q

Diuretic phase of ATN

A

Lasts 7-14 days
Wasting K+ and Na+ ->watch closely!
Gradual improvement of renal function
Urine specific gravity decreases
Monitor for fluid deficit, can cause re-injury
Still needs HD to get rid of waste but don’t take water off

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25
Q

Recovery stage of ATN

A

Can progress to CKD

GFR returns to <80% within 1-2 years but will never be the same

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26
Q

Contrast induced nephropathy

A

Prevention and treatment: HYDRATION

Hydrate patients prior and after

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27
Q

Indications for Dialysis

A 
AEIOU
Acid/base imbalance (acidosis)
Electrolyte imbalance (kyperkalemia, mag, phos)
Intoxications (ODs/toxins like tylenol)
Overload- fluid
Uremic symptoms (climbing creatinine)
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28
Q

Calcium and phosphate have a(n) _____ relationship

A

Inverse

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29
Q

What labs are associated with kidney injury (acute or chronic)?

A

Decreased calcium, increased K, increased creatinine

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30
Q

A patient with chronic renal failure has a Hgb of 7 mg/dL, BUN 38, creatinine 3.2, K+ 4.6. You should anticipate administration of which of the following?

Kayexelate
Calcium gluconate
Epoetin alpha
Mag Sulfate

A

Epoetin alpha to stimulate RBC production

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31
Q

CKD labs

A

Anemia**
Increased BUN/creatinine/PO4
Decreased Ca++, HCO3, protein

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32
Q

Top 2 risk factors for CKD

A

DM and HTN (responsible for 70% of CKD cases)

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33
Q

Your patient is scheduled for HD today at 11 am. You have several 9am meds. You should:

Administer all the meds
Hold all AM meds until after dialysis
Decide which meds are affected by dialysis and adjust as needed
Give only cardiac meds

A

Decide which meds are affected by dialysis and adjust as needed

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34
Q

Meds removed by HD

A

BLIST MED
Barbiturates, lithium, isoniazid, salicylates, theophylline/caffeine, methanol, ethelyene glycol, depakote

Hold all BP meds until after HD!

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35
Q

One of the most common complications of intermittent HD is:

Hypokalemia
Hypotension
Chest Pain
Anemia

A

All are possible but HYPOTENSION is the most common because you’re displacing blood

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36
Q

HD was just initiated on your patient. The BP dropped from 178/64 to 116/52 and they feel lightheaded. Which would be the most appropriate action to take?

Increase the ultrafiltration rate
Start dobutamine infusion
Give 500 mL fluid bolus
Decrease the ultrafiltration rate

A

Decrease the ultrafiltration rate, essentially meaning slow down the removal rate

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37
Q

A 34 year old pt with AKI was dialyzed 1 hour ago. Now she is increasingly confused and agitated. The most likely cause of this is:

Delerium
Azotemia (increased nitrogen in blood)
SAH
Dialysis Disequilibrium Syndrome

A

Dialysis Disequilibrium Syndrome

Usually self-resolving
Wait for the urea nitrogen to equilibrate on both sides of the blood brain barrier

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38
Q

The main reason to utilize CRRT over intermittent HD is:

Hemodynamic instability
Severe anemia
Fluid overload >10 L
Severe hypokalemia

A

Hemodynamic instability

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39
Q

Venous Air Embolus

A

SOB, CP, acute R heart failure (looks like a PE)

Treatment: lay on L side, trendelenburg. Hyperbaric with 100% FiO2 to accelerate the removal of nitrogen

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40
Q

Arterial Air Embolus

A

Change in LOC, decreased arterial flow/ perfusion (looks like stroke or clot)

Treatment: High flow O2, L side trendelenburg

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41
Q

Which of the following lab values would you expect to see in a patient in the oliguric stage of ATN?
(USG= urine specific gravity)

USG 1.025, BUN/creat of 10:1, urine Na 8
USG 1.004, BUN/creat 10:1, urine Na 50
USG 1.004, BUN/creat 25:1, urine Na 50
USG 1.025, BUN/creat 25:1, urine Na 8

A

Last one
USG 1.025, BUN/creat 25:1, urine Na 8

heavy urine, BUN:creat is 10:1 in ATN

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42
Q

Your pt who experienced AKU this hospitalization is being discharged. Which of the following medications should they be instructed to avoid?

Opioids
Tylenol
NSAIDS
ACE inhibitors

A

NSAIDS

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43
Q

Low electrolytes lead to acidosis or alkalosis?

A

Alkalosis

LOW electrolytes= alkaLOsis
Drop acid, get high

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44
Q

A 78 year old pt admitted with N/V and severe dehydration. Na is 152 mEq/L. You would expect to see the following lab profiles?

Elevated urine specific gravity, elevated hemoglobin, decreased serum osmolality
Elevated urine specific gravity, elevated Hgb, elevated serum osmolality
Decreased urine specific gravity, elevated Hgb, decreased serum osmolality
Decreased urine specific gravity, decreased Hgb, elevated serum osmolality

A

Second one

Elevated urine specific gravity, elevated Hgb, elevated serum osmolality

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45
Q

We replace sodium ___ (quickly or slowly) because….

A

Slowly to prevent nerve demyelination (permanent)

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46
Q

Which of the following patients is at highest risk of developing hyperkalemia?

GIB with administration of 3u PRBCs
Severe vomiting and dehydration with administration of 4L LR
HF pt on ACEi and Spironolactone
Refeeding syndrome after being NPO for 5 days

A

HF pt on ACEi and Spironolactone, spironolactone is K+ sparing. ACEi alter ADH which alters K+

Vomiting and dehydration would have high Na+, GIB patient after 3u PRBCs would have high Calcium

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47
Q

Hyponatremia

A

Too much water or Na+ loss?

Water retention or dehydration

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48
Q

Where is the primary excretory source for K+?

A

Kidneys

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49
Q

Development of a “u” wave on ECG is indicative of which of the following?

Hypokalemia
Hypermagnesemia
Hypophosphatemia
Hypercalcemia

A

Hypokalemia

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50
Q

Which of the following EKG changes would you expect with a pt with a potassium of 6.2?

Prolonged PR interval
Shortened QT interval
Tall Peaked T waves
Prominent U waves

A

Tall Peaked T waves

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51
Q

What are some causes of Hyperkalemia?

A

Renal failure, severe trauma and burns, DKA, rhabdo, infection, decreased CO, Acidosis

52
Q

Emergent treatment of Hyperkalemia

A

Move potassium: Insulin , calcium chloride (cardio protective), sodium bicarb, albuterol

Remove potassium: emergent dialysis, loop diuretics, kayexelate

53
Q

Which electrolyte deficiency will produce torsades and is commonly associated with alcoholism?

Potassium
Calcium
Mag
Sodium

54
Q

In a patient with a K of 2.9 and a mag of 1.1 with an arrythmia, which should be replaced first?

55
Q

Signs of hypermagnesemia include the following:

Tetany, rigid extremities
Muscle weakness, lethargy
Decreased deep tendon reflexes, tetany
Lethargy, Torsades de pointes

A

Muscle weakness, lethargy

High risk: renal pts, boosting from repletion, OB

*mag drag with high mag

56
Q

A 65 year old pt is admitted S/P cardiac arrest from the ED. His labs return and are as follows:
K+: 4.7 , Mg++: 5.2, Na+: 148
The patient is hypotensive and extremely flaccid. Which of the following should you anticipate?

Emergent HD
Administer 1 amp of calcium gluconate IV
Administer nebulized mucomyst
Administer Kayexelate

A

Administer 1 amp of calcium gluconate IV, the antidote to increased mag

57
Q

Hypermagnesemia

A

Rare
Caused by renal failure, DKA, or acidosis

vasodilation, flushing, hypotension

Fluids and diuretics

58
Q

Phos and calcium have a(n) ___ relationship

59
Q

Signs of hypocalcemia include:

Tall peaked T waves on ECG
Chvostek’s sign
ST depression
Hepatojugular reflex sign

A

Chvostek’s sign -> facial nerve twitching with twitching on face.

Tall T waves is increased K+
ST depression is decreased K+
Hepatojugular reflex sign is R HF

60
Q

You notice when assessing the BP of your renal failure patient their arm and hand muscles are in spasm. You suspect which of the following electrolyte imbalances?

Hyperphosphatemia
Hypercalcemia
Hyperkalemia
Hypermagnesemia

A

Hyperphosphatemia -> Trosseau’s sign is low Ca++ or high phos

61
Q

How does hypocalcemia affect the respiratory system

A

Bronchospasm, labored, shallow breathing

62
Q

The following ABG is most likely associated with:

pH 7.51, pCO2 35, pO2 188, HCO3 35

Hyperchloremia
Hyperkalemia
Hypercalcemia
Hypochloremia

A

Hypochloremia

Metabolic alkalosis

63
Q

Inotrope vs chronotrope

A

Inotropes effect contractility +inotropic improve, - decrease

Chronotropic effect heart rate + increase HR, - decreases

64
Q

AV valves (mitral and tricuspid) open during

A

Diastole and closed during systole

65
Q

Semilunar valves (Aortic and pulmonic) valves are open during

A

Systole and closed during diastole

66
Q

Posterior wall of the heart is perfused by

A

90% RCA and 10% CRFX

67
Q

Circumflex artery perfuses…

A

Lateral wall of L ventricle, L atrium, back of L ventricle

68
Q

LAD perfuses…

A

Septal and anterior wall of heart, front and bottom wall of L ventricle, and front of septum

69
Q

RCA perfuses…

A

Inferior wall of the heart, R atrium, SA node, AV node, R ventricle, back of the septum

70
Q

Preload

A

initial stretching of myocardium prior to contraction, therefore related to sarcomere length at the end of diastole

71
Q

Afterload

A

Resistance the ventricle has to overcome to eject blood

High afterload= vasoconstriction (HTN)

72
Q

Split heart sounds are best heard during

A

Inspiration

73
Q

Isotonic IV fluids

A

Volume expanders, stay in vasculature

74
Q

Hypertonic IV fluids

A

Shift from cell to vasculature

75
Q

Hypotonic IV fluids

A

Shift from vasculature to cell

76
Q

A patient presents with AMS and tachypnea.
ABG results: pH 7.25, PaCO2 28, PaO2 9-, HCO3 18

Ketones are present in the serum and urine, serum osmo is 320, serum sodium 130, anion gap is 22.

Based on these lab findings, you suspect the following diagnosis:

HHS
DKA
DI
Adrenal crisis

A

DKA, metabolic acidosis

77
Q

Clinical manifestations of DKA include:

Hyperglycemia, hypo-osmolality, and anion gap acidosis
Hyperglycemia, hyper-osmolality, and hypernatremia
Hyperglycemia, hypo-osmolality, and ketone production
Hyperglycemia, hyper-osmolality, and anion gap acidosis

A

Last one

Hyperglycemia, hyper-osmolality, and anion gap acidosis

78
Q

An 18 year old with DM1 is admitted with a hyperglycemia emergency. Her initial glucose was 520 mg/dL with a potassium of 6.2. Your priority when caring for her is:

Correcting her glucose levels
Lowering her potassium level
Restarting her SQ insulin
Correcting her fluid deficit

A

Correcting her fluid deficit

79
Q

Anion gap normal

A

<11-12. Gap >12 is associated with metabolic acidosis

80
Q

Four hours after starting on an insulin infusion in a patient with DKA, the pts blood glucose is 235 mg/dL. Which of the following fluids should be administered?

Hypertonic solution to hydrate the cell
D5 .45NS or D5NS with a glucose source
Isotonic saline bolus to maintain extracellular hydration
Hypotonic saline to provide cellular hydration

A

D5.45NS or D5NS with a glucose source

81
Q

Insulin management in DKA

A

Overlap SQ insluin and insulin gtt by 2 hours, goal is to shut down ketone production

82
Q

A cardinal sign of HHS is

Ketones present in serum and urine with increased serum osmolality
Decreased serum osmolality with rapid and shallow breathing
Markedly elevated serum glucose and AMS
Volume overload and metabolic acidosis

A

Markedly elevated serum glucose and AMS

83
Q

HHS treatment

A

Add dextrose when glucose is 250-300 mg/dL to prevent hypoglycemia

Pts are also 5-10L fluid down so can go into hypovolemic shock

Type 2 DM

84
Q

Nursing consideration with SIADH

A

Safety!! Fall and seizure precautions

Correct Na+ slowly, prevent irreversible damage to neuron myelination

85
Q

A common lab finding in a pt with DI is

Decrease serum osmolality
Decreased UOP
Elevated urine specific gravity
Elevated serum osmolality

A

Elevated serum osmolality

86
Q

DI is caused by

A

Lack of ADH

87
Q

You would expect which of the following lab findings in a pt with DI

Increased serum osmo, decreased serum sodium, increased urine osmo

Increased serum osmo, decreased urine osmo, increased serum sodium

Decreased serum osmo, increased serum sodium, decreased urine osmo

Decreased serum osmo, decreased serum sodium, decreased urine osmo

A

Second one

Increased serum osmo, decreased urine osmo, increased serum sodium

88
Q

56 year old pt S/P cardiac arrest and 45 mins of CPR. On day 2 of hospital stay you notice urine drainage bag is suddenly full. Urine is clear without color. Continues with UOP of 70-1000 mL per hour x2 hours. Which of the following assessment findings would you expect?

Serum sodium level of 126
Serum osmolality of 320
Urine specific gravity of 1.025
Serum potassium of 3.5

A

Serum osmolality of 320

89
Q

Pt from psych unit admitted for close monitoring after drinking 8 L of water in an hour. You would expect to find which of the following:

Hyponatremia
Hypernatremia
Hypokalemia
Elevated serum osmolality

A

Hyponatremia

90
Q

A severely depressed diabetic patient is admitted after taking a large amount of insulin in an attempt to commit suicide. asking about suicidal thoughts and feelings will help you ascertain:

If they have a specific plan to attempt suicide again
Place the patient on suicide watch
Give them ideas for successful suicide
If they are more depressed

A

If they have a specific plan to attempt suicide again

91
Q

You are caring for a pt who was admitted with an occluded VP shunt. Earliest signs of increased ICP include:

Nystagmus
Decreased LOC
Slurred speech
Unequal Pupils

A

Decreased LOC

92
Q

How do you test cranial nerves:

VII
IX/X
XI
XII

A

VII: Smile
IX/X: Swallow, gag, speech
XI: Shrug shoulders
XII: Stick out tongue

93
Q

1 hour goal with stroke care

A

Assessment, CT scan, glucose
NIHSS (higher score is worse)
Treat with fibrinolytic therapy if needed

94
Q

Which of the following patients is at highest risk for developing an embolic stroke?

Atrial septal defect
Supraventricular tachycardia
second degree AV block type 1
Wolff-Parkinson-White Syndrome

A

Atrial Septal Defect

95
Q

A pt is admitted with an acute ischemic stroke. After a head CT scan and assessment, there is high suspicion for embolic stroke. rtPA is ordered. The pt’s BP is 220/160. Your initial priority is:

Preparing for STAT administration fo rtPA
Preparing for STAT cerebral angiogram
Administer Mannitol IV to decrease cerebral edema
Lowering pts BP to less than 185/110

A

Lowering BP to less than 185/110

YOU HAVE TO CONTROL BP PRIOR TO ADMINISTRATION

96
Q

Window from last known normal to be able to give rtPA

A

4.5 hours

3 hour window if over 80, taking oral AC, hx stroke or DM, NIHSS score >25 baseline, or if CT reveals large injury (>1/3 of MCA territory)

97
Q

Door to needle time for rtPA

A

Less than 60 mins

98
Q

3 days after an embolic stroke, your pt is not able to swallow appropriately. Which of the following would be most appropriate to provide nutrition?

Insert a central line to provide TPN
Insert a small bore gastric tube to begin enteral feeding
Arrange for radiology to insert a jejunostomy tube for enteral feedings
Insert a PICC for parenteral nutiriton

A

Insert a small bore gastric tube and begin enteral feedings

99
Q

Stroke care components (5)

A

Cardiac monitoring (A.fib, R/O ASD or PFO, ECHO if unexplained stoke)

Airway support (O2 if sats less than 94%)

TREAT HYPOGLYCEMIA

BP target range

AVOID FEVER! Don’t treat fever, avoid it (associated with higher M/M)

100
Q

46 year old with ruptured cerebral aneurysm will be placed on which of the following class of medication to prevent cerebral artery vasospasm?

Beta blockers
Angiotensin receptor blockers
CCB
ACEi

A

CCBs (i.e nicardipine x21 days)

101
Q

Which of the following should be avoided in a patient with a basilar skull fracture?

NG tubes
Urinary catheters
Fevers
Central lines

102
Q

Gold standard for diagnosing Epidural and subdural hematomas

103
Q

Complications associated with neuro insults (nursing considerations?)

A

Pulmonary complications i.e. airway protection and aspiration

104
Q

You are admitting a pt S/P craniotomy for a ruptured aneurysm. Which of the following nursing actions should you anticipate?

Administer Mannitol Q12 to reduce cerebral edema
Position with HOB 30 degrees to optimize venous outflow
Decrease MAP to improve CPP
Monitor for delirium

A

Position with HOB at 30 to optimize venous outflow

105
Q

Normal ICP

A

0-15 mm Hg

Treatment indicated if sustained >20-25 mmHg

106
Q

Ventriculostomy

A

Drain for hydrocephalus placed in lateral ventricle, can also use to monitor ICP

107
Q

Management of a pt post SAH with increased ICP includes:

Hypotonic saline, osmotic diuretics, and loop diuretics
Beta blockers, hypertonic saline, and CCBs
Optimal positioning, osmotic diuretics, and hypertonic saline
CCBs, hypotonic saline, and anticonvulsants

A

Optimal positioning, osmotic diuretics, and hypertonic saline

108
Q

Managing IICP

A

Positioning to manage venous drainage (30-45 degrees with good head alignment, straight legs, no stimuli)

Normothermia (don’t treat fever, avoid it)

Assess for pain

109
Q

Labs to monitor with mannitol

A

K+, osmo, and Na+

110
Q

Foramen of Monro is at the level of the…

111
Q

In addition for figuring out the cause, priorities when caring for a patient experiencing a seizure include

Safety and dilantin IV
Monitoring for SIRS & preventing aspiration PNA
Safety and administration of a benzo
ICP monitoring and cerebral perfusion pressure optimization

A

Safety and give a benzo

Dilantin takes a while to become therapeutic, ativan kicks in right away

112
Q

Guillain-Barre

A

Autoimmune disorder AFTER A VIRAL INFECTION

Ascending paralysis, concern for it reaching diaphragm. Can be unilateral or bilateral

Treat with IVIG and plasmapheresis (albuminocytologic dissociation in CSF leading to damage to myelin sheath)

Airway protection and respiratory failure

113
Q

Seizure meds

A

Benzos (lorazepam is first line, can repeat in 5-10 mins)

Diazepam (0.15 mg/kg IV repeat in 5 mins)

Phenytoin/Dilantin (GIVE SLOWLY to avoid hypotension and bradycardia. load 10-15 mg/kg, peaks in 15-20 mins. Assess for infiltration @IV site)

114
Q

Targeted temperature management

A

Target goal: 32-36 C for 24 hours to minimize reperfusion injury ->NEURO PROTECTIVE

ONLY in patients remaining comatose after cardiac arrest

Monitor for shivering, bradycardia, elevated lactate

Slowly rewarm over 12-24 hours

115
Q

Which of the following would be expected in a patient experiencing herniation and Cushing’s Triad?

Narrow pulse pressure, bradycardia, and hypotension
Narrow pulse pressure, tachycardia, hypotension
Wide pulse pressure, bradycardia, increased systolic pressure
Wide pulse pressure, tachycardia, increased systolic pressure

A

Third one

Wide pulse pressure, bradycardia, increased systolic pressure

116
Q

Cushing’s triad

A

Increased systolic BP (or widening pulse pressure)
Decreased HR
Decreased or irregular RR

117
Q

A pt experienced a devastating ruptured basilar aneurysm. When preparing for brain death examination, you should expect which of the following findings?

Absent oculocephalic reflexes and positive babinski sign
Positive oculocephalic reflexes and blown pupils
Absent oculocephalic and oculovestibular reflexes
Decorticate posturing and pinpoint pupils

A

Absent oculocephalic and oculovestibular reflexes

118
Q

Which cranial nerves do you assess for “dolls eyes”

A

III, VI, VIII

Absent=brain dead

Normal response= eyes turn with head turn

119
Q

How do you test for an Oculovestibular reflex?

A

“Cold Calorics”

Drop cold water into ear

Normal response is to look towards stimuli

Absent=brain dead

Cranial nerves III, VI, VII

120
Q

What is the only test someone with brain death will test positive for?

A

Apnea test (not breathing)

121
Q

Kernig’s sign

A

Inability to straighten leg when the hip is flexed 90 degrees. Associated with meningitis or SAH

122
Q

Brudinski Sign

A

Severe neck stiffness; when neck flexed, causes knees to bend. Associated with meningitis and SAH

123
Q

Normal PEtCO2 range (Capnography)

A

34-45 mmHg

124
Q

A pt with an asthma exacerbation will exhibit which of the following physiologic signs?

Decreased vital capacity, decreased peak inspiratory flow, decreased peak expiratory flow rate

Increased vital capacity, decreased peak inspiratory flow, increased peak expiratory flow rate

Decreased vital capacity, increased peak inspiratory flow, increased forced expiratory volume

Increased vital capacity, decreased peak inspiratory flow, decreased forced expiratory volume

A

First one

Decreased vital capacity, decreased peak inspiratory flow, decreased peak expiratory flow rate

125
Q

You are caring for a pt with an acute episode of asthma exacerbation. The first line of treatment is

Corticosteroids
Beta2 agonist
IV fluids
CXR to rule out PNA

A

Beta 2 agonists aka albuterol to help with bronchodilation

4EH PCCN (1 decks)

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